Original Article

Evaluation of Cardiac Dysfunction in Thyroid

Disorders by Echocardiography
Vikas Goyal1, Shweta Goyal2

Assistant Professor, Department of Medicine, Chirayu Medical College and Hospital, Bairagarh, Bhopal, Madhya Pradesh, India,
1

Associate Professor, Department of Pediatrics, Chirayu Medical College and Hospital, Bairagarh, Bhopal, Madhya Pradesh, India
2

ABSTRACT
Introduction: Thyroid dysfunction is one of the most common endocrine disorder affecting nearly all age groups. It is
associated with increased cardiovascular morbidity and mortality. The aim of this study is to assess the cardiac dysfunction
in thyroid disorders by echocardiography.
Materials and Methods: A total of 50 patients with thyroid disorder were enrolled. Echocardiography was done to evaluate
the cardiac function, and the parameters were recorded and compared with the controls.
Results: About 26 hypothyroid and 24 hyperthyroid cases were enrolled. The mean age of study subjects was 33.9 years
(range 13-40 years). The common Echocardiography findings were left atrial dilatation, right ventricular dilatation, left
ventricular dilatation, increased left ventricular posterior wall thickness. The left ventricular ejection fraction was decreased
and the diastolic dysfunction was present.
Conclusion: Echocardiography offers a sensitive, non-invasive bedside tool of assessing cardiac status of patients with
thyroid dysfunction. Hence, all patients with thyroid dysfunction should be subjected to echocardiography.
Key words: Systolic, Diastolic, Dysfunction, Thyroid

INTRODUCTION
Thyroid dysfunction is one of the most common metabolic
disorders that are associated with prominent cardiovascular
changes. The hyperdynamic circulatory effect in
hyperthyroidism is due to a marked reduction in peripheral
vascular resistance and an increased total blood volume and
heart rate. Hyperthyroidism can consequently exacerbate
pre-existing cardiac disease or cause de novo cardiovascular
abnormalities such as atrial fibrillation and heart failure.
Recent advances in echocardiographic technology enable
accurate non-invasive assessment of cardiac hemodynamic
parameters related to systolic or diastolic function, cardiac
output, pericardial effusion, or valvular dysfunction.1-4 The
purpose of this study was thus to evaluate echocardiography
changes in thyroid disorders.
MATERIALS AND METHODS
The study was done over a period of 1-year from
February 2014 to February 2015 at Chirayu Medical
College and Hospital.
Cases
A total of 50 patients with thyroid dysfunction were
enrolled.
Controls
About 20 age and sex matched euthyroid controls were
included in the study for comparison. Healthy subjects
matched for age and sex not satisfying inclusion criteria of
the study group and having no evidence of hypertension,
cardiovascular disease, and diabetes.
Inclusion Criteria
1. Newly diagnosed patients with deranged thyroid
profile either hypothyroidism or hyperthyroidism
2. Detected patients not on treatment
3. Patients on levothyroxine for <4 months.
Exclusion Criteria
1. Patients with known cardiac disease
2. Patients with chronic obstructive pulmonary disease,

Corresponding Author: Dr. Shweta Goyal, Department of Pediatrics, Chirayu Medical College and Hospital, Bhopal Indore
Highway, Bairagarh, Bhopal, Madhya Pradesh, India. Phone: +91-9827339299. E-mail: dr_shveta07@rediffmail.com

International Research Journal of Clinical Medicine • Vol 1 • Issue 4 • Apr 2016 13

 Goyal and Goyal: Echocardiography in Thyroid Dysfunction

severe anemia, diabetes mellitus, or any other Table 1: Left atrial dimension in cases and controls
endocrinal disorders Left atrial N (%)
3. Patients taking medications that alter the thyroid dimension in mm Hypothyroidism Hyperthyroidism Control
function such as beta blockers, lithium, oral Below normal (<19) ‑ ‑ ‑
contraceptive pills, steroids, and alcohol. Normal (19‑40) 25 (96.1) 23 (95.8) 20 (100)
Above normal (>40) 1 (3.9) 1 (4.2) ‑
Study Methods Mean 29.7 29.95 28.7
A history was taken to evaluate symptoms and duration
related to thyroid dysfunction. Special emphasis was given
Table 2: RVD in cases and controls
to rule out known cardiac disease (ischemic heart disease
and rheumatic heart disease), hypertension, diabetes, drug RVD in mm N (%)
intake, and other diseases which can modify the findings. Hypothyroidism Hyperthyroidism Control
A detailed examination was performed on every patient. Below normal (<9) ‑ ‑ ‑
Serum T3, T4, and thyroid-stimulating hormone were Normal (9‑26) 23 (88.5) 23 (95.8) 20 (100)
done using sensitive chemiluminescence technology. All Above normal (>26) 3 (11.5) 1 (4.2) ‑
the patients were subjected to two-dimensional, M-mode Mean 21 20.41 20.6
and Color Doppler Echocardiography. RVD: Right ventricular dimension

