|Year : 2023 | Volume
| Issue : 1 | Page : 13-18
Clinical characteristics, risk factors, and thyroid profile of patients admitted with acute left ventricular heart failure from a tertiary hospital in Northeast India: A single-center retrospective cohort study
Anup Kumar Boro1, Prabir Kumar Gupta1, Biplab Paul1, Habibar Rahman1, Sneha Gang2, Ananya Barman2
1 Department of Cardiology, GNRC Hospital, Dispur, Assam, India
2 Department of Research and Analytics, GNRC Hospital, Dispur, Assam, India
|Date of Submission||25-Jan-2023|
|Date of Decision||15-Feb-2023|
|Date of Acceptance||17-Feb-2023|
|Date of Web Publication||12-Apr-2023|
Departments of Research and Analytics, GNRC Hospital, Dispur - 781 006, Assam
Source of Support: None, Conflict of Interest: None
Introduction: Heart failure (HF) is a progressive chronic clinical syndrome. Thyroid dysfunction in HF patients has been reported in the literature. We aimed to explore the prevalence of thyroid dysfunction among acute left ventricular failure (LVF) patients admitted to our hospital.
Materials and Methods: A retrospective study involving 78 patients diagnosed with acute LVF was conducted. Baseline information that included demographics, risk factors, clinical presentations, and biochemical data was recorded. A comparison of acute LVF patients with thyroid dysfunction to those with normal thyroid function was analyzed and documented.
Results: About 29.5% (n = 23; 63.8 ± 11.4 years) of patients had normal thyroid function and 70.5% (n = 55; 65.3 ± 6 years) had thyroid dysfunction (P = 0.0003). The mean age of the cohort was 64.7 ± 12.4 years and 68% (n = 53) were men. Hypertension was the most common risk factor among both groups (56.5%, n = 13 vs. 67.3%, n = 37; P = 0.0006). Around 13% (n = 3) of patients with normal thyroid function and 20% (n = 11) of patients with thyroid dysfunction expired (P = 0.0325). The most common symptom seen in both groups was shortness of breath (28%, n = 16 vs. 72%, n = 41; P = 0009). There was a high prevalence of HF with reduced ejection fraction (60.8%, n = 14 vs. 65.5%, n = 36; P = 0.0018). Electrocardiography abnormalities were noted in 70.5% (n = 55) of patients of the cohort (65.2%, n = 15 vs. 72.7%, n = 40; P = 0.007). Irregularities in two-dimensional echocardiography and Doppler were seen in 76.5% (n = 59) of patients (69.6%, n = 16 vs. 78.2%, n = 43; P = 0.0004).
Conclusions: Thyroid dysfunction can cause significant adverse effects on the heart. Early diagnosis and treatment of thyroid abnormalities can reduce and/or prevent the development of serious cardiac problems including HF.
