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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 276-281

Effect of thyroid dysfunction on left ventricular performance using different echo-Doppler modalities


1 Department of Cardiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
2 Department of Endocrinology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt

Date of Submission28-Apr-2020
Date of Decision14-May-2020
Date of Acceptance19-May-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Inass Hassan Ahmad
Lecturer Endocrinology Department, Faculty of Medicine for Girls, Al-Azhar Univerisity, District Ten, Zahraa Naser City, the Egyptian Army Buildings, Al Mithaq Street, Building 3, Flat 11, 2nd Phase, Cairo, 11528
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_45_20

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  Abstract 


Background Thyroid dysfunction (Thy.D) is one of the commonest endocrinological disorders that increase cardiovascular morbidity and mortality. Echocardiography is a useful, noninvasive, easily accessible, and affordable tool for detection of early cardiovascular changes in patients with thyroid disorders.
Aim To assess the effect of Thy.D on left ventricular (LV) performance using different echo-Doppler modalities.
Patients and methods This study included 60 individuals, divided into three groups: GI: 20 patients (hypothyroidism), GII: 20 patients (hyperthyroidism), and 20 healthy individuals as controls (GIII). All participants underwent history taking, clinical examination, thyroid profile (free triiodothyronine, free tetraiodothyronine, and thyroid-stimulating hormone), conventional echocardiography, tissue Doppler imaging (TDI) velocities averaged from four annular sites (Av-Sa, Av-Ea, and Av-Aa), TDI-derived strain, and two-dimensional-global longitudinal strain (2D-GLS).
Results Despite LV systolic function being preserved in all studied groups, there was a statistically significant reduction in GI and GII compared with GIII (CL), with more reduction in GI (P<0.05). There was a significantly higher Tei-index in patients with Thy.D (P<0.05) by conventional Doppler, with more increase in GI by TDI (P=0.0001). There is a significant lower TDI-strain parameters in both patient groups compared with CL (P<0.01), and regarding 2D-GLS of the LV, there was significant lower LV-GLS in GI and GII, with more significant reduction in GI (P<0.01 and <0.05 respectively). There was a significant increase in E/Ea in both patient groups in comparison with CL, with more increase in GI (P=0.0003 in GI and 0.01 in GII).
Conclusion Thyroid disorders have a significant effect on LV systolic and diastolic functions. TDI (velocities and strain) and 2D-GLS are useful indices for detection of LV functions in patients with Thy.D.

Keywords: echocardiography, left ventricular functions, thyroid dysfunction


How to cite this article:
Hatab AA, Zaki ER, Elmalah AA, Ahmad IH. Effect of thyroid dysfunction on left ventricular performance using different echo-Doppler modalities. Sci J Al-Azhar Med Fac Girls 2020;4:276-81

How to cite this URL:
Hatab AA, Zaki ER, Elmalah AA, Ahmad IH. Effect of thyroid dysfunction on left ventricular performance using different echo-Doppler modalities. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 23];4:276-81. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/276/288282




  Introduction Top


Thyroid diseases are responsible for different alterations in the physiology of cardiovascular system [1].

Hypothyroidism is a condition characterized by failure of thyroid gland to produce sufficient amounts of thyroid hormones to meet the metabolic demands of the body [2].

In hypothyroidism, the abnormalities in cardiac function are impaired left ventricular (LV) diastolic function at rest and LV systolic function on exercise [3].

Hypothyroidism is associated with accelerated atherosclerosis and coronary artery disease. Arterial stiffness may be attributed to diastolic hypertension and impaired endothelial function [4].

Pericardial effusions occur in up to 25% of patients with overt hypothyroidism and are likely owing to increased capillary permeability, volume of distribution of albumin, and impaired lymphatic drainage [5].

Thyrotoxicosis is a clinical condition that results from excess circulating thyroid hormones [6].

Thyrotoxicosis causes a high-output cardiac state characterized by increase in heart rate, cardiac contractility, and cardiac output, with reduction in peripheral systemic vascular resistance (SVR), which then can lead to high-output heart failure [7].