RESULTS Table 3: LVED/LVIDD

LVED in mm N (%)
The study comprises 50 patients suffering from thyroid
dysfunction of which 26 cases were hypothyroid and Hypothyroidism Hyperthyroidism Control
24 cases were of hyperthyroidism. The observation was Below normal (<37) ‑ ‑ ‑
Normal (37‑56) 24 (92.3) 22 (91.7) 20 (100)
made in terms of their age, sex, clinical presentations,
Above normal (>56) 2 (7.7) 2 (8.3) ‑
biochemical profile, and echocardiography parameters. To
Mean 42.66 45.2 42.9
compare the findings, 20 age and sex matched euthyroid
controls were selected. LVIDD: Left ventricular internal dimensions in diastole, LVED: Left
ventricle end‑diastolic
The mean age of study subjects was 33.9 years (range
13-40 years). Among the 26 hypothyroid patients, 7 were Table 4: LVES/LVIDS
males and 19 were females. While in the hyperthyroid LVES in mm N (%)
group, 5 were males and 19 were females. The control
Hypothyroidism Hyperthyroidism Control
group included 4 males and 16 females.
Below normal (<22) ‑ ‑ ‑
Normal (22‑39) 17 (65.3) 17 (70.83) 20 (100)
In patients suffering from hypothyroidism, fatigue and
Above normal (>56) 2 (7.7) 1 (4.2) ‑
weakness (73%) were the most common symptoms,
Mean 28.7 29.5 28.4
whereas weight loss and heat intolerance (83.3%) were the
most common symptoms in hyperthyroidism. The most LVIDS: Left ventricular internal dimensions in systole, LVES: Left
ventricular end systole
common sign was bradycardia (61.5%) in hypothyroidism
and tachycardia (91.6%) in hyperthyroidism. Goiter
was present in 50% cases. Sinus bradycardia (61.5%) Table 5: IVS wall thickness and PW thickness in diastole
was the predominant electrocardiography finding in IVS (D) and PW (D) N (%)
the hypothyroid patients. In the hyperthyroid group, in mm Hypothyroidism Hyperthyroidism Control
sinus tachycardia (79.2%) was the most common Below normal (<6) ‑ ‑ ‑
echocardiography finding. The echocardiography changes Normal (6‑11) 20 (76.93) 23 (95.8) 20 (100)
are described in Tables 1-8. Above normal (>11) 6 (23.07) 3 (12.5) ‑
IVS: Interventricular septal, PW: Posterior wall
DISCUSSION
In this study, the various echocardiography measurements ejection fraction (LVEF), E-wave to A wave (E/A), right
which were analyzed were aortic root dimension, left ventricular systolic pressure, and EF slope. These findings
atrial dimension, left ventricular internal diameter in were then compared with age, sex matched controls and
diastole/left ventricle end-diastolic (LVED/LVIDD), with the results of other studies.
left ventricular internal diameter in systole/left ventricular
Hypothyroidism
end systole (LVES/LVIDS), right ventricular dimension,
left ventricular posterior wall thickness (LVPW), In this study, left atrial dimension was normal (19-40 mm)
interventricular septal (IVS) wall thickness, left ventricular in all groups except one patient each in hypothyroid and

