Rajiv Gandhi University of Health Sciences, Karnataka s52

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE, KARNATAKA

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE Dr. SHASHIKANTH.M, AND ADDRESS (in Block Letters) S/O.SRINIVAS.M, BEHIND KALMAT BRAHMIN STREET, SINDHANUR 584128, RAICHUR (DIST). KARNATAKA. 2 NAME OF THE INSTITUTION J.J.M. MEDICAL COLLEGE DAVANGERE – 577 004, KARNATAKA.

3 COURSE OF STUDY AND POSTGRADUATE DEGREE SUBJECT M.D. GENERAL MEDICINE

4 DATE OF ADMISSION TO 14-05-2012. COURSE

5 TITLE OF THE TOPIC “CROSS SECTIONAL STUDY OF CARDIAC DYSFUNCTION IN HYPOTHYRODISM”

6 BRIEF RESUME OF THE INTENDED WORK:

6.1 Need for the study:

Cardiovascular complications are some of the most profound and reproducible clinical findings associated with thyroid disease.1 Hypothyroidism is associated with increased cardiovascular mortality and morbidity. The dysfunction ranges from functional systolic/diastolic dysfunction to overt failure and coronary artery disease. There are only few studies done in our country to assess the cardiovascular parameters in hypothyroid patients. Cardiac abnormalities associated with hypothyroidism attracted a great deal of investigation efforts.

Thus the need of this study is to assess the CVS parameters in new hypothyroid patients by ECG and ECHO. The completely reversible nature of these complications is well known.

Hence this study aims at studying the cardiac manifestations of hypothyroidism, thereby reassessing the need for early recognition and more aggressive management of the disease, aiming at preventing the aforementioned complications.

6.2 Review of Literature:

Hypothyroidism is a clinical syndrome resulting from a deficiency of thyroid 2 hormones, which in turn results in a generalized slowing down of metabolic processes.

The clinical syndrome of hypothyroidism was first described by Gull in 1874.

The word ‘‘Myxoedema Heart” was first classically described by Zondek in 1918.

Recent study concluded that prevalence of hypothyroidism was 3.9%. The prevalence of subclinical hypothyroidism was also high in this study, the value being 9.4%. In women, the prevalence was higher, at 11.4%, when compared with men, in whom the prevalence was 6.2%. The prevalence of subclinical hypothyroidism increased with age.3

Patients presents with tiredness, weakness, dry skin, feeling cold, hair loss, constipation, hoarse voice, menstrual disturbance, signs include dry coarse skin, puffy face, bradycardia, delayed ankle relaxation etc.

 Haemodynamic alterations in hypothyroidism cause narrowing of pulse pressure, prolongation of circulation time and decrease in blood flow to tissues. In severe primary hypothyroidism the cardiac silhouette is enlarged and heart sounds decrease in intensity due to pericardial effusion.4

 Cardiovascular findings of hypothyroidism are more subtle. Signs and symptoms of hypothyroidism include mild degree bradycardia, diastolic hypertension, a narrowed pulse pressure, cold intolerance and quiet precardium. Pericardial effusion can occur in hypothyroidism consistent with observation that patient has an increase in volume of distribution of albumin and a decrease in lymphatic clearance function.5

 Hypothyroidism produce changes in cardiac contractility, myocardial oxygen consumption, cardiac output, blood pressure and systemic vascular resistance. Hypothyroidism is associated with decreased cardiac output and accelerated atherosclerosis and coronary artery disease. A variety of case reports demonstrated that hypothyroidism may cause prolongation of QT interval. They can develop protein rich pericardial effusion.6

 In hypothyroidism and myxedema, reversible diastolic abnormalities have been reported. In a 2D echocardiographic study asymmetric septal hypertrophy was found in 17 of 19 patients. Presence of prolonged ventricular relaxation time in hypothyroid patients have been confirmed. As hypothyroidism is often associated with hypercholesterolemia, coronary artery disease is common in this population.7

 Subclinical hypothyroidism is associated with impaired left ventricular diastolic function at rest, systolic dysfunction on effort and enhanced risk for atherosclerosis and myocardial infarction.8

 Echocardiography is useful in assessing the response to replacement therapy. With replacement therapy hypothyroid patients showed a decrease in wall thickness.9

 ECG changes observed in patients with hypothyroidism include:10

1. Sinus bradycardia. 2. Sinus tachycardia. (Rare) 3. QT prolongation. 4. Decreased amplitude of P waves 5. Ventricular tachycardia. 6. Low voltage complexes. 7. Atrioventricular and interventricular block. 8. Incomplete or complete Right Bundle Branch Blocks. 9. Atrial fibrillation

6.3 Objectives of the Study:

 To study cardiac manifestations in newly diagnosed hypothyroid patients by ECG and ECHO

7. MATERIALS AND METHODS

7.1 Source of Data:

50 patients, both male and female with hypothyroidism presenting to the OPD and patients admitted in Bapuji Hospital and Chigateri Government Hospital attached to J.J.M. Medical College will be included in this study.

