Shu Wang,     MD, PhD
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Shu Wang, MD, PhD The archiater of Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China. Doctoral supervisor. Received his master degree in 1994 at Shanghai Second Medical University;

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Received his master degree in 1994 at Shanghai Second Medical University;

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Received his master degree in 1994 at shanghai second medical university

Shu Wang, MD, PhD

The archiater of Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China. Doctoral supervisor.

  • Received his master degree in 1994 at Shanghai Second Medical University;

  • Took his doctor’s degree on Endocrinology at shanghai Jiaotong University school of medicine in 2007;

  • From the year 2001 to 2003, He took an advanced study in Baylor College of Medicine , America.

  • Headman, Endocrinology and Metabolism section, Institute of Health Sciences, Shanghai Institutes for Biological Sciences since 2004.

  • Chief of office, Thyroid disease education project team, Ministry of Health, China since 2009;

  • Youth member, Endocrinology society of Chinese Medical Association in 2009.

  • Committee member of Chinese thyroid Association in 2010.


The cardiovascular system in thyrotoxicosis

The Cardiovascular System in Thyrotoxicosis

Dept. of Endocrinology and Metabolism, Ruijin Hospital,

Shanghai Jiaotong University, School of Medicine

Shanghai, China

Dr. Shu Wang

[email protected]


Received his master degree in 1994 at shanghai second medical university

Thyrotoxicosishas important clinical

consequencesfor the cardiovascular systems.

Thyrotoxicosis can increasecardiovascular

morbidity and mortality.

The cause of cardiovascular signs and symptoms by thyrotoxicosis can easily be neglected.

  • Thyrotoxicosis is the clinical syndrome of hyperthyroidism resulting from excessive quantities of the thyroid hormones.

keep

“Thyrotoxicosis”

in mind!


Case 1

Case 1

  • A 63-year-old female patient

  • Chest distress ,palpitation behind fatigue,

    sweating,weight loss of 1 year

  • Oral glyceryl trinitrate provided no relief

  • PE: heart rate:120 beats per minute; arrhythmia

  • ECG: atrial fibrillation; ST-Tchange

  • Diagnosis:coronary heart disease;atrial fibrillation

Is it an accurate diagnosis ?


Received his master degree in 1994 at shanghai second medical university

The causes of atrial fibrillation

★Thyrotoxicosis

Heart

Alcohol

Drugs

Electric shock

Surgery

......

Atrial Fibrillation

Neurogenic AF

Pulmonary disease

Infections


Received his master degree in 1994 at shanghai second medical university

Atrial fibrillation

Angina pectoris

FT3>46.08pmol/L

FT4 67.5pmol/L

TSH<0.0025μU/L

TRAb>40IU/L

TGAb 14.51IU/L

TPOAb 737.14

Sweating

Weight loss

heart rate increased

Thyroid funtion ?

thyrotoxicosis induced cardiovascular dysfunction


Thyrotoxicosis induced c ardiovascular dysfunction

Thyrotoxicosis induced cardiovascular dysfunction

  • The morbidity of thyrotoxicosis induced cardiovascular dysfunction is about 5%~10%.

  • Graves disease is the most common cause of thyrotoxicosis accounting for 60% to 90% of cases.

  • Clinical classification:

  • 1) Hyperthyoidism asan initial cause;

  • 2) Hyperthyoidism as a worsenfactor when patient has underlying cardiac disease.


Clinical manifestation

The patient

presents

Clinical manifestation

Thyrotoxicosis induced cardiovascular dysfunction

Hypermetabolismsyndrome:

Weight loss with increased appetite

Warm and sweating

Coarse tremor in extremities,etc.

Sweating

Weight loss

Cardiac symptoms in an early stage:

Palptations, Exercise intolerance,

Dyspnea on exertion, Tachycardia,etc.

Palpitations

chest distress

Heart complication:

Atrial fibrillation,Cardiomyopathy, Heart failure, Angina pectoris and Myocardial infarction.

Atrial fibrillation

Angina pectoris


Received his master degree in 1994 at shanghai second medical university

Thyrotoxicosis induced cardiovascular dysfunction

Rarely,young patients with thyrotoxicosis may have chest pain similar in almost all respects to angina pectoris.