Although unusual, hyperthyroidism can cause low-output heart failure in 6–15% patients. Even in those patients, dilated cardiomyopathy with impaired systolic function is rare [8].

Echocardiography is a useful, noninvasive, easily accessible, and an affordable tool for studying the structure and physiological function of the heart. Assessment of ventricular function, particularly the LV, is one of the commonest and most important applications of echocardiography [9].


  Patients and methods Top


This study is an observational controlled study. It included 60 individuals divided into three groups (each group 20 cases): GI (hypothyroid patients), GII (hyperthyroid patients), and GIII (control group).

The study cases were selected from those coming for follow-up at Endocrinology and Internal Medicine Outpatient Clinics or Departments of Al-Zahraa University Hospital, Faculty of Medicine for Girls, from May to October 2019.

All participants were informed of the purpose of the study, and written consent was obtained in adherence with the guidelines of the ethical committee of AL-Azhar University, Cairo, Egypt.

Exclusion criteria

Patients with thyroid dysfunction (Thy.D) who had a history of diabetes, hyperlipidemia, valvular heart disease, significant arrhythmia, IHD, congenital heart disease, renal failure, and pregnant females were excluded.

Methodology

All groups were subjected to the following: full history, with special emphasis on demographic data, including age and sex, chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitation; thorough clinical examination, including weight, height, and body surface area (BSA); full clinical examination; blood pressure measurement; and 12-lead-ECG to detect the electrical effect of hypothyroidism and hyperthyroidism, either brady- or tachy-arrhythmias.

Laboratory investigation

Thyroid profile, thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and free tetraiodothyronine (FT4), complete blood count, lipid profile, and renal functions were performed for all participants.

Echo-Doppler evaluation

Trans-thoracic echocardiographic examination was performed for all cases at the Cardiology Department, Al-Zahraa University Hospital, using Vived-9GE System (Vivid-9GE General Electric Health Care Schenectady, New York, United States), with matrix probe M3S multi frequency 2.5 MHz, having the capability of tissue Doppler imaging (TDI) and gray scale recording for speckle tracking study.

All measurements were done by a staff cardiologist over at least three cardiac cycles, and the average value for each parameter was calculated. Comprehensive trans-thoracic echocardiographic M-mode, 2D, and Doppler (pulsed, continuous, color flow mapping, and TDI) in the standard views from all accessible windows were obtained with displayed ECG physiosignals. The loops of three cycles were recorded and digitally stored for later offline analysis either automatically or manually when needed at GE echoPAC GE, version 110-1-3.

All echo-Doppler measures were obtained according to guidelines and standards recommended for cardiac chamber quantification by echo in adults [10].

Conventional measurements included LV end diastolic and systolic dimensions, end diastolic interventricular septal thickness, LV posterior wall thickness, relative wall thickness, LV-mass index (LVMI), transmitral valve early and late diastolic velocity (MV-E vel and MV-A vel), MV-E/A ratio, and Tei-index.

The LV-mass was calculated using Troy’s formula by estimation of LV internal dimensions and wall thickness at end-diastole as in the following equation [11]:

.



LVMI was calculated by dividing LV mass/BSA, using Mosteller’s formula [12],[13]:



The TDI was obtained from apical 4-chamber and 2-chamber views. For data acquisition, three complete cardiac cycles were recorded and stored in acine loop format. The image sector width was set as narrow as possible to allow a frame rate acquisition greater than 90 frames/s. TDI systolic and early and late diastolic velocities were obtained from four annular sites (inferoseptal, lateral, inferior, and anterior) and average values from these sites were calculated (Av-Sa, Av-Ea, and Av-Aa). Likewise average Av-Ea/Av-Aa ratio and MV-E/Av-Ea ratio were calculated.

The LV two-dimensional-global longitudinal strain (2D-GLS) was assessed with QRS onset as the reference point, applying a commercially available strain software package to the LV. Images were acquired at 70–90 frames/s at end expiration in the apical 4-chamber, 3-chamber, and 2-chamber views. A point-and-click approach was used to identify three-anchor points (two basal and one apical), following which the software automatically tracked endocardial contour with manual adjustment when needed.

