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ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 185-189  

Risk of cardiovascular changes in hypothyroidism in North-west Punjab population


1 Centre for Interdisciplinary Biomedical Research, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
2 Department of Biochemistry, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
3 Department of Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Date of Submission19-Nov-2019
Date of Decision05-Jan-2020
Date of Acceptance11-Mar-2020
Date of Web Publication05-Feb-2021

Correspondence Address:
Rajinderjit Singh Ahi
Department of Biochemistry, Adesh Institute of Medical Sciences and Research, Adesh University, Buchu Kalan, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_314_19

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  Abstract 


Background: This study was done with an objective to study the cardiovascular involvement associated with newly detected overt and subclinical hypothyroidism. Methods: A total number of 150 newly detected hypothyroid patients, diagnosed by the clinical evaluation, confirmed by thyroid hormone assay, were subjected to electrocardiograph and echocardiography. It was a cross-sectional study design based on the random sampling method, which was conducted for 2 years in the Central Laboratory of Adesh Institute of Medical Sciences and Research and Center for Interdisciplinary Biomedical Research, Adesh University. Results: Of 150 patients studied, 62 were overt hypothyroid and 88 were subclinical hypothyroid. Forty-one were male and 109 were female. Hypothyroidism was newly diagnosed more in females and maximum in the age group of 41–70 years (69.9%). Of 150 patients, 63.3% had symptoms <2-month duration. Cardiovascular symptoms were present in 68.0% of patients. Bradycardia was observed in 44.0% of patients. Stage 1 hypertension was noticed in 30.7% (systolic high blood pressure). Low-voltage complexes in electrocardiogram (ECG) were present in 34.0% study group. Pericardial effusion was present in 32.7% of patients. Diastolic dysfunction was noticed in 20.0% study group. Altered lipid profile was present in 74.0% (total cholesterol) and 65.3% (total triglycerides). Conclusions: Hypothyroidism is common in female, maximum between the age group of 17 and 47 years. Majority of the patients have cardiovascular changes such as ECG abnormalities, pericardial effusion, diastolic hypertension, and diastolic dysfunction. Systematic study was done to know the early effects of hypothyroidism on cardiovascular system. The identification of patients with hypothyroidism is an important individual as well as public health issue. Hence, early detection and initiation of hormone replacement therapy can minimize the associated cardiovascular changes.

Keywords: Cardiovascular, hypothyroidism, overt and subclinical hypothyroidism


How to cite this article:
Jagota G, Ahi RS, Singh R, Singh S. Risk of cardiovascular changes in hypothyroidism in North-west Punjab population. Med J DY Patil Vidyapeeth 2021;14:185-9

How to cite this URL:
Jagota G, Ahi RS, Singh R, Singh S. Risk of cardiovascular changes in hypothyroidism in North-west Punjab population. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 12];14:185-9. Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/185/308719




  Introduction Top


Hypothyroidism is the most common functional disorder of the thyroid gland.[1] It is due to decreased secretion of thyroid hormones or impaired activity of tissue due to thyroid gland failure or disorder of the pituitary gland or hypothalamus.[2]

Overt hypothyroidism is defined as elevated serum thyrotropin (thyroid-stimulating hormone [TSH]) concentration and serum T4 (free thyroxine) below the reference range, while subclinical hypothyroidism is defined as an elevated serum TSH value associated with a serum-free T4 within the reference range.[3]

Thyroid hormones have cellular effects on almost all tissues of the body which causes multiorgan dysfunction.[4],[5],[6] Cardiovascular complications are some of the most profound and reproducible clinical findings associated with thyroid disease.[7] Hypothyroidism is associated with increased cardiovascular mortality and morbidity. The dysfunction ranges from functional systolic/diastolic dysfunction to overt failure.[8] A systematic study was done to know the early effects of both overt and subclinical hypothyroidism on the cardiovascular system. The identification of patients with both overt and subclinical hypothyroidism is an important individual and public health issue which can minimize the associated cardiovascular changes.[9],[10]

Hence, this study was done with an objective to study the cardiovascular involvement associated with newly detected overt and subclinical hypothyroidism.

This study was done with an objective to study the cardiovascular involvement associated with newly detected overt and subclinical hypothyroidism.