14 International Research Journal of Clinical Medicine • Vol 1 • Issue 4 • Apr 2016

 Goyal and Goyal: Echocardiography in Thyroid Dysfunction

Table 6: LVEF in cases and controls When compared with the control patients, the mean
LVEF in % N (%)
LVPWD was higher for hypothyroid group and the
difference was significant in our study.
Hypothyroidism Hyperthyroidism Control
Below 7 (26.9) 3 (12.5) 2 (10) In our study, 20 (76.93%) cases of hypothyroidism and
normal (<58)
all the controls showed the IVS thickness values to be
Normal (58‑75) 19 (73) 19 (79.2) 18 (90)
Above ‑ 2 (8.3) ‑
within the normal range with a mean value of 10.52 mm
normal (>75) and 9.27  mm, respectively. Six (23.07%) cases of
Mean 59.8 63.8 61.65 hypothyroidism had IVS thickness exceeding the normal.
LVEF: Left ventricular ejection fraction
The mean value of IVS in hypothyroid group was 11 mm.
These values were significant in hypothyroid group when
compared with controls. Santos et al. reported a mean IVS
Table 7: Distribution of ratio of E wave to A wave
thickness of 15.4 mm in 19 hypothyroid cases with a range
in cases studied
of 9-20 mm. 16 out of 19 patients had an abnormally
E/A wave N (%)
increased IVS thickness.6 Of the 10 who returned to
Hypothyroidism Hyperthyroidism Control euthyroid state following thyroxine replacement, the
<1 3 (11.5) ‑ ‑ IVS thickness was demonstrated to return to normal in
>1 23 (88.5) 24 (100) 20 (100) 9 patients (90%).
Mean 1.2 1.35 1.37
In our study, the mean EF of hypothyroid cases was
Table 8: Echocardiography variables in cases and controls found to be 59.8%. Seven patients (26.9%) had EF below
ECG variables N (%)
normal. Forfar et al. in a study of left ventricular function
in hypothyroidism in 8 female hypothyroid patients with
Hypothyroidism Hyperthyroidism Control
a mean age of 53 years have reported that the resting
Pericardial 6 (23.07) ‑ ‑
effusion
LVEF was reduced in hypothyroid patients (46 ± 2%)
MVP 1 (3.8) 5 (20.8) 1 (5) compared with the euthyroid (53 ± 2).7 In this study, a
Left ventricular 5 (19.2) 3 (12.5) ‑ subnormal EF was found in seven patients, 3 of whom
hypertrophy were in cardiac failure.
Tricuspid ‑ 2 (8.3) ‑
regurgitation In our study, diastolic dysfunction was observed in
Mitral ‑ 1 (0.2) ‑ 3 patients (11.5%) as assessed by ratio of E-wave to
regurgitation
A-wave in hypothyroid patients. Diastolic dysfunction was
ECG: Echocardiography, MVP: Mitral valve prolapsed observed in both subclinical and overt hypothyroidism
in a study conducted by Gupta and Sinha.8 Varma et al.
hyperthyroid group, in whom left atrium was dilated. In found diastolic dysfunction in 6 cases out of 44 cases
our study, LVIDD was normal (37-56 mm) in 24 (92.3%). (27.27%) as assessed by doppler echocardiography.5
Two patients (7.7%) had left ventricular internal diameter
above the normal range (56mm). The mean value for Hyperthyroidism
LVED was 42.66 mm. Varma et al. in a study of 22 cases
of hypothyroid patients found that LVED ranged from In this study, LVIDS was normal in 22 (91.7%) patients of
46 ± 6 mm to 44.6 ± 6.5 mm, and the mean LVED hyperthyroidism while 2 patient (8.3%) had left ventricular
value was 44.9 mm.5 In this study, LVIDS was normal internal dimension above the normal range. The mean
(22-39 mm) in 24 (92.3%) patients. Two patients (7.7%) value for LVED was 45.2 mm. When compared to the
had left ventricular internal dimension above the normal control group, in whom the LVED was 42.9 mm, the
range. Varma et al. in a study of 22 cases of hypothyroid difference was found significant (P < 0.05). Lewis et al.
patients found a mean LVES value of 27.3 mm. When studied the echocardiography left ventricular function
compared statistically, the results of this study were shown in 11 hyperthyroid patients and LVID was in range of
not to differ significantly from that of Varma et al. In our 46 ± 6 mm.9
study, LVPW thickness in diastole (LVPWD) was normal
(6-11 mm) in 21 (80.76%) patients. Five (19.23%) patients In our study, LVIDS was normal in 23 (95.8%) patients.
had LVPW thickness above the normal range. The mean It was above normal in one patient (4.2%). The mean
for hypothyroid patients was 10.07 mm and for controls LVES value for all the patients was 28.4 mm. Lewis
was 9.12 mm. Varma et al. observed that LVPW thickness et al. have reported the mean LVES of 11 patients with
was increased in overt hypothyroidism (mean 13.2 ± thyrotoxicosis to be 28 ± 6 mm without treatment which
2 mm). This increase was found to be significant only in was not significant statistically when compared with
severe hypothyroidism while the dimensions were within LVES values after the treatment with beta blockers.9
normal range in subclinical and mild hypothyroidism. The study showed that in hyperthyroidism, the left

International Research Journal of Clinical Medicine • Vol 1 • Issue 4 • Apr 2016 15

