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Heart Size in Thyrotoxicosis

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Heart Size in Thyrotoxicosis Postgrad Med J: first published as 10.1136/pgmj.44.518.885 on 1 December 1968. Downloaded from Postgrad. med. J. (December 1968) 44, 885-890. Heart size in thyrotoxicosis J. S. STAFFURTH N. D. W. MORRISON M.D., F.R.C.P. D.M.R.D. Consultant Physician Consultant Radiologist Lewisham Hospital, London, S.E.13 Sunmary ingly little information on any change in the (1) Enlargement of the heart was found in size of the heart that may occur after treatment 35 % of a group of older patients with thyro- of the thyrotoxicosis whether sinus rhythm or toxicosis who had no evidence of associated AF was present originally. heart disease. Atrial fibrillation was present in In this study the chest X-rays have been ex- 48% of patients with cardiac enlargement and in amined retrospectively in a selected series of 10% with a normal sized heart. Both complica- patients with thyrotoxicosis who were referred tions were more common when there was associ- for treatment with radioactive iodine, and where ated heart disease. possible, these have been compared with X-rays (2) In patients with an enlarged heart but no after completion of treatment when the patients associated heart disease a reduction in heart-size were euthyroid. after treatment of thyrotoxicosis was observed in Protected by copyright. five of twenty-three who had sinus rhythm Subjects and methods throughout, and in three of eleven who had The patients have been drawn from 239 con- atrial fibrillation on presentation with subsequent firmed cases of thyrotoxicosis who were treated reversion to sinus rhythm. There was no reduc- with radioactive iodine in Lewisham Hospital tion in heart size in ten who had persistent atrial from 1958 to 1965. In some instances, the first fibrillation after completion of treatment. Reduc- chest X-ray and preliminary treatment had been tion in heart size was most marked in patients performed at other hospitals in the area. The sub- who had presented with frank cardiac failure. jects are a selected group because only older (3) The incidence of cardiac enlargement and patients are normally accepted for this treat- atrial fibrillation both increased with advancing ment, and many of them were particularly age but whereas enlargement was common over referred because of the presence of heart disease. 45 years atrial fibrillation was rarely seen under Many of the subjects have been included in other 55 years of age. Only one of thirteen patients reports from our department dealing with dif- with an enlarged heart under 55 years had atrial ferent aspects of management with radioactive http://pmj.bmj.com/ fibrillation. iodine (Staffurth, Gibberd & Hilton, 1965; (4) It is concluded that enlargement of the heart Staffurth & Young, 1967). may be a manifestation of thyrotoxic heart The heart size has been measured direct on disease, that it may precede the onset of atrial standard PA chest X-rays at 6 ft. The trans- fibrillation in some instances, and consequently verse diameter of the heart (t.d.) was determined that atrial fibrillation is not necessarily the cause as the sum of the greatest distances from the of an enlarged heart in thyrotoxicosis. mid-line to the right and left cardiac borders, on September 26, 2021 by guest. care being taken to exclude epipericardial fat and Introduction any other non-cardiac shadow. The internal Although the heart is involved from the onset transverse diameter (i.d.) of the thorax was in most patients with thyrotoxicosis since sinus measured as the greatest distance between the tachycardia is one of the cardinal signs, the inner borders of the ribs. The cardio-thoracic term Thyrotoxic Heart Disease is usually re- ratio (CTR) was determined by expressing t.d. as served for patients with atrial fibrillation (AF) a percentage of i.d. (Lusted & Keats, 1967). For or congestive cardiac failure (Wood, 1961). En- descriptive purposes the CTR has arbitarily been largement of the heart with sinus rhythm may considered to be normal when less than 50%. also occur in thyrotoxicosis but this is not so In the follow-up X-rays, which were taken at widely recognized, though it is quite common varying intervals between 6 months and 5 years (Parkinson & Cookson, 1931). There is surpris- after treatment, a difference in t.d. of 1-0 cm or Postgrad Med J: first published as 10.1136/pgmj.44.518.885 on 1 December 1968. Downloaded from 886 J. S. Staffurth and N. D. W. Morrison less has not been considered a significant change. whom twenty-one had AF and twenty-three were Hypertension has been considered to be pre- in sinus rhythm. Following treatment eleven of sent in any patient