  Methods Top


It was a cross-sectional study design based on the random sampling method, which was conducted for 2 years in the Central Laboratory of Adesh Institute of Medical Sciences and Research, and Centre for Interdisciplinary Biomedical Research, Adesh University. This study was conducted after taking institutional ethical clearance from the Ethics Committee of Adesh University, Bathinda (Ref. no.: AU/EC/FM/41/2018, dated January 20th, 2018) and informed consent of the patients. The study population was diagnosed by clinical evaluation and confirmed by thyroid hormone assay reference ranges TSH (0.39–5.50 μIU/ml), total T4 (4.5–10.9 μg/dl), and total T3 (0.60–1.80 ng/dl). Patients with TSH >20 μIU/ml and low total T4 were considered overt hypothyroidism, and TSH ranging (4.2–20 μIU/ml) were considered subclinical hypothyroidism.

Inclusion criteria

All patients of newly detected hypothyroidism diagnosed by clinical evaluation and confirmed by serum TSH, T4, and T3 level.

Exclusion criteria

Hypothyroid patients who were already on treatment; patients on antihypertensives, steroids, glucocorticoids, antineoplastic drugs, nonsteroidal anti-inflammatory drugs; and patients with other diseases such as diabetes, pernicious anemia, collagen disorders, cardiac diseases, and other endocrine disorders, moreover, pregnant women were also excluded from the study.

Investigations

The following investigations were done to diagnose hypothyroidism and cardiac profile: random blood sugar, serum T3, T4, TSH, lipid profile, electrocardiogram (ECG), and two-dimensional (2D) echocardiogram (Echo).

Statistics

The analysis of the data was made on the basis of measures of central tendency, dispersion and graphical representation of the data, mean deviation, standard error, and Chi-square test. P < 0.05 was considered statistically significant.


  Results Top


Of 150 patients studied, 62 (41.3%) were overt hypothyroid and 88 (58.7%) were subclinical hypothyroid. Forty-one were male and 109 were female. Hypothyroidism was newly diagnosed more in females and maximum in the age group of 41–70 years.

Cardiovascular symptoms were seen in 98 (65.3%) patients, which include effort intolerance in 98 (65.3%), chest pain 43 (28.7%), breathlessness 57 (38.0%), and palpitation in 68 (45.3%) patients each [Table 1].
Table 1: Cardiovascular symptoms in the study group

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Prehypertension (systolic) was present in 28 males and 38 females which constituted 66 (44.0%) of the total population. Stage 1 systolic hypertension is present in 36 (24.0%) and Stage 2 systolic hypertension is present in 14 (9.3%) [Table 2].
Table 2: Prevalence of systolic hypertension (JNC 7 criteria)

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Prehypertension (diastolic) was present in 24 males and 89 females which constituted 75.3% of the total population. Similarly, Stage 1 diastolic hypertension was present in 13.3% of the study group and Stage 2 diastolic hypertension was present in 4.7% of the study group [Table 3].
Table 3: Prevalence of diastolic hypertension (JNC 7 criteria)

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Lipid profile in this study revealed 111 (74.0%) of patients had high serum total cholesterol. Ninety-eight (65.3%) had high serum triglyceride, 36 (24.0) had higher low-density lipoproteins, lower high-density lipoproteins in 65.3% patients, and higher very low-density lipoproteins in 58.0% [Table 4].
Table 4: Lipid changes in the study population

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In this study, low voltage complexes in ECG were found in 24 (60%) of patients, of which 6 (10%) were male and 18 (30%) were female. Similarly, 15% of males had T-inversion in V3–V6 leads [Table 5].
Table 5: Electrocardiogram changes in the study population

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ECG findings were normal in 43.3% of patients. Bradycardia was commonly seen in 44.0%, ST segment changes in 36.0%, low-voltage complexes in 34.0% patients, and T-wave (flat/inverted) in 31.3% patients.

2D Echo findings were normal in 33% of cases. Diastolic dysfunction and pericardial effusion were found in 16 (26.6%) cases followed diastolic dysfunction in 16 (26.6%), systolic dysfunction in 4 (6.6%), and increased interventricular septum spectrum thickness 4 (6.6%) cases. Majority of the diastolic dysfunction were mild dysfunction. No cases found to have severe diastolic dysfunction [Table 6].
Table 6: Echocardiographic changes in the study population

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  Discussion Top


This study included 150 newly detected patients with hypothyroid. The patient's age range was 20–70 years in the study. Most patients belonged to the age group of 31–70 years. Overall, there was a female preponderance over the age of 31–70 years. The female population constituted about 72.7% of the total, that is, female: male ratio 3:1.

