Can thyroid break your heart? Role of thyroid in Takotsubo cardiomyopathy: A single center retrospective study

Takotsubo cardiomyopathy as the primary manifestation of decompensated Graves' disease

Takotsubo cardiomyopathy (TCM) is characterized by transient left ventricular dysfunction with apical ballooning, usually observed in postmenopausal women after a stressful event. We discuss a rare presentation of TCM induced by thyrotoxicosis secondary to Graves' disease. This case raises interesting questions about the pathogenesis, diagnosis, and management of TCM.

Learning objectives

1. To recognize hyperthyroidism as a possible etiology of takutsubo cardiomyopathy.2. To identify the effect of radioiodine contrast on diagnosis of some types of takutsubo cardiomyopathy.

The association between Takotsubo cardiomyopathy and thyrotoxicosis: A systematic review

PURPOSE

This study aims to review all published cases on the association between thyrotoxicosis and Takutsubo Syndrome by describing clinical characteristics, diagnostic work-up, treatment, and outcome.

METHODS

We searched PubMed and Embase databases from inception to the 17th of February 2022 for case reports or series reporting the above-mentioned association. We extracted data on demographic characteristics, clinical features, diagnostic work-up, treatment, and clinical outcomes. Cases were stratified into groups based on the presumed cause of the thyrotoxicosis (iatrogenic vs non-iatrogenic and Graves' diseases vs non-Graves' disease, respectively).

RESULTS

We identified 25 cases from 24 articles. The mean age was 61.7 years (+/- SD 14.5). Most patients were women (88%). Graves' disease (52%) was the leading cause of thyrotoxicosis. Previous cancer was significantly more common in patients with iatrogenic thyrotoxicosis (P = 0.03). The most common symptoms were respiratory symptoms (68%), chest pain (56%), and palpitations (40%). The most common ECG characteristics were T-wave abnormalities (48%) and ST-elevations (36%). Elevated troponin levels were found in 92% of the cases. Patients with Graves's disease and Takutsubo Syndrome had higher plasma levels of serum thyroxine (P = 0.03) and were more often treated with beta-blockers (P = 0.01) compared to patients with thyrotoxicosis of other origins. Notably, 40% of cases experienced in-hospital complications. No deaths were reported. All patients had improved cardiac function within a median follow-up of 42 days.

CONCLUSION

Evidence-based on current case reports suggests an increased risk of Takutsubo Syndrome and subsequently increased risk of in-hospital complications in patients with thyrotoxicosis.

Takotsubo Cardiomyopathy in the Setting of Myxedema Coma

Myxedema coma and its treatment are potent physical stressors that likely predispose patients to develop Takotsubo cardiomyopathy (TCM). We postulate a multifactorial pathophysiology for TCM that includes a mechanism involving catecholamine-induced potentiation of cardiac adrenoreceptors during thyroid hormone replacement in the setting of severe hypothyroidism. Furthermore, TCM can be difficult to anticipate when presenting as a complication of another diagnosis. In this case report, we aim to improve awareness of TCM as a consequence of extreme hypothyroid states.

The Role of Thyroid Diseases and their Medications in Cardiovascular Disorders: A Review of the Literature

The association between thyroid disease and cardiovascular manifestations is significant and undeniable. Previous studies have explained several aspects of the effects of thyroid hormone on the heart and cardiovascular system. Accordingly, both hyper and hypothyroidism can cause important alterations in cardiac rhythm, output and contractility as well as vascular resistance and blood pressure. Since treating the thyroid abnormality, especially in its initial stages, could lead to a significant improvement in most of its resultant cardiovascular disturbances, early suspicion and recognition of thyroid dysfunction, is necessary in patients with cardiovascular manifestations. In this in-depth review, we discuss the physiological roles as well as the effects of abnormal levels of thyroid hormones on the cardiovascular system. We also review the effects of the medications used for the treatment of hyper and hypothyroidism on cardiac function. In the end, we discuss the association between thyroid function and amiodarone, an effective and frequently-used antiarrhythmic drug, because of its well-known effects on the thyroid.

