source: Journal of the American College of Cardiology

year: 2018

authors: Gloria Ayuba, Ifeoma Ugonabo, Steven Werns

Background:
Heart failure is typically seen in patients with hyperthyroidism because of longstanding untreated disease with or without concomitant atrial fibrillation with rapid ventricular rates at an average reported age of 66 years. Approximately 6% of hyperthyroid patients have left heart failure but isolated right heart failure with associated pulmonary hypertension is not commonly seen in hyperthyroidism.

Case:
We describe a case of a 27-year-old female, who presented to the hospital with worsening lower extremity edema, palpitations and increased abdominal girth. Her physical exam was notable for tachycardia at a rate of 111 bpm, thyromegaly with an associated bruit, exophthalmos, elevated JVP, and abdominal distension with shifting dullness on percussion. ECG showed sinus tachycardia. Her TSH was low at 0.03 uIU/ml, her free T4 was elevated at 5.68 ng/dL, and her thyroglobulin (75.8 ng/ml), antithyroglobulin antibody (179 IU/ml) and thyroid peroxidase auto antibody (> 1000 IU/ml) levels were elevated, consistent with a diagnosis of Graves disease. Her CXR showed no evidence of pulmonary vascular congestion. Her 2D Echocardiogram showed normal left ventricular systolic and diastolic function with an estimated ejection fraction of 57%, mildly dilated right ventricle, dilated IVC with < 50% collapse with inspiration, with an estimated right ventricular systolic pressure (RVSP) of 56 mmHg.

Decision-making:
She was started on propranolol 40 mg TID, Lasix 40 mg QD and methimazole 20 mg BID and subsequently she underwent radioactive iodine I-131 therapy. A follow up 2D echocardiogram 9 months later which showed normalization of right ventricular dilatation and pulmonary pressure with an estimated right ventricular systolic pressure of 24 mmHg and resolution of her right heart failure physical findings. Her thyroid function test at the time her echo was repeated showed a slightly reduced TSH of 0.20 uIU/ml and free T4 0.20 ng/dL.

Conclusion:
This case highlights the infrequent presentation of pulmonary hypertension and clinical right heart failure in Graves disease and the successful management of this heart failure with treatment of the underlying thyroid disease.

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