On general examination, the commonly found symptoms were easy fatigability 56.9% in males and 63.2% in females; weight gain 54.5% in males and 45.3% in females; aches and pain 53.1% in males and 32.8% females; menorrhagia 43.1% in females, dry skin in 22.0% in males and 36.3% in females; intolerance too cold around 31.3% in males and 42.7% in females; swelling of limbs in 39.2% in males and 32.1% in females; puffiness of face in 26.7% in males and 26.9% in females; chest pain 24.9% in males and 30.0% in females; and breathlessness 17.7% in males and 20.0% in females. These results were similar as compared to the results of Shashi and Watanakunakorn.[20],[21],[22]

On general examination, the general signs include body mass index >25 kg/m2 in 73.2% males and 56.0% females, thyromegaly seen in 30% of females, delayed ankle jerk in 14.6% males and 27.5% females, and lower limb edema in 29.3% males and 47.7% females.

In our study, diastolic dysfunction was seen in 18%, but in a study by Verma, it was seen that 27% of patients had diastolic dysfunction.[17] Systolic dysfunction was seen in 33.3% of patients, but Forfar et al.[16] and others have described low systolic function indices in hypothyroid patients; however, Fouron et al., Grossman et al., and Verma et al. did not find any evidence of systolic dysfunction in hypothyroid patients.[17],[19],[24],[25] Rawat and Satyal showed no systolic dysfunction.[9] Zoncu et al. found impairment in both systolic and diastolic function in subclinical hypothyroidism.[18]

In this study, there is an increase in the levels of total cholesterol, low-density lipoprotein, very low-density lipoprotein, and triglycerides and decrease in the levels of high-density lipoprotein. Alka et al. Shende et al. and Williams's Textbook of Endocrinology showed increase of total cholesterol. [26, 2, 23]

In ECG changes, bradycardia was present in 44%, low-voltage complexes in 34%, followed by “T”-wave (flat/inverted) changes 31.3%, and ST segment changes in 36.0%. This finding is not consistent with other studies by Varma et al. Nikoo also documented sinus tachycardia, QT prolongation, and ventricular tachycardia, which was not found in our study.[14],[15]

In 2D echo changes, left ventricular diastolic dysfunction was abnormal in 17.3%, pericardial effusion in 32.7%, LWH in 25.4%, RWMA in 7.4%, and ejection fraction (<50%) in 34.7%. This finding is consistent with other studies of Verma et al. that showed the prevalence of effusion to be 22.75%.[14] Pericardial effusion is reported to occur in 30%–80% of patients with hypothyroidism Rawat and Satyal.[8] Some studies show a relatively low incidence of pericardial effusion, which may be due to the selection of new hypothyroid.[13],[11],[12]

In this study, major manifestations were dyslipidemia, systolic and diastolic hypertension, ECG changes [Table 7], and ECHO changes. There was a statistically significant association between degrees of hypothyroidism and all these manifestations.
Table 7: Overall cardiovascular involvement in hypothyroidism

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  Conclusions Top


Cardiovascular symptoms and signs were present in hypothyroid patients. Hence, a high index of suspicion is the key to the early diagnosis of hypothyroidism. Cardiovascular disease is highly associated with newly detected hypothyroidism. The occurrence of cardiovascular disease in hypothyroidism is significantly related to the duration of disease, so there is a need for the early diagnosis of hypothyroidism. Hence, electrocardiogram, echocardiogram, and lipid profile are the investigation of choice for the diagnosis of cardiovascular disease. Early identification, diagnosis, and correction of hypothyroidism are necessary, so that early effects on cardiovascular disease can be minimized.

Acknowledgments

The help provided by the Chairperson, Centre for Interdisciplinary Biomedical Research, Adesh University, is gratefully acknowledged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Larsen PR, Davies TF, Hay ID. Thyroid physiology and diagnostic evaluation of patients with thyroid disorders. Hypothyroidism and thyroiditis. Williams Text Book of Endocrinology. 11th ed., Ch. 10, 12. Philadelphia: W.B. Saunders Company; 2012. p. 377-405.  Back to cited text no. 2
    
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Hall R, Scanlon MF. Hypothyroidism: Clinical features and complications. Clin Endocrinol Metab 1979;8:29-38.  Back to cited text no. 3
    
