Cardiac Considerations

in Systemic Diseases

ERWIN AZMAR

DIVISION OF CARDIOLOGY DEPARTMENT OF INTERNAL MEDICINE

UNIVERSITY OF SRIWIJAYA PALEMBANG

2017
 Cardiac Considerations in Systemic Diseases

 CVD in Pregnancy
 Aging and CV system
 Neuromuscular Diseases and the Heart
 CV Manifestations of Endocrine Diseases
 Connective Tissue Diseases and the Heart
 Cardiac Tumors
 PH and Thromboembolic Diseases
 Substance Abuse and the Heart
 HIV and the Heart
 Sleep disorders and the CV System
 CV Toxicity of Noncardiac Medications
 Sudden Cardiac Death in Athletes
 Thyroid Disorders

Hyperthyroidism
 Graves’ disease & Toxic multinodulars goiter
 Tachycardia, palpitation, dyspnea, HF
 Cardiac dysrhythmia : AF
 PF : hyperdinamic precordium, accentuated heart
sound, systolic murmur, MVP
 T3, T4, TSH
 Anti Thyroid Drugs
Thyroid hormone exerts a major influence on the cardiovascular system by a
number of direct and indirect mechanisms, and not surprisingly, cardiovascular
effects are prominent in both hypo- and hyperthyroidism.

Thyroid hormone causes increases in total-body metabolism and oxygen

consumption that indirectly place an increased work load on the heart. In addition,
although the exact mechanism has not been defined, thyroid hormone exerts direct
inotropic, chronotropic, and dromotropic effects that are similar to those seen with
adrenergic stimulation (e.g., tachycardia, increased cardiac output).

Thyroid hormone increases the synthesis of myosin and of Na, K-ATPase, as well as
the density of myocardial –adrenergic receptors.
Figure 1. T3 effects on the cardiac myocyte.

Irwin Klein, and Sara Danzi Circulation. 2007;116:1725-1735

Copyright © American Heart Association, Inc. All rights reserved.

Figure 2. Effects of thyroid hormone on cardiovascular hemodynamics.

Irwin Klein, and Sara Danzi Circulation. 2007;116:1725-1735

Copyright © American Heart Association, Inc. All rights reserved.
Figure 4. Low T3 syndrome and ejection fraction as predictors of mortality.

Irwin Klein, and Sara Danzi Circulation. 2007;116:1725-1735

Copyright © American Heart Association, Inc. All rights reserved.
Hypothyroidism

 Autoimmune, Hashimoto’s
 Unrecognized (Occurs over a periode of several years)
 ↑ peripheral vascular resistance, ↓ SV & CO
 ↓ cardiac contractility, pericardial effusion
 PF : Slow pulse, diastolic hypertension, soft heart
sounds, non pitting peripheral edema
 ECG : bradycardia, low voltage, AV block
 Tx : Thyroid Hormone Replacement
Figure 1. Thyroid function and HF progression: the vicious pathophysiological circle.

Anthony Martin Gerdes, and Giorgio Iervasi Circulation. 2010;122:385-393

Copyright © American Heart Association, Inc. All rights reserved.
 Diabetes Mellitus

 ↑ incidence of atherosclerosis
 Hypertension
 Risk factor for CAD
 Cardiomyopathy
There is an increased incidence of large-vessel atherosclerosis and myocardial

infaction in patients with both insulin- and non insulin dependent DM

Coronary artery disease is the most common cause of death in adults with

diabetes mellitus. Diabetes mellitus is an independent risk factor for coronary

artery disease and the incidence of coronary artery disease is related to the

duration of diabetes.

In patients with diabetes mellitus, myocardial infarctions

are not only more frequent but also tend to be larger in size and more

likely to result in complications such as heart failure, shock, and death.

How Diabetes influence our Heart ?
Development and progression of atherosclerosis
in diabetes mellitus

Low Wang et al, Circulation June 14, 2016

DM associated with the development of premature cardiovascular disease (CVD),
which relates to the clustering of risk factors such as dyslipidaemia, hypertension,
obesity and hyperglycaemia in the presence of insulin resistance. associated with an
inflammatory and pro-thrombotic environment, exacerbating the development of
atherothrombosis.

Insulin resistance and hyperglycaemia both contribute to the development of

endothelial cell dysfunction and increased oxidative stress, culminating in
accelerated atherosclerosis. Clot formation and function are also directly affected by
insulin resistance and hyperglycaemia, with increased levels of coagulation factors
and anti-fibrinolytic proteins and a fibrin network that is more resistant to lysis,
coupled with increased platelet activation.

The intensification of glycaemic control leads to a reduction in microvascular

complications in type 1 and type 2 diabetes; however, the same is less clear with
macrovascular disease. The overall interpretation of several trials suggests that
intensive glycaemic control in patients with a relatively short duration of diabetes,
without very poor control and with no CVD, might be safe and associated with fewer
cardiovascular events.
R. J. King , P. J. Grant, Herz, May 2016, Volume 41, Issue 3, pp 184–192
 Connective Tissue Diseases

 Rheumatoid arthritis
 Systemic lupus erythematosus
 Ankylosing spondylitis
 Inflammatory myopathy
 Scleroderma
 Antiphospholipid syndrome
 Systemic Lupus Erythematosus

 Multisystem autoimmune disorder

 Female : Male = 10 : 1
 Pericardium and endocardium involved
 Cardiac tamponade
 Thromboembolic phenomena
 Conduction abnormalities, Myocarditis
 Hyperhomocysteinema  CAD
 Tx : steroid, cytotoxic agents
Vascular Disease and Lupus

Hahn B, NEJM Dec 2003

Peripartum Heart Disease
Beri beri Heart Disease
Beriberi caused due to deficiency of Vitamin B1 --- individuals who
consumepolished or refined rice gets beri beri. Alcoholics -- generally retards the
absorption of the vitamin.symptoms: weakness irritable
nature,depression,drowsiness ,loss ofsleep,appetite ,nausea,abdominal discomfort.

Eventual symptos: peripheral neuritis,cramping of leg muscles,

psychologicaldistrubances,CHF.

Depending upon the symptoms beriberi it classified in to 4 types.

1.Dry Beriberi: peripherial neuritis,muscular atrophy,numbness,burning
sensationof legs.wasting of muscles,paralysis in children ,tachycardia.
2.Wet beriberi: vomiting,waxyskin,albuminuria and casts in urine.
3. Acute pernicious beriberi: leasions in cardiac tissue,peripheral nerves and
skincardiomegaly,edematous legs , finally death results due to cardiac failure.
THANK YOU