How does Graves' disease cause right heart failure?

From the Guidelines

Graves' disease can lead to right heart failure through a cascade of cardiovascular effects triggered by thyrotoxicosis, ultimately causing pressure overload on the right ventricle and leading to right heart failure, as supported by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The excessive thyroid hormones in Graves' disease cause a hyperdynamic circulatory state with increased heart rate, stroke volume, and cardiac output. This persistent high-output state places significant strain on the heart, eventually leading to high-output heart failure. Some key points to consider in the development of right heart failure in Graves' disease include:

• Increased pulmonary vascular resistance due to autoimmune-mediated pulmonary endothelial damage, increased pulmonary blood flow from the hyperdynamic circulation, and left ventricular dysfunction
• Pressure overload on the right ventricle, leading to right ventricular hypertrophy, dilation, and eventually right heart failure
• The importance of controlling the hyperthyroidism with antithyroid medications, beta-blockers, and definitive therapy with radioactive iodine or thyroidectomy, as prompt treatment can lead to reversal of cardiac manifestations, including right heart failure, when euthyroidism is restored, as noted in the guidelines for the management of adults with congenital heart disease 1. The 2012 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure also highlight the importance of cautious use of diuretics and vasodilators in patients with isolated right ventricular failure, such as those with pulmonary hypertension 1. Overall, the management of Graves' disease and its cardiac complications, including right heart failure, requires a comprehensive approach that addresses the underlying thyroid dysfunction and its effects on the cardiovascular system, with the goal of improving morbidity, mortality, and quality of life.

From the Research

Graves Disease and Right Heart Failure

• Graves disease is an autoimmune disorder that can lead to hyperthyroidism, which in turn can cause various cardiovascular complications, including right heart failure 2.
• The exact mechanism of how Graves disease causes right heart failure is not fully understood, but it is thought to be related to the increased levels of thyroid hormones, which can lead to increased heart rate, cardiac output, and pulmonary vascular resistance 2.
• Severe pulmonary hypertension is a known complication of Graves disease, and it can lead to right heart failure 2.
• A case study reported a patient with Graves disease who presented with bi-ventricular heart failure, severe pulmonary hypertension, and pre-eclampsia during pregnancy, highlighting the importance of considering Graves disease as a possible cause of cardiovascular complications in pregnancy 2.

Treatment of Graves Disease

• The treatment of Graves disease typically involves antithyroid medications, radioactive iodine ablation, or surgical thyroidectomy 3, 4, 5.
• Antithyroid medications, such as methimazole and propylthiouracil, can help control hyperthyroidism, but they may not address the underlying cardiovascular complications 6, 4.
• Radioactive iodine ablation and surgical thyroidectomy can provide a more definitive treatment for Graves disease, but they may also have potential risks and complications 3, 5.

Cardiovascular Complications of Graves Disease

• Graves disease can cause various cardiovascular complications, including tachycardia, anxiety, and tremor, which can be relieved with beta-blockers 5.
• The disease can also lead to more severe cardiovascular complications, such as bi-ventricular heart failure and severe pulmonary hypertension, which require prompt and effective treatment 2.
• A high index of clinical suspicion is necessary to diagnose Graves disease as a possible cause of cardiovascular complications, especially in pregnancy 2.