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Selly EW, Williams GH. The heart in endocrine disorders. The Heart Disease A Text Book of Cardio Vascular Medicine. 9th ed. Philadelphia: Saunders; 2012. p. 183-340.  Back to cited text no. 4
    
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Caroline GP, Roberts CG, Ladenson PW. Hypothyroidism. Lancet 2004;363:793-803.  Back to cited text no. 7
    
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Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med 2001;344:501-9.  Back to cited text no. 8
    
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Rawat B, Satyal A. An echocardiographic study of cardiac changes in hypothyroidism and the response to treatment. Kathmandu Univ Med J (KUMJ) 2004;2:182-7.  Back to cited text no. 9
    
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Fazio S, Palmieri EA, Lombardi G, Biondi B. Effects of thyroid hormone on the cardiovascular system. Recent Prog Horm Res 2004;59:31-50.  Back to cited text no. 10
    
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Kerber RE, Sherman B. Echocardiographic evaluation of pericardial effusion in myxedema. Incidence and biochemical and clinical correlations. Circ 1975;52:823-7.  Back to cited text no. 11
    
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Streeten DH, Anderson Jr GH, Howland TI, Chiang RI, Smulyan HA. Effects of thyroid function on blood pressure. Recognition of hypothyroid hypertension. Hypertension 1988;11;1:78-83.  Back to cited text no. 12
    
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Vanhaelst L, Neve P, Chailly P, Bastenie PA. Coronary-artery disease in hypothyroidism. Observations in clinical myxoedema. Lancet 1967;2:800-2.  Back to cited text no. 13
    
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Varma R, Jain AK, Ghose T. Heart in hypothyroidism-an echocardiographic study. J Assoc Physicians India 1996;44:390-2.  Back to cited text no. 14
    
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Nikoo MH. Cardiovascular manifestations of hypothyroidism. Shiraz E Med J 2000;2:1-14.  Back to cited text no. 15
    
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Forfar JC, Muir AL, Toft AD. Left ventricular function in hypothyroidism. Responses to exercise and beta adrenoceptor blockade. Br Heart J 1982;48:278-84.  Back to cited text no. 16
    
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Verma R. Heart in hypothyroidism. J Assoc Physicians India 1996;44:390-3.  Back to cited text no. 17
    
18.
Zoncu S, Pigliaru F, Putzu C, Pisano L, Vargiu S, Deidda M, et al. Cardiac function in borderline hypothyroidism: A study by pulsed wave tissue Doppler imaging. Eur J Endocrinol 2005;152:527-33.  Back to cited text no. 18
    
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Behera BK, Satpathy A, Samal K. Cardiovascular changes in newly detected hypothyroid patients in Eastern India. Int J Res Med Sci 2017;5:4302-6.  Back to cited text no. 19
    
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Shashi BM. A Study of Cardiovascular Changes in Newly Detected Hypothyroid Patients. Karnataka: The Rajiv Gandhi University of Health Sciences; 2006. p. 104.  Back to cited text no. 20
    
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Watanakunakorn C, Hodges RE, Evans TC. Myxedema; A study of 400 cases. Arch Intern Med 1965;116:183-90.  Back to cited text no. 21
    
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Pyarsabadi P, Saluja M, Chittora S, Swami Y, Richariya H, Jaiswal K, et al. An unusual case of pericardial tamponade in primary hypothyroidism. Int J Adv Med 2017;4:581-4.  Back to cited text no. 22
    
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Shende P, Choudhari S, Kelkar M, Chafekar N. A study of cardiovascular changes in newly detected hypothyroid patients. MVP J Med Sci 2017;4:102-6.  Back to cited text no. 23
    
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Fouron Je, Bourgin J.H, Letarte J, Dassault T.H, Ducharme G, Davignon A. Cardiac dimensions and myocardial functions of infants with congenital hypothyroidism: An echocardiographic study.-Br. Heart.J 1982,6;584-7.  Back to cited text no. 24
    
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Grossman G, Keck F.S, Weishammer S, GollerV, Schmidt A, Hombach. Systolic ventricular function in acute hypothyroidism: a study using Doppler echocardiography-Exp. Clin.Endocrinol 1994,2;104-10.  Back to cited text no. 25
    
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Kanaya AM, Harris F, Volpato S, Pérez-Stable EJ, Harris T, Bauer DC. Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition study. Archives of internal medicine 2002 8;7:773-9.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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