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Treatment of Myxedema-Associated Cardiogenic Shock
- Irwin Klein, MD
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TO THE EDITOR:
MacKerrow and colleagues [1] reported on the ability of triiodothyronine to treat cardiogenic shock resulting from severe hypothyroidism (myxedema); however, certain points must be clarified.
First, the authors conclude that their patient had Sheehan syndrome because she was unable to lactate after her last pregnancy. In the absence of significant hemorrhage or obstetrical trauma, an equally likely diagnosis would be lymphocytic hypophysitis [2], which would account for secondary adrenal and thyroid failure.
That the patient failed to improve and, in fact, worsened over the first 5 days while receiving therapy with oral L-thyroxine, 50 g/d, is not surprising. As they suggest, hypothyroidism may impair the absorption of orally administered thyroid hormone. In addition, the doses of thyroxine were less than those usually required for inducing rapid cellular and clinical responses. This is confirmed by the failure of the serum thyroxine level to increase after 8 days of treatment.
Much of the hemodynamic improvement after triiodothyronine treatment can be explained by decreases in systemic vascular resistance. Recent observations suggest that one of the major sites of action of thyroid hormone is in the peripheral circulation and specifically at the level of regulating tone of vascular smooth muscle cells [3, 4]. If indeed these direct effects are relatively specific for triiodothyronine, then the current case would suggest that intravenous triiodothyronine may be the treatment of choice in severe hypothyroidism associated with impaired cardiac performance. Known or suspected coexistent ischemic heart disease, however, requires that the triiodothyronine dose be at physiologic replacement levels and that the patient be carefully monitored.
That the patient continued to manifest left ventricular dysfunction long after both the adrenal insufficiency and hypothyroidism were treated is consistent with our observation that true heart failure accompanying hypothyroidism should suggest underlying left ventricular dysfunction [5].
Irwin Klein
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
