Endocrine Abstracts

Thyrotoxicosis is an uncommon cause of congestive heart failure with depressed ejection fraction. However, when it presented in patients without classical cardiovascular risk factors and high heart rate, that not response to usual therapy, other conditions should be considered.

Case report: A 36-year-old male was admitted to our hospital’s Coronary Critical Care Unit in acute hypertensive pulmonary oedema. He had noted weight loss, palpitations, shortness of breath and abdominal pain during the previous months. Physical exam: temperature (T) was 37.5°C, heart rate (HR) 150 beats per minute (bpm), firm grade II goiter, gynecomastia, bilateral wet rales and inferior limbs oedema. The neurologic examination demonstrated intense fine tremor of hands and proximal muscle weakness. EKG: atrial fibrillation with high ventricular rate response (HR: 165 bpm). Chest X-Ray: cardiothoracic index pulmonary congestion. The initial echocardiogram revealed left ventricular dilatation with an ejection fraction (EF) of 30%. The coronary angiogram was negative for atheromatous lesions. Laboratory: TSH was undetectable. fT3: 25.73 (2.04–4.4) pg/ml, fT4 >7.7 (0.93–1.71) ng/dl, TSI 21.59 (0–1.75) UI/l. Laboratory findings were negative for acute myocardial ischemia. The patient received digoxine, furosemide, nitroglycerine perfusion, 40 mg/24 h thiamazole and 2 mg/6 h dexamethasone at first, and then i.v. propranolol. Initial evolution: 24 hours after initial treatment: HR was 130 bpm, T 36.8°; fT3 6.12, fT4 5.39; 48 hours later: HR was 120 bpm, T 36°; fT3 2.61, fT4 1.94, TSI 17.98. Mild dyspnea. At 4th day: fT3 1.65, fT4 1.12. HR 87 bpm. Endocrinology was consulted and advised total thyroidectomy with previously administration of potassium iodine solution. Total thyroidectomy was performed on day 12. Two months later the patient was asymptomatic, in sinus rhythm, on levothyroxine alone. Five months later, the patient was found to be euthyroid, symptoms were relieved and the echocardiogram findings for left ventricular ejection fraction were drastically improved (EF of 64%). In conclusion, an overt congestive heart failure, with left ventricular dilatation and depressed ventricular ejection fraction, is potencially reversible with restoration of the thyroid state in this case. However, other causes of myocardiopathy should be rule out previously, as coronary artery disease.