From the Guidelines
Uncontrolled Graves' disease can lead to several serious long-term complications, including increased risk of atrial fibrillation, heart failure, and cardiomyopathy, as well as bone loss and osteoporosis, particularly in older adults or those with pre-existing heart disease or osteopenia. The most concerning complications include thyroid storm, a life-threatening condition with extreme hyperthyroidism, and heart problems such as atrial fibrillation, heart failure, and cardiomyopathy due to the heart working overtime from increased metabolism 1. Graves' ophthalmopathy may develop, causing bulging eyes, double vision, and in severe cases, vision loss. Bone density can significantly decrease, leading to osteoporosis and increased fracture risk, especially in patients older than 60 years or those with estrogen deficiency 1. Patients may experience neuropsychiatric issues including anxiety, depression, and cognitive impairment. Untreated pregnant women face risks of miscarriage, preterm birth, and fetal thyroid dysfunction. Muscle weakness and wasting can occur, and some patients develop pretibial myxedema (skin thickening).
Key Complications
- Atrial fibrillation and heart failure
- Bone loss and osteoporosis
- Graves' ophthalmopathy
- Neuropsychiatric issues
- Increased risk of miscarriage, preterm birth, and fetal thyroid dysfunction in pregnant women
- Muscle weakness and wasting
- Pretibial myxedema
Management
Treatment typically involves antithyroid medications, radioactive iodine therapy, or thyroid surgery, depending on individual factors, with the goal of restoring a euthyroid state to prevent long-term complications 1. Beta blockers are effective in controlling the ventricular rate in patients with atrial fibrillation, and treatment with beta blockers is particularly important in cases of thyroid storm; nondihydropyridine calcium channel antagonists are recommended for rate control 1. Prompt recognition and effective management of cardiac and other organ-system manifestations are crucial to prevent morbidity and mortality.
From the Research
Long-term Complications of Uncontrolled Graves' Disease
The long-term complications of uncontrolled Graves' disease can be severe and affect various aspects of a patient's health. Some of the potential complications include:
- Cardiovascular consequences, such as congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension 2
- Increased risk of heart failure, with a study finding that 5.4% of patients with Graves' disease developed heart failure 3
- Atrial fibrillation, which can occur in patients with Graves' disease, especially those with overt hyperthyroidism, and is associated with higher mortality and cardiac hospitalizations 4
- Increased risk of cardiovascular hospitalizations and mortality, especially in patients with heart failure with reduced ejection fraction (HFrEF) 3
Risk Factors for Long-term Complications
Several risk factors have been identified for the long-term complications of uncontrolled Graves' disease, including:
- Atrial fibrillation, which is a significant risk factor for heart failure and cardiovascular hospitalizations 3, 4
- Higher thyrotropin receptor antibody (TRAb) levels, which are associated with an increased risk of heart failure 3
- Overt hyperthyroidism, which is a risk factor for atrial fibrillation and heart failure 3, 4
- Older age, chronic obstructive pulmonary disease, and higher body mass index (BMI), which are risk factors for heart failure with preserved ejection fraction (HFpEF) 3
Treatment and Management
Treatment and management of Graves' disease are crucial to preventing long-term complications. Some of the treatment options include:
- Antithyroid medications (ATMs), which can control thyrotoxicosis symptoms but may not correct the underlying etiology of the disease 5
- Radioactive iodine (RAI) therapy, which can manage thyrotoxicosis by destroying thyroid tissue 2, 5
- Surgery, which is a treatment option for patients with Graves' disease and is associated with a lower risk of long-term complications compared to medical treatment and RAI ablation 2