Statistical analysis

The study cases were grouped into three groups. Data were collected and statistically analyzed. They were expressed as mean±SD and were statistically analyzed to see the association of various variables using Microsoft excel, version 2010. Differences between groups were analyzed with paired t test. P value less than 0.05 was considered to be significant.


  Results Top


Our study included 60 individuals divided into three groups: GI (20 hypothyroid patients), GII (20 hyperthyroid patients), and GIII (20 CL).

Our study revealed no statistically significant differences between each group and CL regarding age, weight, height, and BSA.

Our study showed female predominance in GI and GII, which included 17 (85%) females and three (15%) males, and GIII included 14(70%) females and six (30%) males (P=NS).

There was a statistically significant increase in diastolic blood pressure (DBP) in GI compared with GIII and GII (P=0.003 and P<0.0001, respectively) and significant decrease in DBP in GII compared with GIII (P=0.01).

There was a statistically significant increase in TSH in GI compared with GIII (P<0.05), with significant decrease in FT3 and FT4 (P<0.001 and 0.01, respectively).

However, GII showed statistically significant increase in FT3 and FT4 than GI and GIII (P<0.01 for all), with lower TSH (P=0.01 and P<0.0001, respectively), which is shown in [Table 1].
Table 1 Baseline demographic and laboratory data in studied groups with significance level of difference between each two groups

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According to the echocardiographic data, which are shown in [Table 2], there were no statistically significant differences between patients with Thy-D (GI and GII) compared with GIII or between GI and GII in parameters of LV thickness (interventricular septum dimension, LV posterior wall thickness, LVMI, and relative wall thickness).
Table 2 Baseline left ventricular echocardiographic parameters in studied groups with significance level of difference, between each two groups

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There were statistically significant increases in LV end systolic dimension in patient groups (GI and GII) compared with GIII (P=0.01), whereas it did not show any significant difference between GI and GII.

The LV end diastolic dimension was statistically significantly increased in GII compared with GIII (P=0.01), with no difference between GI compared with GII or GIII.

Despite the LV systolic function being preserved in all studied groups, there was a statistically significant reduction in GI and GII compared with GIII in EF% (M-mode and 2D), with more significant reduction in GI (P<0.05), whereas there was no significant difference between GI and GII.

Pulsed Doppler parameters showed a statistically significant increase in MV-A vel between Thy.D cases an GIII (P<0.01), with no significant difference between GI and GII.

However, MV-E vel or E/A ratio failed to show statistically significant difference in any of the study group compared with GIII. The Av-Ea was significantly lower in GI compared with GIII (P<0.01), with no difference either between GII and CL or between GI and GII.

The Av-Aa was statistically significant higher in GII compared with GI and GIII (P<0.01 in both), whereas there was no significant difference between GI and GIII.

There was no statistically significant difference between GI and GII as well as between GI and GIII regarding Av-Ea/ Aa, but GII showed a significantly lower value than GIII (P<0.01).

MV-E/Av-Ea was statistically significantly higher in both GI and GII compared with GIII, with more increase in GI (P=0.0003 and 0.01, respectively), with no difference between GI and GII.

LV Tei-index was significantly higher in both GI and GII compared with GIII, also GI was significantly more higher by TDI than GII and GIII (P<0.05 in Thy.D cases by conventional Doppler, P<0.0001 in GI, and P=0.002 in GII by TDI in comparison with control group).

There is a significant reduction in Av-Sa in GI compared with both GIII (P<0.0001) and GII (P<0.001), with no significant difference between GII and CL.

There was a reduction of TDI strain in both GI and GII compared with GIII (P<0.01), with no significant difference between groups GI and GII.

2D-GLS was significantly lower in patients with Thy.D compared with GIII, with more reduction in GI (P<0.01 and 0.05, respectively), with no significant difference between GI and GII.