Keywords: Acute, diastolic, left ventricular failure, risk factor, systolic, thyroid, thyroid dysfunction
|How to cite this article:|
Boro AK, Gupta PK, Paul B, Rahman H, Gang S, Barman A. Clinical characteristics, risk factors, and thyroid profile of patients admitted with acute left ventricular heart failure from a tertiary hospital in Northeast India: A single-center retrospective cohort study. Heart India 2023;11:13-8
|How to cite this URL:|
Boro AK, Gupta PK, Paul B, Rahman H, Gang S, Barman A. Clinical characteristics, risk factors, and thyroid profile of patients admitted with acute left ventricular heart failure from a tertiary hospital in Northeast India: A single-center retrospective cohort study. Heart India [serial online] 2023 [cited 2023 May 28];11:13-8. Available from: https://www.heartindia.net/text.asp?2023/11/1/13/374106
| Introduction|| |
Heart failure (HF) is a complex and progressive disease in which the heart fails to pump (systolic) or fill (diastolic) blood adequately. In general, HF is a chronic condition but it might also at times happen suddenly (acute). Left ventricular failure (LVF) occurs when the left ventricle of the heart gradually weakens and results in failure in supplying blood to the vital organs. LVF can be further categorized as HF with reduced ejection fraction (HFrEF) or systolic failure where the ejection fraction is <40%, HF with mid-range ejection fraction (HFmrEF) where the ejection fraction is between 41% and 49%, and HF with preserved ejection fraction (HFpEF) or diastolic failure where the ejection fraction is over 50%. There is a high rate of occurrence of HF in developed and developing countries with an estimated prevalence of 37 million individuals. It is one of the leading causes of hospitalization among the elderly and a major cause of morbidity and mortality across the globe. In India, HF affects around 8–10 million individuals which accounts for 1% of the population. About 1.8 million hospitalizations occur annually in India due to HF and the estimated mortality is about 0.1–0.16 million individuals per year. Patients with HF may present with shortness of breath, fatigue, nausea, palpitations, weight gain, wheezing, and swellings in the legs, ankles, and abdomen. Several studies have been conducted that showed the relationship between thyroid dysfunction and HF. Thyroid hormones regulate diverse metabolic processes including multiple cardiovascular events and dysfunction of thyroid hormones can cause adverse cardiac abnormalities including HF. The main aim of this study was to investigate the prevalence of thyroid dysfunction among acute LVF patients treated at our hospital.
| Materials and Methods|| |
This retrospective study was performed at a super specialty Tertiary Health Care Centre situated in Guwahati, Assam, India. There were 111 acute LVF patients enrolled for 1 year (January 1st, 2021–December 31st, 2021) at the inpatient unit of the department of cardiology of our hospital. Patients were identified from the medical records department (MRD) of the hospital. Medical records from MRD were reviewed to retrieve patient information. Baseline information of the patients that included age, gender, locality, and risk factors if any were recorded.
Adults (≥21 years) diagnosed with acute LVF regardless of gender and no missing medical records were selected. Patients, who were <21 years of age with missing data and who had a history of thyroid dysfunction, and were on medications that altered thyroid hormone metabolism such as antithyroid, corticosteroids, and nonsteroidal anti-inflammatory drugs, were excluded. A total of 78 acute LVF patients were considered for the study.
Diagnosis of the patients with acute LVF was done based on clinical signs and symptoms. The patients underwent tests for a detailed investigation that included laboratory tests such as fasting serum glucose, hemoglobin, and Vitamin D; chest X-ray; electrocardiography (ECG); two-dimensional echocardiography (2D ECHO); Doppler and color flow mapping. Further, left ventricle ejection fraction (LVEF) was categorized into HFrEF when LVEF ≤40%, HFmrEF when LVEF was between 41% and 49%, and HFpEF when LVEF ≥50%.
The thyroid function test in our hospital was defined as followed normal thyroid function or euthyroidism (Thyroid stimulation hormone or [TSH] 0.34–5.60 μlU/ml, triiodothyronine or T3 0.81–1.78 ng/ml, and thyroxine or T4 4.5–12.5 μg/dl) and thyroid dysfunction that included hypothyroidism (T4 <4.5 μg/dl and TSH >5.60 μlU/ml), subclinical hypothyroidism (normal T3 and T4 levels and TSH >5.60 μlU/ml), hyperthyroidism (T4 >12.5 μg/dl and TSH <0.34 μlU/ml), subclinical hyperthyroidism (normal T3 and T4 levels and TSH <0.34 μlU/ml), and low T3 syndrome (normal T4 and TSH levels and T3 <0.81 ng/ml).