in whom the diastolic blood the patients with AF reverted to sinus rhythm, in pressure before treatment was 100 mmHg or five of whom there was no change in heart size; more. Ischaemic heart disease has been diag- in three there was a marked reduction in size and nosed when either there was a history of angina in three there was further increase in size, all of pectoris or a frank myocardial infarct; or if whom had gained a considerable amount of there were unequivocal changes on the electro- weight. None of the patients with persistent AF cardiogram of S-T depression, T wave inversion after treatment showed any reduction in heart or bundle branch block (Sandler & Wilson, 1959; size. Following treatment of those in sinus Summers & Surtees, 1961). rhythm, there was no change in heart size in thirteen, it became moderately smaller in three Results and markedly smaller in two. One of the two Satisfactory chest X-rays were available for patients who had a marked diminution in heart assessment in 175 patients, of whom twenty-two size following treatment had presented with frank had hypertension, sixteen had ischaemic heart cardiac failure (R.L., Table 3) but in the other, disease, eight had rheumatic heart disease, one a female aged 50 who had severe thyrotoxicosis, had a ventricular septal defect and one had there had been only moderate exertional severe anaemia. In the remainder an original dyspnoea. In another patient with sinus rhythm film had never been taken, it had been destroyed throughout, who had had a prior chest X-ray or mislaid, or it had to be rejected because of de- for an unrelated condition, there was an in- formity of the chest wall. crease in t.d. of 1-5 cm in 6 months with the development of thyrotoxicosis and a return to Heart size before and after treatment of thyro- the original heart size after treatment. Protected by copyright. toxicosis in cases without associated heart disease (see Table 1) Heart size before and after treatment of thyro- There were 127 patients in whom thyro- toxicosis in cases with associated hypertension toxicosis was the only clinical cause of heart or ischaemic heart disease disease and in eighty-three the heart was normal There were thirty-eight patients with thyro- in size. Follow-up chest X-rays were not re- toxicosis who had hypertension, ischaemic heart quested in the seventy-five subjects with sinus disease or both, of whom twelve, two with AF, rhythm and a normal sized heart. In eight sub- had a normal sized heart. The heart was en- jects with AF and a normal sized heart there larged in twenty-six, of whom fourteen had AF was no change in size after treatment in the six and twelve were in sinus rhythm. Any changes in instances where a second film was available, heart size in these patients is summarized in whether or not they had reverted to sinus rhythm. Table 2. A comparison of the two tables shows The heart was enlarged in forty-four cases, of that relatively more subjects with associated heart http://pmj.bmj.com/ BLE 1 Change in heart size after treatment of thyrotoxicosis in patients without associated heart disease Transverse diameter of heart Size of heart Not >2-1 cm 1 1-2 cm No 1 1-2 cm available smaller smaller change larger Cardio-thoracic ratio <50% on September 26, 2021 by guest. fSR (75) 75 Total (83) A ( Reverted to SR (3) - 3 AF (8) Persistent AF (5) 2 3 Cardio-thoracic ratio > 50 % fSR(23) 5 2 3 13 - Total (44) Reverted to SR (11) 3 0 5 3 fAF(21)A Persistent AF (10) 2 7 1 SR - Sinus rhythm; AF - Atrial fibrillation. Postgrad Med J: first published as 10.1136/pgmj.44.518.885 on 1 December 1968. Downloaded from Heart size in thyrotoxicosis 887 TABLE 2 Change in heart size after treatment of thyrotoxicosis in patients with associated hypertension or ischaemic heart disease Transverse diameter of heart Size of heart Not >2-1 cm 1-1-2 cm No 1P1-2 cm available smaller smaller change larger Cardio-thoracic ratio <50% fSR (10) 7 - - 3 Total (12) 2 Reverted to SR (2) 2 AF (2) VPersistent AF (0) Cardio-thoracic ratio > 50 % fSR (12) 1 - 1 9 1 Total (26) Reverted to SR AF (14) (8) 2 1 5 Persistent AF (6) 3 - 2 1 SR = Sinus rhythm; AF = Atrial fibrillation. disease had cardiac enlargement and AF, but portional increase in the incidence of AF, which that the proportion with AF who reverted to was uncommon under 55 years. Protected by copyright. sinus rhythm when euthyroid was approximately the same in both groups, irrespective of the original size of the heart. Changes in heart size in severe cardiac failure (Table 3) Ten patients had severe cardiac failure on to 0 admission hospital. In four this was due to U thyrotoxicosis only, two had associated hyper- 0 tension and four had mitral valve disease.
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