  Discussion Top


Thyroid disorders (hypothyroidism or hyperthyroidism) are associated with clinically significant cardiovascular abnormalities. They are responsible for different alterations in the physiology of cardiovascular system causing LV dysfunction; therefore, echocardiography should be a part of the screening in patients with Thy.D.

This study includes 20 healthy individuals and 40 patients with thyroid disorders (20 hypothyroidism and 20 hyperthyroidism).

The current study showed that Thy.D cases had female predominance (85%), which coincides with Bal et al. [14], who also found female preponderance (76% in hypothyroid group and 83% in hyperthyroid group), suggesting the disease being more common in female population.

Our study showed that DBP was affected than systolic blood pressure (SBP), which was higher in hypothyroid patients and lower in hyperthyroid patients than CL. This has been explained in a study which demonstrated that endothelial dysfunction occurring in hypothyroidism causes impairment in smooth muscle relaxation, leading to increased SVR in contrast to hyperthyroidism, where SVR is decreased due to increased basal metabolic rate and metabolic demands [15].

Our study revealed no statistically significant difference between patients with Thy-D (GI and GII) and CL or between GI and GII in parameters of LV thickness, which were concordant with the results of studies that found no significant effect of hypothyroidism or hyperthyroidism on LV wall thickness when compared with controls [16],[17].

In our study, patients with Thy.D showed impaired parameters of LV systolic function in comparison with CL. This agreed with the study that revealed 26.9% of hypothyroid cases with reduced EF% [16]. Abdulrahman et al., 2010 [18], revealed significant reduction in LVEF in hyperthyroid cases.

Tei-index in Thy.D had a significant higher value than CL, which is an indicator of impaired LV systolic function. Moreover, Begum et al. [19], found significantly increased Tei-index in patients with thyroid carcinoma compared with control, and LV-Tei-index by TDI was significantly elevated in Hashimoto’s thyroiditis in the study by Vatan et al. [20], because of a prolongation of IVRT and ET shortening.

Doin et al. [21], used conventional Doppler in patients with central hypothyroidism and found that Tei-index was significantly higher in patients than in controls.

Av-Sa velocity is significantly impaired in hypothyroid patients than GIII, whereas hyperthyroidism showed no significant difference from GIII, as tachycardia induced by hyperthyroidism may cause false increase in Sa, which is concordant with Nakova et al. [22], who found lower Sa in hypothyroid group compared with controls.

Kiris et al. [23], revealed that there was no significant difference between overt hyperthyroid patients and controls regarding Sa.

In patients with Thy.D, TDI strain is a useful echocardiographic parameter in assessment of LV systolic function. However, no recent studies have used this parameter.

Many studies nowadays have concluded that 2D-GLS should be incorporated into the group of techniques that evaluate LV function [24], which was significantly lower in patients groups compared to GIII in our results. This is concordant with a study that showed 2D-GLS in hypothyroid patients and GIII group was within normal range but still significantly lower in hypothyroid patients [22]. Abdulrahman et al. [18], found 2D-GLS in subclinical hyperthyroidism was significantly lower than GIII.

Diastolic dysfunction caused by Thy.D interferes with LV performance. It refers to abnormalities in mechanical properties of the heart (decreased diastolic dispensability, slowed filling, or relaxation) regardless of patient symptoms [25].

In the current study, conventional Doppler could not clearly highlight the presence of LVDD, but TDI was impaired compared with GIII, because conventional Doppler is very load dependent and can change dramatically owing to small alterations in heart rate or ventricular preload [26].

Moreover, hypothyroid patients showed significantly raised E/Ea as compared with controls in the study by Sunita et al. [27], and Vatan et al., 2016 [20], who found that hyperthyroid patients showed significantly higher E/Ea as compared with controls.

Limitations of the study

The study was limited by a small number of patients included. Studies with higher sample size would confirm our findings regarding impairment of LV functions in patients with Thy.D.


  Conclusion Top


Thyroid disorders have significant effect on LV systolic and diastolic functions, which were more pronounced in hypothyroid patients. TDI (velocities and strain) and 2D-GLS are useful indices for detection of LV functions in patients with Thy.D.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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