All statistical analyses were performed using SPSS Software Version 17 (IBM SPSS Statistics, Chicago, Illinois, US). Descriptive statistical values were expressed as mean ± standard deviation for continuous variables and frequencies (percentages) for categorical variables. A Chi-square P < 0.05 was considered statistically significant.
| Results|| |
During the study period, 111 patients were diagnosed with acute LVF in the inpatient unit of the department of cardiology at our hospital. Out of these medical records of 78 patients aged ≥21 years with no known history of thyroid abnormalities were studied [Table 1]. The cohort included 68% (n = 53) males and 32% (n = 25) females. The male/female ratio was 2.1:1. The age range was 22–95 years, mean age of the entire cohort was 64.7 ± 12.4 years, and the overall mortality was 18% (n = 14). The studied cohort consisted of 53.8% (n = 42) of patients from rural areas and 46.2% (n = 36) of patients from urban areas. Hypertension was the predominant risk factor seen in 64.1% (n = 50) patients followed by diabetes as seen in 43.6% (n = 34) of the patients. Only 1.3% (n = 1) of patient had a history of dyslipidemia. There were 23.1% (n = 18) patients with no known associated risk factors. Patients with normal thyroid function or euthyroidism were 29.5% (n = 23). Thyroid dysfunction was found in 70.5% (n = 55) of patients with subclinical hypothyroidism in 21.8% (n = 17), hypothyroidism in 7.7% (n = 6), subclinical hyperthyroidism in 1.3% (n = 1), hyperthyroidism in 5.1% (n = 4), and low T3 syndrome in 34.6% (n = 27) patients.
The demographic and risk factor profile of the acute LVF patients according to their thyroid status is shown in [Table 2]. The mean age of patients without thyroid dysfunction was 63.8 ± 11.4 years and for patients with thyroid dysfunction was 65.3 ± 6 years (P = 0.8946). Around 87% (n = 20) of males were with normal thyroid function and 60% (n = 33) of males had thyroid dysfunction (P = 0.0741), whereas 13% (n = 3) of females were without any thyroid dysfunction and 40% (n = 22) females had thyroid dysfunction (P = 0.0001). There were 56.5% (n = 13) of patients with normal thyroid function and 52.7% (n = 29) of patients with thyroid dysfunction that belonged to rural areas (P = 0.0135). Patients from urban areas with and without normal thyroid function comprised 43.5% (n = 10) and 47.3% (n = 26), respectively (P = 0.0076). Hypertension was found in 56.5% (n = 13) of patients with normal thyroid function and 67.3% (n = 37) of patients with thyroid dysfunction (P = 0.0006). Around 39.1% (n = 9) and 45.5% (n = 25) of patients without thyroid dysfunction and patients with thyroid dysfunction had diabetes, respectively. Dyslipidemia was not found in patients with normal thyroid function and was only observed in 1.8% (n = 1) thyroid dysfunction patient (P = 0.3173). Patients with no associated comorbidities were 26.1% (n = 6) and 21.8% (n = 12), respectively, in the case of normal thyroid function and thyroid dysfunction (P = 0.1572). In the study period, 13% (n = 3) of normal thyroid function patients with HF died, whereas the mortality of HF patients with thyroid dysfunction was 20% (n = 11) (P = 0.0325).
|Table 2: Demographic and risk factor profile of the heart failure patients included in our study according to their thyroid status|
Click here to view
The clinical profile of the acute LVF patients according to their thyroid status is summarized in [Table 3]. Shortness of breath or dyspnea (69.6%, n = 16 vs. 74.5%, n = 41; P = 0.0009), chest pain (47.8%, n = 11 vs. 43.6%, n = 16; P = 0.0279), fatigue (8.7%, n = 2 vs. 16.4%, n = 9; P = 0.0348), swelling of limbs (4.3%, n = 1 vs. 1.8%, n = 1; P = 1.0000), and syncope (4.3%, n = 1 vs. 0%, n = 0; P = 0.3173) were the common clinical presentation of the patients. Both the groups had similar systolic (126.8 ± 30.2 mmHg vs. 139 ± 11.3 mmHg; P = 0.4542) and diastolic (78.4 ± 12.1 mmHg vs. 82.1 ± 6; P = 0.7702) blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]). Heart rate (HR) was 94 ± 17 beats/min for patients with normal thyroid function and for the other group, it was 89.6 ± 9.5 beats/min (P = 0.7453). Interestingly, elevated fasting blood glucose (FBG) of 188.2 ± 96.2 mg/dl was seen for patients with normal thyroid function as compared to fasting glucose of 156.2 ± 49.3 mg/dl for patients with thyroid dysfunction (P = 0.0846). There was no difference in hemoglobin levels in both the groups (11.8 ± 2.6 g % vs. 11 ± 1.2 g %; P = 0.8669). Similar Vitamin D levels of 30.2 ± 17.2 ng/ml for normal thyroid function patients and 26.2 ± 4.8 ng/ml for thyroid dysfunction patients were observed (P = 0.5942). HFmrEF made up 65.2% (n = 15) and 21.8% (n = 12) in acute LVF patients with normal thyroid function and dysfunction, respectively (P = 0.3638). Acute LVF patients with HFpEF comprised 8.7% (n = 2) with normal thyroid function and 12.7% (n = 7) with thyroid dysfunction (P = 0.0955).