Chinese scholars’ consensus

NYHA

(New York Heart Association)

Along with hyperthyroidism,One having at least one item of heart abnormality can diagnosed hyperthyroidism heart disease:

①enlarged heart;②Arrhythmias;③congestive heart failure;④Angina pectoris and myocardial infarction;

Meanwhile,another factors changing heart functions should be excluded

① AtrialArrhythmias, enlarged heartor ventricular failure

②Clinical manifestations

and biochemical proof of Hyperthyroidism

③After specific treatment,the above-mentioned can disappear

Diagnostic criteria

?


Received his master degree in 1994 at shanghai second medical university

Thyrotoxicosis induced cardiovascular dysfunction

What type of thyrotoxicosis induced cardiovascular diseases is the patient?

Types:Arrhythmia type

Heart failure type

Cardiomyopathy type


Received his master degree in 1994 at shanghai second medical university

Arrhythmia Type

Atrial fibrillation is the most common arrhythmia.

The incidence is about 10%~20%hyperthyroidism patients.

Heart failure Type

Present in 6% of cases.It can be divided into high output failure and pump failure.

Risk factors: Age>60,long term uncontrolled hyperthyroidism,underlying heart disease and AF .

Cardiomyopathy Type: (rare)

Rate-related cardiomyopathy: Tachycardiainduced cardiomyopathy can cause heart failure, although LVEF usually normalizes after heart rate or rhythm control.

Dilated cardiomyopathy: Associated with Graves disease might have an auto-immune origin.

Thyrotoxicosis induced cardiovascular dysfunction


Received his master degree in 1994 at shanghai second medical university

Arch Intern Med. 2004;164:1675-1678

In patients with hyperthyroidism :Morbidity of AF is 8.3%

Male sex, increasing age, ischemic heart disease, congestive heart failure, and heart valve disease are associated with an increased risk of AF


Mechanisms

Thyrotoxicosis induced cardiovascular dysfunction

Mechanisms

★The heart is main target organ of Thyroid Hormone.

T3 influence cardiac action by three different routes:

  • T3exerts a direct effect on cardiac myocytes;

    2) T3 may influence the sensitivity of the sympathetic system;

    3) T3 leads to periphery hemodynamic changes.


T3 effects on the cardiac myocyte

T3 effects on the cardiac myocyte

Genomic nuclear effects:

T3 binds to nuclear thyroid hormone receptors (TRs), combined with recruited cofactors.The complex then bind or release specific sequences of DNA , modifying the rate of transcription of specific cardiac genes.

Non-genomic effects:

T3 direct modulate the transport of ions (calcium, sodium andpotassium) across the plasma membrane, glucose and amino acid transport,mitochondrial function and various intracellular signalling pathways.


Received his master degree in 1994 at shanghai second medical university

Regulated cardiac gene as reported


Received his master degree in 1994 at shanghai second medical university

Interactions between THs and the sympathetic system

Some T3 effects are mediated by an increased activity of the sympathetic system or an increased responsiveness and sensitivity of cardiac tissue to normal sympathomimetic stimuli.

The enhanced sympathetic sensitivity of the hyperthyroid heart may be mediated by an increased number of β-adrenergic receptors.


Haemodynamic changes

Haemodynamic changes


Received his master degree in 1994 at shanghai second medical university

membrane

ion channels

vascular relaxation

SVR decreases

vascular smooth muscle cells

nongenomic

NO

T3

paracrine manner

endothelial

cell

NO

genomic

T3 relaxs vascular smooth muscle cells though regulation of nitric oxide ( NO), and decreases peripheral resistance.


Received his master degree in 1994 at shanghai second medical university

only 50% of hyperthyroidism patients with congestive heart failure have impaired left ventricular(LV) systolic function .

LVdiastolic dysfunctionmay involve in theremaining half.


Received his master degree in 1994 at shanghai second medical university

Thyrotoxicosis induced cardiovascular dysfunction

The patient has been confirmed,and how to treat it ?


Management and treatment

Thyrotoxicosis induced cardiovascular dysfunction

Management and Treatment

  • Principle:

  • ①Recover the thyroid function as soon as possible.To rapidly reduce the actions of thyroidhormone,ATDs and Radioiodine isrecommended;

    ②Acute treatment of cardiaccomplications;

  • Most patients who get immediate controlof hyperthyroidism,can self-recover cardiac disorders gradually.


T herapy of a trial fibrillation

Therapy of atrial fibrillation

  • Control the thyroid function

  • About 50% AF in young and new onsetscanconvert to sinus rhythm after keeping euthyroid for 6~12 months.

