Right ventricular dysfunction and pulmonary hypertension: a neglected presentation of thyrotoxicosis

Abstract

SummaryThyrotoxicosis is associated with cardiac dysfunction; more commonly, left ventricular dysfunction. However, in recent years, there have been more cases reported on right ventricular dysfunction, often associated with pulmonary hypertension in patients with thyrotoxicosis. Three cases of thyrotoxicosis associated with right ventricular dysfunction were presented. A total of 25 other cases of thyrotoxicosis associated with right ventricular dysfunction published from 1994 to 2017 were reviewed along with the present 3 cases. The mean age was 45 years. Most (82%) of the cases were newly diagnosed thyrotoxicosis. There was a preponderance of female gender (71%) and Graves’ disease (86%) as the underlying aetiology. Common presenting features included dyspnoea, fatigue and ankle oedema. Atrial fibrillation was reported in 50% of the cases. The echocardiography for almost all cases revealed dilated right atrial and or ventricular chambers with elevated pulmonary artery pressure. The abnormal echocardiographic parameters were resolved in most cases after rendering the patients euthyroid. Right ventricular dysfunction and pulmonary hypertension are not well-recognized complications of thyrotoxicosis. They are life-threatening conditions that can be reversed with early recognition and treatment of thyrotoxicosis. Signs and symptoms of right ventricular dysfunction should be sought in all patients with newly diagnosed thyrotoxicosis, and prompt restoration of euthyroidism is warranted in affected patients before the development of overt right heart failure.Learning points:Thyrotoxicosis is associated with right ventricular dysfunction and pulmonary hypertension apart from left ventricular dysfunction described in typical thyrotoxic cardiomyopathy.Symptoms and signs of right ventricular dysfunction and pulmonary hypertension should be sought in all patients with newly diagnosed thyrotoxicosis.Thyrotoxicosis should be considered in all cases of right ventricular dysfunction or pulmonary hypertension not readily explained by other causes.Prompt restoration of euthyroidism is warranted in patients with thyrotoxicosis complicated by right ventricular dysfunction with or without pulmonary hypertension to allow timely resolution of the abnormal cardiac parameters before development of overt right heart failure.

The clinical characteristics and outcomes of patients with pulmonary hypertension in association with hyperthyroid state: A systematic review

“…She died due to a right temporoparietal infarct with hemorrhagic transformation. [ 32 ] The exact details and the cause of death was not mentioned in the other patient (the patient was a part of a retrospective study with cumulative data). [ 22 ]…”

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

“…Increased cardiac output caused by thyrotoxicity induced high output state also leads to RV failure. 10 Initial management of thyrotoxicosisinduced atrial fibrillation and heart failure can be challenging. In patients presenting acutely, initial measures must be focused on achieving hemodynamic stability.…”

Pulmonary Hypertension and Hypocholesterolemia Secondary to Thyrotoxicosis

“…The association of thyrotoxicosis with right ventricular dysfunction was first reported in the literature in 1973 [ 5 ]. Thyrotoxicosis as a cause for pulmonary hypertension and reduction of pulmonary artery pressure with treatment of antithyroid medication have been clearly established recently [ 6 , 7 ]. Therefore, most clinicians are not aware of this important association.…”