7.2 Method of collection of Data (including sampling procedures if any):

50 patients, with hypothyroidism presenting to the OPD or getting admitted in Bapuji Hospital and Chigateri Government Hospital will be studied using random sampling methods over a period of one and half years. Patient will be studied with the following investigations.

Investigations.

 T3, T4, TSH - 3 ml of early morning fasting samples containing plain clotted blood are collected and sent for T3, T4, TSH estimation. The hormone estimation is done by chemiluminescence assay.

 Hemoglobin, TC, DC, ESR.

 Urine routine

 RBS

 Blood urea

 Serum creatinine

 Lipid profile

 Standard 12 lead ECG

 Echocardiography Inclusion criteria:

Hypothyroid patients which include

a) Newly diagnosed patients

b) Age above 18 years.

Exclusion criteria:

a) Patients with known cardiac disease.

b) Patients with COPD, severe anemia, diabetes mellitus or any other endocrine disorder.

c) Patients taking medications that alter the thyroid function like beta blockers, lithium, OCP’s, alcohol.

Study design:

A Cross sectional clinical study consisting of 50 new cases of hypothyroidism is undertaken to study the cardiac manifestations by ECG and ECHO.

7.3 Does the Study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.

ECG, ECHO, thyroid profile, complete hemogram, lipid profile, RBS Blood urea, serum creatinine.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes 8. LIST OF REFERENCES

1) Rawat and Satyal. An echocardiographic study of cardiac changes in hypothyroidism and the response to treatment, Kathmandu University Medical Journal. 2003;(2), No. 3, Issue 7: 182- 187.

2) J.Larry Jameson, Anthony P. Weetman. Disorders of thyroid gland. In: Longo DL, Jameson JL, Fauci AS, Hauser SL Loscalzo J, Editors Harrison’s principles of internal medicine. Chapter-341, 18th edition; 2011(2):2918-2922.

3) Ambika Gopalakrishnan, Unnikrishnan, Usha V Menon. Thyroid disorders in India: An epidemiological perspective. Indian journal of endocrinology and metabolism.2011; (15):P:78-81.

4) Larsen RP, Davis FT. Hypothyroidism and Thyroiditis 10th ed. Chapter 12. In: William’s text book of Endocrinology, Larsen, Kronenberg, Melmed, Polonsky, eds. Philadelphia: Saunders; 2003:423-55.

5) Klein I. Endocrine Disorders and Cardiovascular Disease. 8th ed. Chapter 81. In: Braunwald’s Heart Disease, Libby, Bonow, Mann, Zipes. eds. Philadelphia: Saunders; 2008:432-49.

6) Klein I, and Danzi S, Thyroid Disease and the Heart. Circulation 2007; 116: 1725-35.

7) Polikar R, Burger GA, Scherrer U, Nicod P. The Thyroid and the Heart. Circulation 1993; 87: 1435-41.

8) Biondi B, Palmieri AE, Lombardi G, Fazio S. Effects of Subclinical Thyroid Dysfunction on the Heart, Annuals of Internal Medicine 2002; 137: 904-14.

9) Rawat B, Satyal A. An echocardiographic study of cardiac changes in hypothyroidism and the response to treatment. Kathmandu University Medical Journal. 2004 Jul-Sep; 2(3): 182-7.

10) Goldberger. Clinical electrocardiography.7th edition, 2012:132. 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE As prevalence of clinical and subclinical hypothyroidism is high ,it is interesting to study CVS involvement and its effects

11. NAME & DESIGNATION OF (in block letters) 11.1 GUIDE Dr.VISHWANATH.B.M. MD MRCP(UK) PROFESSOR , DEPT OF GENERAL MEDICINE, J.J.M MEDICAL COLLEGE, DAVANGERE-577004.

11.2 SIGNATURE

11.3 CO-GUIDE (if any)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT Dr.S.N.VISHWAKUMAR MD PROFESSOR AND HEAD, DEPT OF GENERAL MEDICINE, J.J.M.MEDICAL COLLEGE, DAVANGERE-577004

11.6 SIGNATURE

12. 12.1 REMARKS OF THE CHAIRMAN & THE PRINCIPAL

12. 2 SIGNATURE