Heart in Overt and Subclinical Hypothyroidism

  • Bernadette BiondiEmail author


Important changes in cardiac structure and function have been reported in patients with hypothyroidism, whose severity depends on the degree and duration of thyroid hormone deficiency. The most important cardiac abnormality in patients with overt and subclinical hypothyroidism is the impairment of the left ventricular diastolic function, which is characterized by an altered myocardial relaxation and ventricular filling. Left ventricular systolic and diastolic dysfunctions at rest and during effort have been documented by sensitive techniques such as Doppler echocardiography, cardiac magnetic resonance imaging, and radionuclide ventriculography. Cardiovascular hemodynamic is progressively worsened in long-term untreated hypothyroidism, leading to heart failure in patients with overt and severe subclinical hypothyroidism. Data from prospective cohorts show that the risk of HF events is significantly increased among patients with TSH greater than 10.0 mU/L.

Thyroid hormone deficiency is usually associated with lipid abnormalities, especially increased total and LDL cholesterol, triglycerides, and lipoprotein (a). Overt and subclinical hypothyroidism can increase the risk of atherosclerosis by several mechanisms. It can impair vascular function by increasing systemic vascular resistance and arterial stiffness and by altering endothelial function, thereby increasing the possibility of atherosclerosis and coronary disease. More severe vascular and metabolic adverse effects have been reported in patients with serum TSH above 10 mU/L and in those with insulin resistance. A meta-analysis of individual participant data from 11 prospective studies on subclinical hypothyroidism demonstrated a significant trend toward an increased risk in both coronary heart disease events and mortality at higher serum TSH concentrations, particularly in participants with a TSH level of 10 mU/L or greater. Treatment with levothyroxine is recommended in hypothyroid patients with overt hypothyroidism and in those with serum TSH level above 10 mU/L.

Literature data support that mild subclinical hypothyroidism (TSH 4.5–9.9 mU/L) is linked to a greater cardiovascular risk in young people and indicate that replacement therapy is associated with a better outcome in these patients. The evidence of reversible cardiovascular abnormalities supports the indication for treating mild thyroid failure with appropriate doses of levothyroxine in young patients with cardiovascular risk factors.

Serum TSH is physiologically higher in older subjects. Thus, the diagnosis of subclinical hypothyroidism in elderly patients should only be considered when TSH is above its cut-off limits in an advanced age. Replacement therapy should only be considered in overt and severe hypothyroidism; an age-adjusted serum TSH should be obtained during levothyroxine therapy in the elderly.

Large randomized controlled studies will be necessary to assess the effects of levothyroxine therapy in patients with subclinical hypothyroidism.


Overt hypothyroidism Subclinical Mild hypothyroidism Cardiac morphology Systolic and diastolic function Exercise tolerance Heart failure Coronary heart disease events Coronary mortality 


Disclosure Statement

The author has nothing to disclose.


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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Clinical Medicine and SurgeryUniversity Federico II NaplesNaplesItaly

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