Atrial fibrillation hyperthyroidism
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Anahita Deylamsalehi, M.D.[3] Varun Kumar, M.B.B.S.
Overview
Atrial fibrillation occurs in 10% to 25% of patients with hyperthyroidism, nevertheless only 1% of patients with new onset atrial fibrillation detected to have hyperthyroidism. Elevation of thyroid hormones in hyperthyroidism is responsible for chronotropic and dromotropic effects on heart. Mechanisms such as increase in left ventricular mass in addition to impaired ventricular relaxation which lead to elevation of left atrial pressure , Heart rate elevation and subsequent ischemia and atrial ectopic activity are proposed as possible explaination for increased risk of atrial fibrillation in hyperthyroid patients. Atrial fibrillation in the setting of thyrotoxicosis has been shown to be associated with decompensated heart failure and a significant increase in morbidity and mortality rate. Up to two-thirds of patients will reach sinus rhythm with appropriate treatment and control of hyperthyroidism.
Atrial Fibrillation and Hyperthyroidism
- Atrial fibrillation occurs in 10% to 25% of patients with hyperthyroidism.[1]
- Based on another study 15% of patients with hyperthyroidism develop atrial fibrillation in comparison to 4% chance of atrial fibrillation development in normal population. It's incidence is also more common in males and among hyperthyroidism patients with triiodothyronine (T3) toxicosis.[2]
- On the other hand only near 1% of patients with new onset atrial fibrillation detected to have hyperthyroidism. In other words in the absence of hyperthyroidism's symptoms and signs, hyperthyroidism is not a common etiology for atrial fibrillation.
- Subclinical hyperthyroidism increases the risk of atrial fibrillation up to 3 fold. [2][3]
- Elevation of thyroid hormones in hyperthyroidism is responsible for chronotropic and dromotropic effects on heart. [2]
- Numerous mechanisms have been explained about increased risk of atrial fibrillation among patients with hyperthyroidism. The following are some of the responsible mechanism:[2]
- Increase in left ventricular mass in addition to impaired ventricular relaxation which lead to elevation of left atrial pressure
- Heart rate elevation and subsequent ischemia
- Atrial ectopic activity
- Decreased action potential
- The following are some of the well known risk factors for atrial fibrillation development among hyperthyroidsm patients: [4][5]
- Atrial fibrillation in the setting of thyrotoxicosis has been shown to be associated with decompensated heart failure and a significant increase in morbidity and mortality rate.[6][2][7][8][9]
- Beta blockers and non-dihydropyridine calcium channel blockers may be used to control ventricular rate.[1]
- In patients with hyperthyroidism, oral anticoagulation may be recommended to prevent systemic embolism.[10]
- Up to two-thirds of patients will reach sinus rhythm with appropriate treatment and control of hyperthyroidism.[2]
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[11]
| Class I |
| "1. Beta blockers are recommended to control ventricular rate in patients with atrial fibrillation complicating thyrotoxicosis unless contraindicated. (Level of Evidence: C)" |
| "2. In circumstances in which a beta blocker cannot be used, a nondihydropyridine calcium antagonist is recommended to control the ventricular rate. (Level of Evidence: C)" |
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[12]
Hyperthyroidism (DO NOT EDIT) [12]
| Class I |
| "1. Administration of a beta blocker is recommended to control the rate of ventricular response in patients with atrial fibrillation complicating thyrotoxicosis, unless contraindicated. (Level of Evidence: B)" |
| "2. In circumstances when a beta blocker cannot be used, administration of a nondihydropyridine calcium channel antagonist (diltiazem or verapamil) is recommended to control the ventricular rate in patients with atrial fibrillation and thyrotoxicosis. (Level of Evidence: B)" |
| "3. In patients with atrial fibrillation associated with thyrotoxicosis, oral anticoagulation (INR 2.0 to 3.0) is recommended to prevent thromboembolism, as recommended for atrial fibrillation patients with other risk factors for stroke. (Level of Evidence: C)" |
| "4. Once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism. (Level of Evidence: C)" |
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [14]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [15]
References
- ↑ 1.0 1.1 Clozel JP, Danchin N, Genton P, Thomas JL, Cherrier F (1984) Effects of propranolol and of verapamil on heart rate and blood pressure in hyperthyroidism. Clin Pharmacol Ther 36 (1):64-9. PMID: 6734051
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Bielecka-Dabrowa A, Mikhailidis DP, Rysz J, Banach M (2009). "The mechanisms of atrial fibrillation in hyperthyroidism". Thyroid Res. 2 (1): 4. doi:10.1186/1756-6614-2-4. PMC 2680813. PMID 19341475.
- ↑ Krahn AD, Klein GJ, Kerr CR, Boone J, Sheldon R, Green M; et al. (1996). "How useful is thyroid function testing in patients with recent-onset atrial fibrillation? The Canadian Registry of Atrial Fibrillation Investigators". Arch Intern Med. 156 (19): 2221–4. PMID 8885821.
- ↑ Frost L, Vestergaard P, Mosekilde L (2004). "Hyperthyroidism and risk of atrial fibrillation or flutter: a population-based study". Arch Intern Med. 164 (15): 1675–8. doi:10.1001/archinte.164.15.1675. PMID 15302638.
- ↑ Agner T, Almdal T, Thorsteinsson B, Agner E (1984). "A reevaluation of atrial fibrillation in thyrotoxicosis". Dan Med Bull. 31 (2): 157–9. PMID 6723378.
- ↑ Staffurth JS, Gibberd MC, Fui SN (1977). "Arterial embolism in thyrotoxicosis with atrial fibrillation". Br Med J. 2 (6088): 688–90. doi:10.1136/bmj.2.6088.688. PMC 1631908. PMID 902055.
- ↑ Robinson K, Frenneaux MP, Stockins B, Karatasakis G, Poloniecki JD, McKenna WJ (1990) Atrial fibrillation in hypertrophic cardiomyopathy: a longitudinal study. J Am Coll Cardiol 15 (6):1279-85. PMID: 2329232
- ↑ Russell JW, Biller J, Hajduczok ZD, Jones MP, Kerber RE, Adams HP (1991) Ischemic cerebrovascular complications and risk factors in idiopathic hypertrophic subaortic stenosis. Stroke 22 (9):1143-7. PMID: 1822968
- ↑ Shigematsu Y, Hamada M, Mukai M, Matsuoka H, Sumimoto T, Hiwada K (1995) Mechanism of atrial fibrillation and increased incidence of thromboembolism in patients with hypertrophic cardiomyopathy. Jpn Circ J 59 (6):329-36. PMID: 7666571
- ↑ Hirsh J (1991) Oral anticoagulant drugs. N Engl J Med 324 (26):1865-75. DOI:10.1056/NEJM199106273242606 PMID: 1801769
- ↑ January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
- ↑ 12.0 12.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA; et al. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". J Am Coll Cardiol. 57 (11): e101–98. doi:10.1016/j.jacc.2010.09.013. PMID 21392637.
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199