• Amanj Abubakr Khaznadar Department of Medicine, College of Medicine, University of Sulaimani, Kurdistan Region, Iraq.
  • Aiman Muhammed Mareay Sulaimani Directory of Health and Kurdistan board Candidate, Kurdistan Region, Iraq.




Primary hypothyroidism, Echocardiogram, Electrocardiogram, Thyroid stimulating hormone



Hypothyroidism is a common clinical condition of variable prevalence in different regions that has significant effect on cardiovascular function. Deficiency of thyroid hormones can cause great changes in cardiovascular hemodynamics and regulation of cardiac function. Hypothyroidism directly influences vascular smooth muscles, provokes diastolic hypertension, changes coagulability, and increases the circulation level of highly atherogenic low-density lipoprotein (LDL) cholesterol particles, which consequently leads to an increase in the risk of atherosclerotic cardiovascular diseases. 


To identify the different cardiovascular manifestations and complications of primary hypothyroidism. 

Patients and methods

A cross-sectional retrospective study was carried out at Sulaimani Teaching Hospital in Sulaimani city, the Kurdistan Region of Iraq from July, first 2018 to Jun, first 2019. A total number of 103 patients were recruited in the study, of whom, 93 were females and 10 were males. The patients’ age ranged from (19 to 82) years. The patients were grouped based on their age, sex, residency, heart rate, blood pressure, BMI, and presence of other cardiovascular risk factors. All the participants were sent for thyroid function test (thyroid-stimulating hormone (TSH), and T4), electrocardiogram (ECG), and echocardiogram (Echo), with full history and clinical examination had been done.


The total number of cases were (103) patients with primary overt hypothyroidism who received thyroxin therapy. Their age group was between (19 and 82) years with a mean age of 50.99. Female predominance is obvious with a female-to-male ratio of about 9:1. The results showed that the patients’ age, sex, and family history of cardiovascular diseases did not have a significant association with the incidence of hypothyroidism or euthyroid (p>0.05). 


Cardiovascular risk factors were found to be associated with euthyroid and hypothyroid. Both electrocardiogram (ECG) and echocardiogram (Echo) were significantly effective in detecting cardiovascular complications in patients with thyroid disorders. TSH level assessed through thyroid function test was found as the more reliable means of detecting thyroid diseases.


Udovcic M, Pena RH, Patham B, Tabatabai L, Kansara A. Hypothyroidism and the Heart. Methodist Debakey Cardiovasc J. 2017;13(2):55-59. doi:10.14797/mdcj-13-2-55

Ramesh K, Nayak BP. A study of cardiovascular involvement in Hypothyroidism. 2016;3(5):74-80.

Garmendia Madariaga A, Santos Palacios S, Guillen-Grima F, Galofre JC. The incidence and prevalence of thyroid dysfunction in Europe: a meta-analysis. J Clin Endocrinol Metab. 2014;99:923–931.

Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet. 2017;390:1550–1562.

Asvold BO, Vatten LJ, Bjoro T. Changes in the prevalence of hypothyroidism: the HUNT Study in Norway. Eur J Endocrinol. 2013;169:613–620.

Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet (London, England). 2017;390(10101):1550-1562. doi:10.1016/S0140-6736(17)30703-1

Rastogi MV, LaFranchi SH. Congenital hypothyroidism. Orphanet J Rare Dis. 2010;5:17. doi: 10.1186/1750-1172-5-17.

Joseph G. Hollowell, Norman W. Staehling, W. Dana Flanders, W. Harry Hannon, Elaine W. Gunter, Carole A. Spencer, Lewis E. Braverman, Serum TSH, T4, and Thyroid Antibodies in the United States Population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III), The Journal of Clinical Endocrinology & Metabolism, Volume 87, Issue 2, 1 February 2002, Pages 489–499,

Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007;116(15):1725-1735. doi:10.1161/CIRCULATIONAHA.106.678326

Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med. 2001;344(7):501-509. doi:10.1056/NEJM200102153440707

Cappola AR, Ladenson PW. Hypothyroidism and atherosclerosis. J Clin Endocrinol Metab. 2003;88(6):2438-2444. doi:10.1210/jc.2003-030398

Chahine J, Ala CK, Gentry JL, Pantalone KM, Klein AL. Pericardial diseases in patients with hypothyroidism. Heart. April 2019. doi:10.1136/heartjnl-2018-314528

Meier C, Staub JJ, Roth CB, et al. TSH-controlled L-thyroxine therapy reduces cholesterol levels and clinical symptoms in subclinical hypothyroidism: a double blind, placebo-controlled trial (Basel Thyroid Study). J Clin Endocrinol Metab. 2001;86(10):4860-4866. doi:10.1210/jcem.86.10.7973

Danese MD, Ladenson PW, Meinert CL, Powe NR. Clinical review 115: effect of thyroxine therapy on serum lipoproteins in patients with mild thyroid failure: a quantitative review of the literature. J Clin Endocrinol Metab. 2000;85(9):2993-3001. doi:10.1210/jcem.85.9.6841

Ladenson PW, Singer PA, Ain KB. American Thyroid Association guidelines for detection of thyroid dysfunction. Arch Intern Med. 2000;160(11):1573–1575.