|Table 3: Clinical profile of the heart failure patients included in our study according to their thyroid status|
Click here to view
[Table 4] shows the thyroid profile of acute LVF patients. Both thyroid normal and dysfunction patients had similar T3 (1.4 ± 2.2 ng/ml vs. 0.8 ± 0.3 ng/ml; P = 0.6858) and T4 levels (8.1 ± 1.4 μg/dl vs. 8.3 ± 4.1 μg/dl; P = 0.9606). Thyroid dysfunction patients had higher levels of TSH (10 ± 13.1 μl/ml) than the normal thyroid function patients (2.6 ± 1.7), and this difference was statistically significantç (P = 0.0371).
|Table 4: Thyroid profile of the heart failure patients in our study according to their thyroid status|
Click here to view
[Table 5] summarizes the ECG, 2D ECHO, and Doppler profiles of the acute LVF patients according to their thyroid status. Around 70.5% (n = 55) of patients of the cohort had irregular ECG. Irregularities were seen in 65.2% (n = 15) of the normal thyroid function patients and 72.7% (n = 40) in the case of thyroid dysfunction patients (P = 0.0007). The most common ECG abnormality noted in both groups was sinus tachycardia (26.1%, n = 6 vs. 27.3%, n = 15; P = 0.0495). Other ECG abnormalities that include sinus bradycardia, atrial fibrillation, intraventricular conduction delay, complete left branch block, complete right branch block, and complete heart block were also noted in patients of both the groups (34.8%, n = 8 vs. 40%, n = 22; P = 0.0105). Only one thyroid dysfunction patient had sinus arrhythmia (1.8%). Abnormalities in 2D ECHO and Doppler were observed in 69.6% (n = 16) of normal thyroid function patients and 78.2% (n = 43) of thyroid dysfunction patients (P = 0.0004). Left ventricular (LV) dysfunction (43.5%, n = 10 vs. 29.1%, n = 16; P = 0.2393) and mitral regurgitation (52.2%, n = 12 vs. 25.5%, n = 14; 0.6948) were the common abnormalities noted. Atrial regurgitation, tricuspid valve regurgitation, LV hypertrophy, regional wall motion abnormality, pericardial effusion, and biventricular dysfunction were the other irregularities observed in patients from both groups. Pulmonary arterial hypertension was seen in only one thyroid dysfunction patient (1.8%).
|Table 5: Electrocardiography, 2D echocardiography, and Doppler profile of the heart failure patients in our study according to their thyroid status|
Click here to view
| Discussion|| |
Thyroid hormones produced by the pituitary gland regulate various cardiovascular functions., Cardiac abnormalities are caused by either insufficient or excess thyroid hormones or both. Surplus production of thyroid hormones results in atrial arrhythmias, whereas ventricular arrhythmias and hyperlipidemia are caused by inadequate thyroid hormones and both are responsible for HF and hypertension. In general, thyroid hormones impart effects on cardiac contractility and output, systemic vascular resistance, and decreased LV systolic function. These cardiac anomalies are usually reversible and can be managed by proper treatment of the underlying thyroid condition. There are multiple cohort studies that have investigated the relationship between thyroid dysfunction with HF. However, studies pertaining to this topic from Northeast India are scarce.