 Goyal and Goyal: Echocardiography in Thyroid Dysfunction
ventricle is normal in size with increased contractility and
fractional shortening. Only one patient in this study had
an enlarged left ventricle with relatively low contractility.
When compared statistically, the results of this study were
shown not to differ significantly from that of Lewis et al.
In our study, there was no significant effect of
hyperthyroidism on LVPW thickness in diastole when
compared with controls (P > 0.05). These results were
consistent with a similar study by Lewis et al.9
In our study, only three patients had increased IVS
thickness. In a study by Lewis et al., there was no significant
difference among treated and untreated patients with
regards to IVS thickness.9
In our study, the finding of increased EF in
hyperthyroidism as compared to controls is consistent
with the findings of Forfar et al.7 The findings of three
patients having a subnormal EF is at variance with other
studies. Left ventricular hypertrophy associated with
an accelerated heart rate, arrhythmias, and myocardial
ischemia may contribute to heart failure. Likof and Levine
and Sandler et al. have shown the existence of heart
failure in hyperthyroidism even in the absence of any
cardiac disease.10 The right ventricular systolic pressure of
hyperthyroid group was higher than the control group (P
< 0.05).
Gupta and Sinha studied 44 patients of hypothyroidism
and found pericardial effusion in 10 (22.7%) of overt
hypothyroidism.8 In our study, a significantly high
incidence of mitral valve prolapse (MVP) was found
in hyperthyroid patients. The exact pathogenesis of
MVP is known. Myxomatous transformation of valve
leaflets, abnormalities of the subvalvular apparatus and
an elevated adrenergic tone have been implicated as a
causative factor. Cooper et al. studied the left ventricle
hypertrophy in hyperthyroidism and concluded that
thyroid induced cardiac hypertrophy is caused mainly by
an increase in cardiac workload.11 Dougherty and Craige
have described two case reports of hyperthyroidism
presenting as tricuspid regurgitation. It is often associated
with right ventricular failure. It is felt to be functional
rather than primary valvular disease.12
How to cite this article: Goyal V, Goyal S. Evaluation of Cardiac Dysfunction in Thyroid Disorders by Echocardiography. Int Res J Cli
Med 2016;1(4):13-16.
Source of Support: Nil. Conflict of Interest: None declared.
Month of Submission: 12-2015  Month of Peer Review: 03-2016  Month of Acceptance: 04-2016  Month of Publishing: 04-2016
16 International Research Journal of Clinical Medicine • Vol 1 • Issue 4 • Apr 2016
CONCLUSION
Thyroid dysfunction can present with myriad
cardiovascular changes. Echocardiography offers a
sensitive, non-invasive, easily available diagnostic tool to
assess cardiac status of patients with thyroid disorders.
Hence, echocardiography should be done in all such
patients to detect cardiac changes early as these are
reversible with treatment.
REFERENCES
1. Siu CW, Yeung CY, Lau CP, Kung A, Tse HF. Incidence, clinical
characteristicsand outcome of congestive heart failure as the
initial presentation in patientswith primary hyperthyroidism.
Heart 2007;93(4):483-7.
2. Feldman T, Borow KM, Sarne DH, Neumann A, Lang RM.
Myocardial mechanics in hyperthyroidism: Importance of left
ventricular loading conditions, heart rate and contractile state.
J Am Coll Cardiol 1986;7:967-74.
3. Kahaly GJ, Kampmann C, Mohr-Kahaly S. Cardiovascular
hemodynamics and exercise tolerance in thyroid disease.
Thyroid 2002;12:473-81.
4. Klein I. Thyroid hormone and the cardiovascular system. Am J
Med 1990;88:631-7.
5. Varma R, Jain AK, Ghose T. Heart in hypothyroidism –
An echocardiographic study. J Assoc Physicians India
1996;44:390-2.
6. Santos AD, Miller RP, Mathew PK, Wallace WA,
Cave WT Jr, Hinojosa L. Echocardiographic characterization
of the reversible cardiomyopathy of hypothyroidism. Am J
Med 1980;68:675-82.
7. Forfar JC, Muir AL, Sawers SA, Toft AD. Abnormal left
ventricular function in hyperthyroidism: Evidence for a possible
reversible cardiomyopathy. N Eng J Med 1982;307:1165-70.
8. Gupta A, Sinha RS. Echocardiographic changes and alteration
in lipid profile in cases of subclinical and overt hypothyroidism.
JAPI 1996;44:551-3.
9. Lewis BS, Ehrenfeld EN, Lewis N, Gotsman MS.
Echocardiographic LV function in thyrotoxicosis. Am Heart J
1979;97:460-8.
10. Likoff WB, Levine SA. Thyrotoxicosis as a sole cause of heart
failure. Am J Med Sci 1943;206:425-34.
11. Cooper DS, Halpern R, Wood LC, Levin AA, Ridgway EC.
L-Thyroxine therapy in subclinical hypothyroidism. A double-
blind placebo-controlled trial. Ann Intern Med 1984;10:18-24.
12. Dougherty M, Craige E. Apathetic hypothyroidism presenting
as tricuspid regurgitation. Chest 1973;63:767-72.