Frequently Recurrent Takotsubo Syndrome in COPD

Cardiovascular disease is common among patients with chronic obstructive pulmonary disease (COPD). Takotsubo syndrome (TTS) is a transient cardiac disorder that, in its typical form, involves left ventricular dysfunction with apical ballooning and mimics acute coronary syndrome (ACS). “Bronchogenic TTS” has been proposed as a specific form of TTS (during severe acute dyspnea in asthma or COPD) with atypical presentation. Recurrent TTS in COPD seems to be exceptionally rare since only a handful of clinical cases have previously been reported in the literature. Here, we present a unique case of a frequently recurrent TTS during COPD exacerbation in a 70-year-old woman, with at least 4 different episodes of TTS within 5 years. This case report exemplifies the difficulties of the diagnosis of TTS at the onset of acute COPD exacerbation. Potential pathophysiological mechanisms and therapeutic strategies are also briefly discussed.

Regadenoson cardiac stress test-induced stress cardiomyopathy

Takotsubo cardiomyopathy, also described as apical ballooning syndrome/stress-induced cardiomyopathy, imitates acute coronary syndrome and is usually related to a massive physiological or emotional stressor. We describe perhaps the first reported case to the best of our knowledge of a 55-year-old Caucasian woman who presented with congestive heart failure after having a regadenoson cardiac stress test a few hours prior to presentation to the hospital. Transthoracic echocardiogram revealed reduced heart function. She had normal coronaries on cardiac catheterisation, and left ventriculography confirmed apical ballooning syndrome. She underwent guideline-directed therapy, and heart function improved in the repeat echocardiogram along with clinical resolution of symptoms.

Takotsubo Myocardiopathy and Hyperthyroidism: A Case Report and Literature Review

Patient: Male, 34

Final Diagnosis: Takotsubo myocardiopathy and hyperthyroidism

Symptoms: Chest pain • dyspnea

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Takotsubo cardiomyopathy in amiodarone-induced hyperthyroidism

Summary

Takotsubo cardiomyopathy (TC) is an atypical, severe but reversible form of acute heart insufficiency. It typically presents with left ventricular failure, transient apical and mid-segments hypokinesis, absence of significant coronary stenosis and new electrographic abnormalities and/or elevation in serum cardiac enzymes. Although TC (‘broken heart syndrome’) has classically been associated with emotional trauma, evidence suggests that other precipitants might exist, including iatrogenic and thyroid-mediated forms. Thyroid disease is a relatively common comorbidity in TC patients. We report a case of TC in a postmenopausal female with no history of emotional trauma or other potential precipitant factors who was diagnosed with amiodarone-induced hyperthyroidism during her hospital stay. Though some case reports of thyroid-related TC exist, we are not aware of any other reported case of TC precipitated by amiodarone-induced hyperthyroidism.

Learning points:

Stress cardiomyopathy (Takotsubo) following radioactive iodine therapy

Summary

A 55-year-old female patient presented to the endocrine clinic with Grave's disease. She was initially treated with carbimazole. After an early relapse, a decision was made to proceed with radioactive iodine therapy. Four days after radioiodine administration, she presented to the emergency department with chest tightness and dyspnea due to heart failure. Biochemistry revealed thyrotoxicosis and significantly elevated Troponin-T. There was ST segment elevation on electrocardiography. However, coronary angiography was normal. Ventricular function was fully restored after 6 weeks of supportive medical management. A diagnosis of stress cardiomyopathy following radioactive iodine therapy was made. This is the second case reported in the literature so far to the best of our knowledge.

Learning Points

Stress cardiomyopathy in the context of radiation thyroiditis is a rare complication following radioiodine therapy. A degree of awareness is essential because the approach is multidisciplinary. Management is mainly supportive and cardiac dysfunction is completely reversible in most cases. The pathogenesis of this condition remains unclear. Post-menopausal women and susceptible individuals appear to be pre-disposed.