In our study, there was a significant number of HF patients with thyroid dysfunction as compared to HF patients without thyroid dysfunction (P = 0.0002). No significant difference in terms of age was noted between the two groups (P = 0.8946) which is supported by a previous study. The male gender was significantly associated with HF than the female gender (P = 0.0015) while females with HF had a significant association with thyroid dysfunction (P = 0.0001). A significant association of the male gender with HF has also been supported by earlier studies.
Hypertension and diabetes were the predominant risk factors associated with HF in our study which was in accordance with studies as reported in the literature., Between the two groups, both hypertension and diabetes were largely seen among thyroid dysfunction patients. Hypertension causes LV systolic and diastolic dysfunction which progresses to ventricular hypertrophy and finally leads to HF. On the other hand, diabetes causes impairment in myocardial energetics and decreased systolic strain which leads to LV concentric remodeling. Other risk factors of HF include smoking, obesity, and sedentary lifestyle.
In our study, a significant difference in overall mortality was noted between the two groups (P = 0.0325). A higher mortality of acute LVF patients with thyroid dysfunction was noted. Mortality was high in males (68%) as compared to females (32%). Despite improvements in the treatment of HF, mortality in HF patients still remains high as suggested in the literature.
Majority of the HF patients were symptomatic with shortness of breath or dyspnea (P = 0.0009) and chest pain (P = 0.0279) being the most common presenting symptoms between the two groups. There was no significant difference in the different parameters screened at the time of admission between the two groups. The SBP (P = 0.4542), DBP (P = 0.7702), HR (P = 0.7453), FBG (P = 0.0846), hemoglobin (P = 0.8669), and Vitamin D (P = 0.5942) were similar between the two groups. Our study demonstrated a higher prevalence of HFrEF among thyroid dysfunction patients. A similar result has also been reported in some studies where it has been mentioned that thyroid dysfunction patients with HFrEF are more likely to have HF in comparison to patients with HFpEF.
There was no difference in T3 and T4 levels between the two groups. On the other hand, TSH level was significantly high in thyroid dysfunction patients. This was expected as we have selectively grouped the thyroid normal and dysfunctional patients. There are many studies in the literature that have reported an association of higher TSH levels with increased cardiovascular diseases including HF which is in accordance with our findings.
In our study, a significant difference between the two groups in terms of overall ECG, 2D ECHO, and Doppler profile was noted. Sinus tachycardia is one of the most common symptoms noted in HF patients. We observed the same symptom in both thyroid normal and dysfunctional patients of our study. Mitral regurgitation is another poor prognostic marker commonly seen in HF and was also noted in both study groups.
LVF can have some serious complications such as respiratory distress, generalized swelling, arrhythmias, and cardiogenic shock. Lifestyle changes, pharmacologically treating the underlying cause, and control of risk factors can reduce the rate of hospitalizations and also improve patient conditions. A multidisciplinary approach that involves educating the patient on the importance of lifestyle modifications can play a key role in reducing mortality and morbidity due to HF.
The findings of our study provide valuable information about the relationship between thyroid dysfunction with HF. This is the first study conducted in Northeast India which focuses on the cardiovascular implications in thyroid dysfunction patients. Our hospital is involved in screening all patients with thyroid disorders for cardiovascular manifestations. Thyroid function tests are routinely carried out in patients with unexplained cardiac problems and also with no known associated risk factors.
The first limitation of our study was the relatively small number of patients. Second, the data were collected retrospectively. Third, the sample was less heterogeneous as it was a single-center study. Moreover, fourth, it was a cross-sectional observational study. Thus, the finding of this study should be considered preliminary and further multicenter prospective studies needs to be carried out in the future.
| Conclusions|| |
Thyroid dysfunction was found to be relatively common in patients with HF. Dysfunction of thyroid hormone can lead to significant and adverse cardiac functions. Thyroid function tests should be routinely carried out in patients with cardiovascular problems as thyroid profiles can provide key insights into cardiovascular diseases including HF. Early detection and initiation of treatment of thyroid anomalies can reduce and also prevent major cardiac problems.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This study was approved by the Institutional Ethics Committee of GNRC Hospitals.
