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Reviews: Lewis J. Rubin and David B. Badesch Evaluation and Management of the Patient with Pulmonary Arterial Hypertension Ann Intern Med 2005; 143: 282-292 [Abstract] [Full text] [PDF]

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Thyroid Disease and Pulmonary Artery Hypertension

Lewis J Rubin, David B. Badesch   (17 October 2005)

Thyrotoxicosis as a risk factor for pulmonary hypertension

Ronald C Ma, Chun Chung Chow   (6 September 2005)

Thyroid Disease and Pulmonary Artery Hypertension 17 October 2005
Lewis J Rubin, MD University of California, San Diego, David B. Badesch Send rapid response to journal: Re: Thyroid Disease and Pulmonary Artery Hypertension ljrubin{at}ucsd.edu Lewis J Rubin, et al.	Dear Sir: We agree with Ma and Chow that there is some justification for screening patients with pulmonary arterial hypertension (PAH) for thyroid dysfunction. We were among the first to make the observation that thyroid abnormalities might occur with increased frequency in patients with PAH (1). In that report, we speculated that there might be a common underlying autoimmune disorder. The concept that antithyroid antibodies could play a role in the pathogenesis of PAH is indeed quite intriguing, and there have been a number of subsequent reports of both hypo- and hyper-thyroidism occurring in patients with pulmonary hypertension (2-5), although a causal relationship has not been proven. Irrespective of whether thyroid disease and PAH share a common pathogenic mechanism, their frequent coexistence is important to recognize: thyroid disease produces cardiovascular stresses that are poorly tolerated in the setting of PAH and should therefore be treated aggressively. However, beta adrenergic-receptor blockers, which are commonly used as adjunct therapy in hyperthyroidism, may precipitate worsening of right ventricular dysfunction and should be avoided or used very cautiously. Lewis J. Rubin, MD La Jolla, CA David B. Badesch, MD Denver, CO 1 Badesch DB, Wynne KM, Bonvallet S, et al. Hypothyroidism and primary pulmonary hypertension: an autoimmune pathogenetic link? Ann Intern Med 1993; 119:44-46 2 Arroliga AC, Dweik RA, Rafanan AL. Primary pulmonary hypertension and thyroid disease. Chest 2000; 118:1224-1225 3 Curnock AL, Dweik RA, Higgins BH, et al. High prevalence of hypothyroidism in patients with primary pulmonary hypertension. Am J Med Sci 1999; 318:289-292 4 Ferris A, Jacobs T, Widlitz A, et al. Pulmonary arterial hypertension and thyroid disease. Chest 2001; 119:1980-1981 5 Kashyap AS, Kashyap S. Thyroid disease and primary pulmonary hypertension. JAMA 2001; 285:2853-2854 Conflict of Interest: None declared
Thyrotoxicosis as a risk factor for pulmonary hypertension 6 September 2005
Ronald C Ma, MB BChir, MRCP Prince of Wales Hospital, Chinese University of Hong Kong, Chun Chung Chow Send rapid response to journal: Re: Thyrotoxicosis as a risk factor for pulmonary hypertension rcwma{at}cuhk.edu.hk Ronald C Ma, et al.	Dear sir, We read with interest the recent review by Rubin et al on the evaluation and management of patients with pulmonary arterial hypertension. Whilst the authors have pointed out the importance of assessing for underlying autoimmune ˇVcollagen vascular disease, the need to assess for thyroid dysfunction and autoimmune thyroid disease was not addressed. Previous studies have suggested a link between primary pulmonary hypertension and autoimmune thyroid disease (1). More recently, it has become apparent that thyrotoxicosis is itself an important risk factor for pulmonary hypertension (2, 3). This may partly be due to the haemodynamic effects of hyperthyroidism, as biochemical improvement in thyroid function following treatment has been associated with improvement in pulmonary hypertension on Doppler echocardiography (2, 4). However, there is also evidence suggesting that thyroid autoantibodies present in autoimmune thyroid disease may have a direct role in the pathogenesis of the pulmonary hypertension by contributing to pulmonary vascular endothelial injury. This is supported by a report of pulmonary hypertension associated with neonatal thyrotoxicosis due to transplacental passage of thyroid-stimulating immunoglobulins, and complete reversal of pulmonary hypertension following treatment of the thyrotoxicosis (5). All patients with pulmonary arterial hypertension should be evaluated for thyroid dysfunction as this may be a readily treatable and reversible cause of pulmonary arterial hypertension. 1. Chu JW, Kao PN, Faul JL, Doyle RL. High prevalence of autoimmune thyroid disease in pulmonary arterial hypertension. Chest. 2002;122(5):1668-73. 2. Nakchbandi IA, Wirth JA, Inzucchi SE. Pulmonary hypertension caused by Graves' thyrotoxicosis: normal pulmonary hemodynamics restored by (131)I treatment. Chest. 1999;116(5):1483-5. 3. Marvisi M, Brianti M, Marani G, Del Borello R, Bortesi ML, Guariglia A. Hyperthyroidism and pulmonary hypertension. Respir Med. 2002;96(4):215-20. 4. Merce J, Ferras S, Oltra C, et al. Cardiovascular abnormalities in hyperthyroidism: a prospective Doppler echocardiographic study. Am J Med. 2005;118(2):126-31. 5. O'Donovan D, McMahon C, Costigan C, Oslizlok P, Duff D. Reversible pulmonary hypertension in neonatal Graves disease. Ir Med J. 1997;90(4):147-8.