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1998 Presentations for the Poster and Vignette Sessions
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THYROTOXIC HEART DISEASE. Mouhammed Rihawi, MD. Sinai Samaritan and St. Luke's Medical Centers, Milwaukee, WI

Heart failure associated with hyperthyroidism is classically characterized by high output heart failure. We would like to present a patient with thyrotoxicosis presenting with pulmonary hypertension and right­sided failure.

A 49­year­old African­American female was well until 1996 when she started to have fatigue, dyspnea, and generalized anxiety. She presented later that year with anasarca.

The physical exam was remarkable for thyromegaly, jugular vein distention, hypatojugular reflux, loud S2, holosystolic murmur and massive edema. Initial labs showed normal CBC and electrolytes, LFT's, renal function, and albumin. Chest x­ray was normal. The TSH level was undetectable; free T4 level was 3.8 (normal range less than 1.4). An echocardiogram showed right ventricular dilitation with severe pulmonary hypertension. In addition there was moderate to severe tricuspid regurgitation, moderate mitral regurgitation, and an estimate left ventricular ejection fraction of forty percent.

The patient was started on diuretics, a beta blocker, and Tapizol. She subsequently received I131 after better control of her initial symptoms. By January she was clinically euthyroid with TSH levels of 1.47. A repeat echocardiogram in February 1998 showed marked improvement in her pulmonary hypertension and right ventricular function.

Discussion: About thirty percent of cases of hyperthyroidism present with thyrotoxic heart disease. The patient's elevated right sided pressure was possible due to increased blood volume and a more rapid venous return. There may also be organic change in pulmonary vasculature due to the hyperdynamic state.

In conclusion, thyrotoxicosis should be considered as a possible cause of pulmonary hypertension and right ventricular failure.

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