  • Those AF consisting for more than 4 months after euthyroid,Drugs and Electroversion can be considered.

  • Anticoagulative therapy isrecommended in the absence of a specific contraindication, at least until a euthyroid state has been restoredand heart failure has been cured.(ACC/AHA)


T herapy of h eart f ailure

Thyrotoxicosis induced cardiovascular dysfunction

Therapy of heart failure

  • Control the thyroid function;

    (The treatment of HF follows its conventional therapy.)

  • Expectant treatment: Sedation, oxygenuptaking, sodium limiting,etc.

  • β-blokers is used to stable the heart rate

  • Digitalis and Diuretic can effectively relieve heart burden and pulmonary congestion symptoms. However it is hard to restore totally.

  • Dosage of Digitalis is greater than usual loading and maintenance dosage maybe needed.


Case 2

what about thyroid function?

laboratory analysis:FT3:20.08pmol/LFT4:44.5pmol/LTSH:0.083U/L

  • A 60-year-old male patient

  • Palpitations, fatigue, weakness,

    weight loss of 1 month's duration

  • The patient had been taking amiodarone for 2.5 years for non-sustained ventricular tachycardia episodes.

    amiodarone had been discontinued for six months

  • PE: heart rate:98 beats per minute

Case 2

Is it Amiodarone-Induced Thyrotoxicosis?


Amiodarone induced thyrotoxicosis ait

Amiodarone-Induced Thyrotoxicosis(AIT)

  • The incidence of AIT reported in different studies varies but remains within the range of 5–10% in most studies.

  • AIT may develop suddenly and early or after many years of treatment, the usual time period is 2–47 months;

  • AIT may also develop many months after drug withdrawal.

  • Iodine deficient individuals render more sensitive to exogenous iodine

  • Risk factors:female sex, complex cyanotic heart disease, previous Fontan type surgery, and a total daily dose above 200 mg


Received his master degree in 1994 at shanghai second medical university

Why does Amiodarone can Induce Thyrotoxicosis?


Received his master degree in 1994 at shanghai second medical university

Types

★ Some patients exhibit a mixed pattern


Received his master degree in 1994 at shanghai second medical university

The decision to stop amiodarone in the setting of thyrotoxicosis should be determined on an individual basis in consultation with a cardiologist, based on the presence or absence of effective alternative antiarrhythmic therapy.

Is it need for amiodarone discontinuation?


Received his master degree in 1994 at shanghai second medical university

The need for amiodarone discontinuation is controversial, because :

(1) This drug is frequently the only medication able to control cardiac arrhythmia,

(2) The effects of this fat soluble drug may persist for many months.

(3) Amiodarone may have T3-antagonistic properties and inhibit T4 to T3 conversion, withdrawal Amiodarone may aggravate cardiac manifestations of thyrotoxicosis.

(4) AIT typically resolves even if amiodarone therapy is continued.


Received his master degree in 1994 at shanghai second medical university

Conclusion:

a: Euthyroidism was reached despite continuation of amiodarone in all patients.

b: Prednisone remains the preferred treatment of AIT type 2.


Thyrotoxicosis and pregnancy

Thyrotoxicosis and Pregnancy

  • Effects On Cardiovascular hemodynamics are additive

  • Mother: spontaneous abortion, hyperthyroidism crisis, heart failure, preeclampsia, premature delivery, etc;

  • Fetus:stillbirth, Growth restriction, goiter, heart failure, etc;

  • It is more urgent to control thyroid function and monitor heart function.


Received his master degree in 1994 at shanghai second medical university

Use β-blocker Cautiously in pregnancy

  • There is no evidence of teratogenesis following maternal exposure to beta-blockers in the first trimester.

  • The risk of IUGR associated with maternal use of beta-

    blockers exists, use the smallest effective dose (avoiding large doses) and useis limited to the third trimester.

  • There is also a theoretical risk of neonatal bradycardia, hypotension and hypoglycaemia if beta-blockers are used up to the time of delivery.


Take home message

Take Home Message

  • In clinics, the patient's history and thyroid function tests are important. (monitor)

  • The first step for treating heart complications is hyperthyroidism control. (treatment)

  • It is important to take risk factors into account, such as age, sex, hyperthyroidism type, underlying health problems. (prevention)


Received his master degree in 1994 at shanghai second medical university

Thank you!


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