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Dysfunction as Comorbid in
Cardiovascular Disease
By: dr. Fikri
• Introduction
• Aim
• Case Illustration
• Discussion
• Conclusion
2
Introduction
Klein I, Danzi S. Thyroid Disease and The Heart. Curr Prob Cardiol. 2015(146): 1-28. 3
Introduction
• Danish national registries
• 563,700 residents at least 18 years old who had thyroid
function tests run between 2000 and 2009.
6
Case Discussion
7
Case Illustration
CASE 1 CASE 2
Mrs. AW, 53 years. Mr. AD, 46 years.
Chief Compliant: Chief Compliant:
• DOE, OP, PND since 3 • Chest pain since 1 day ago
days ago . • DOE, PND suffered since 1
• Risk Factor: HT, DM, year ago
menopause. • Risk Factor: HT, smoker.
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Case Illustration
CASE 1 CASE 2
Mrs. AW, 53 years. Mr. AD, 46 years.
1. CHF ec HHD 1. Acute coronary syndrome
2. Mitral 2. CHF ec HHD
Regurgitation
3. AF RVR
3. Diabetes Mellitus
type II
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Physical Examination
CASE 1 CASE 2
• BP: 151/122 HR: 77 x/m • BP: 160/92 HR: 125 x/m
regular RR: 24 x/m SpO2 irregular RR: 22 x/m SpO2
98% 98%
• JVP 5 + 3 cm H2 0 • JVP 5 + 2 cm H2 0
• Rales 1/3 base bilateral • Rales minimal
• S1-2 regular, PSM 3/6 apex • S1-2 regular
• Hepatomegaly • Warm extremity
• Pitting edema+/+
Bothextremity
• Warm this case shows characteristic of heart failure
10
ECG CASE 1
• CTR 65%, normal segmen aorta&pulmonal, • CTR 70%, normal segmen aorta&pulmonal,
cardiac waist (+), apex lateral downward, cardiac waist (-), apex lateral downward,
sign of congestion (+), infiltrate (-). sign of congestion (+), infiltrate (-). 13
Laboratory
CASE 1 CASE 2
Hb 11,3 gr/dl Hb 14,4 gr/dl
Ht 34 % Ht 43,4 %
Leuko 4380 /uL Leuko 7260 /uL
Trombo 169.000 Trombo 244.000
CRP 6, LED 42
INR 1,16
GDS= 467 mg/dl Keton 0,3
CKMB 36 HsTrop T 40
OSM 298,25
Ur 31,9 Cr 0,44 CCT 116 Ur 26,5 Cr 0,85 eGFR 93
Na 130 K 3,5 Cl 94 GDS 151
Ca T Mg 1,5 Na 139 K 3,9 Cl 103 Ca T 2,25
14
Mg 2,0
Previously Drugs
CASE 1 CASE 2
Case 1 Case 2
EDD 48 EDD 55 mm
ESD 26 ESD 47 mm
EF 69% EF 45%
TAPSE 2 cm TAPSE 1,8 cm
Global normokinetik E/A >2, fusi (AF)
Katup mitral regurgitasi Hipokinetik anteroseptal
severe, TR mild
IVC 23/18
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Case I Asses Thyroid function
700
TSH <0,065
fT4: 7,54
600
561 mg/dl Hyperthyroidism
524 mg/dl
Blood Sugar
500
Well Controlled
400 Blood Sugar 3 days
after PTU drug
300 256 mg/dl 481 mg/dl started
200
0
98 mg/dl
27-Jun 28-Jun 29-Jun 30-Jun 1-Jul 2-Jul 3-Jul 4-Jul 5-Jul 6-Jul 7-Jul 8-Jul 9-Jul
EMG
90 bpm
AF RVR
CVC
60 bpm
AF RVR
WARD
AF NVR
Day1 Day2 Day 3-5
18
Physiology of Thyroid Hormone
Hypotalamus
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Guyton AC, Hall JE (ed). Textbook of medical physiology 11th ed. Philadelphia. 2006
Effects of Thyroid Hormones on Cardiomyocyte
Thyroid Activity:
1. Genomic: simpathetic
overdrive
2. Non-genomic :
activation T4 into T3
Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007; 116:1725-35 20
Effects of Thyroid Hormones on
Cardiovascular Hemodynamics
Increased Tissue Decreased Systemic
Thermogenesis Vascular Resistance
Decreased Effective
Arterial Filling Volume
TriiodoThyronine (T3)
Increased Renal
Sodium
Reabsorption
Martinez F et al. Thyroid hormones and heart failure. Heart Fail Rev. 2016:1-4.
23
Klein I, Danzi S et al. Thyroid disease and the heart. Circulation. 2007;116(15):1725-35.
Hyperthyroidism & Atrial Fibrillation
24
ESC Guidelines for management of atrial fibrillation. 2016
25
ESC Guidelines for management of atrial fibrillation. 2010
January CT et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
26
Hyperthyroid dan Atrial Fibrillation
Optimal management
27
ESC guidelines 2016. atrial fibrilation
ESC Guideline on HF
Voors A, Anker D, Bueno H, et al. 2016 Guideline on Acute and Chronic Heart Failure. European Society of
Cardiology.
28
Research Thyroid and ACS
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation 30
Thyroid and Diabetes Control
Wang C et al. The Relationship between Type 2 Diabetes Mellitus. J Diabetes Res.
2013;2013:1-9. doi:10.1155/2013/390534 31
Hyperthyroid Effect in Glucose Control
Biguanides,
ex: Metformin
Wang C et al. The Relationship between Type 2 Diabetes Mellitus. J Diabetes Res. 2013;2013:1-9. doi:10.1155/2013/390534
33
Hyperthyroidism Algorithm
Normal Value
TSH = 0.270 - 4.200 uIU/mL
fT4 = 0.93 - 1.70 ng/dL
Vargas-Urichoecha H, Bonelo-Perdomo A, Sierra-Torres CA. Effects of thyroid hormones on the heart. Clin Invest Arterioscl. 2014;26(6):296---309
35
Douglas R, Burch B, Cooper D. Guideline for Diagnosis and Treatment of Hyperthyroidism. American Throid Association. 20016(26(:1343-1418)
Resume
36
Take home message
37
THANK YOU
38