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Treatment of Myxedema-Associated Cardiogenic Shock
- Chris S. Mantzoros, MD; and
- Jyotsna Ravi, MD
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TO THE EDITOR:
The interesting report of a myxedema-associated cardiogenic shock treated with intravenous triiodothyronine [1] raised several questions.
Intravenous triiodothyronine rapidly normalizes both myocardial performance and metabolic abnormalities [2]; on the other hand, although most thyroxine-treated patients may respond clinically within 48 hours [3], it may take up to 1 week before beneficial effects are seen [1, 2]. Finally, a low-dose (25 g) triiodothyronine regimen for 1 week is equivalent to an equipotent (100 g) dose of thyroxine in reversing cardiac and metabolic abnormalities, although such a regimen is significantly less effective in lowering serum thyroid-stimulating hormone (TSH) levels [2].
The patient described by Mackerrow and colleagues [1] was started on triiodothyronine after having been on thyroxine for 1 week and continued to be on both for the rest of his hospitalization. Thus, it is unclear whether the hemodynamic improvement of this patient was attributable to a rapid effect of triiodothyronine, a late effect of thyroxine, or both.
Hypothyroidism may not only coexist with coronary artery disease [4], its associated symptoms and laboratory findings may be similar to those seen with a cardiovascular event [5]. Although triiodothyronine proved to be a rapidly effective and safe treatment for the major organ system consequences of hypothyroidism in a limited group of patients without evidence of ischemic heart disease [2], patients with clinically or electrocardiographically evident ischemic heart disease may require a course of gradual hormone replacement.
Because case reports support the effectiveness of both thyroxine and triiodothyronine for the treatment of myxedematous patients [1, 5] and because any controlled clinical study to define the treatment of choice for such patients would be extremely difficult [2], the recommendation for intravenous triiodothyronine therapy for all hypothyroid patients with severe heart failure seems to be premature.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright 2004 by the American College of Physicians