Concept, design, and literature search: AKB, PKG, HR, BP, and AB. Data acquisition: AKB, PKG, and AB. Data analysis: AKB, PKG, HR, BP, SG, and AB. Statistical analysis: AKB and AB. Manuscript writing: AB. Manuscript review and editing: AKB, PKG, HR, BP, and SG. Guarantor: AB.
| References|| |
Savarese G, Lund LH. Global public health burden of heart failure. Card Fail Rev 2017;3:7-11.
Chahine J, Alvey H. Left ventricular failure. In: StatPearls. Treasure Island (FL): StatPearls Publication; 2022.
Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol 2016;13:368-78.
Kuchulakanti PK, Bandaru Srinivasarao VC, Kuchulakanti A, Lakshumiah T, Rathod M, Khare R, et al
. Association of subclinical hypothyroidism in heart failure: a study from South India. Br J Cardiol 2019;26-35.
Chaturvedi V, Parakh N, Seth S, Bhargava B, Ramakrishnan S, Roy A, et al.
Heart failure in India: The INDUS (INDia Ukieri study) study. J Prac Cardiovas Sci 2016;2:28-35.
Thibodeau JT, Drazner MH. The role of the clinical examination in patients with heart failure. JACC Heart Fail 2018;6:543-51.
Biondi B. Mechanisms in endocrinology: Heart failure and thyroid dysfunction. Eur J Endocrinol 2012;167:609-18.
Kannan L, Shaw PA, Morley MP, Brandimarto J, Fang JC, Sweitzer NK, et al.
Thyroid dysfunction in heart failure and cardiovascular outcomes. Circ Heart Fail 2018;11:e005266.
Arrkelin D. Using SPSS to understand research and data analysis. Pysch Curr Mat I; 2014.
Klein I, Danzi S. Thyroid disease and the heart. Circulation 2007;116:1725-35.
Gerdes AM, Iervasi G. Thyroid replacement therapy and heart failure. Circulation 2010;122:385-93.
Mohamud MA, İbrahim İG, Ahmed SA, Karataş M, Jeele MO. Prevalence of thyroid dysfunction among patients with heart failure at a tertiary hospital in Mogadishu, Somalia. Int J Gen Med 2022;15:6335-9.
Walsh JP, Bremner AP, Bulsara MK, O'Leary P, Leedman PJ, Feddema P, et al.
Subclinical thyroid dysfunction as a risk factor for cardiovascular disease. Arch Intern Med 2005;165:2467-72.
Dunlay SM, Weston SA, Jacobsen SJ, Roger VL. Risk factors for heart failure: A population-based case-control study. Am J Med 2009;122:1023-8.
Bauters C, Lamblin N, Mc Fadden EP, Van Belle E, Millaire A, de Groote P. Influence of diabetes mellitus on heart failure risk and outcome. Cardiovasc Diabetol 2003;2:1.
Bytyçi I, Bajraktari G. Mortality in heart failure patients. Anatol J Cardiol 2015;15:63-8.
Samuel NA, Cuthbert JJ, Brown OI, Kazmi S, Cleland JG, Rigby AS, et al.
Relation between thyroid function and mortality in patients with chronic heart failure. Am J Cardiol 2021;139:57-63.
Francois J, Al-Sadawi M, Casillas J, Botti E, Soni L, Ponse D, et al.
Hypothyroidism and heart failure: Epidemiology, pathogenetic mechanisms and therapeutic rationale. Int J Clin Res Trials 2020;5:146.
Demir S, Tufenk M, Karakaya Z, Akilli R, Kanadas M. The treatment of heart failure-related symptoms with ivabradine in a case with peripartum cardiomyopathy. Int Cardiovasc Res J 2013;7:33-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]