Morganti S, Ceda GP, Saccani M, Milli B, Ugolotti D, Prampolini R, et al Thyroid disease in the elderly: sex-related differences in clinical expression. J Endocrinol Invest. 2005;28(11 Suppl Proceedings):101-4

Musa IR, Gasim GI, Khan S, Ibrahim IA, Abo-Alazm H, Adam I. No Association between 25 (OH) Vitamin D Level And Hypothyroidism among Females. Open Access Maced J Med Sci. 2017;5(2):126–130. Published 2017 Mar 19. doi:10.3889/oamjms.2017.029

Manji N., Carr-Smith J.D., Boelaert K., Allahabadia A., Armitage M., Chatterjee V.K., et al. Influences of age, gender, smoking, and family history on autoimmune thyroid disease phenotype, J. Clin. Endocrinol. Metab. , 2006, vol. 91 (pg. 4873-4880).

Andrade LJ, Atta AM, Atta ML, Mangabeira CN, Parana R. Thyroid disorders in patients with chronic hepatitis C using interferon-alpha and ribavirin therapy. Braz J Infect Dis. 2011;15:377–381.

Boelaert K & Franklyn JA. Thyroid hormone in health and disease. Journal of Endocrinology2005 ;187:1–15.

Larsson SC, Allara E, Mason AM, Michaëlsson K, Burgess S. Thyroid Function and Dysfunction in Relation to 16 Cardiovascular Diseases: A Mendelian Randomization Study. Circ Genom Precis Med. 2019;12:e002468. DOI: 10.1161/CIRCGEN.118.002468

Ravishankar S.N, Champakamalini, Venkatesh, Mohsin. A prospective study of thyroid dysfunction in patients with Type 2 diabetes in general population. iMedPub Journals. 2013; 5(1:2). doi: 10.3823/105

Chen Z, Liang X, Zhang C, et al. Correlation of thyroid dysfunction and cognitive impairments induced by subcortical ischemic vascular disease. Brain Behav. 2016;6(4):e00452. Published 2016 Mar 14. doi:10.1002/brb3.452

Walsh JP, Bremner AP, Bulsara MK. Subclinical thyroid dysfunction as a risk factor for cardiovascular disease, Arch Intern Med, 2005;165:2467–72.

Razvi S, Weaver JU, Butler TJ, Pearce SH. Levothyroxine treatment of subclinical hypothyroidism, fatal and nonfatal cardiovascular events, and mortality. Arch Intern Med. 2012;172:811-7.

Abdulsalam K, Yahaya IA. Prevalence of thyroid dysfunction in gestational hypertensive Nigerians. Sub Saharan Afr J Med 2015;2:19-27.

Peppa M, Betsi G, Dimitriadis G. Lipid abnormalities and cardiometabolic risk in patients with overt and subclinical thyroid disease. J Lipids. 2011: 575840.

Saric MS, Jurasic MJ, Sovic S, Kranjcec B, Glivetic T, Demarin V. Dyslipidemia in subclinical hypothyroidism requires assessment of small dense low density lipoprotein cholesterol (sdLDL-C). Rom J Intern Med. 2017; 55:159–166. Medline, Google Scholar

Asvold, B.O., Bjoro, T., Nilsen, T.I. et al. Tobacco smoking and thyroid function: a population based study. Archives of Internal Medicine. 2007; 167, 1428– 1432.

Jorde RSundsfjord J Serum TSH levels in smokers and non-smokers: the 5th Tromso study. Exp Clin Endocrinol Diabetes 2006;114 (7) 343- 347

Holm IAManson JEMichels KBAlexander EKWillett WCUtiger RD Smoking and other lifestyle factors and the risk of Graves' hyperthyroidism. Arch Intern Med 2005;165 (14) 1606- 1611

Mohamedali M, Reddy Maddika S, Vyas A, Iyer V, Cheriyath P. Thyroid disorders and chronic kidney disease. Int J Nephrol. 2014;2014:520281. doi:10.1155/2014/520281

Zhang Y, Post WS, Cheng A, Blasco-Colmenares E, Tomaselli GF, Guallar E. Thyroid hormones and electrocardiographic parameters: findings from the third national health and nutrition examination survey. PLoS One. 2013;8(4):e59489. Published 2013 Apr 12. doi:10.1371/journal.pone.0059489

Dorr M, Ruppert J, Robinson DM, Kors JA, Felix SB. The relation of thyroid function and ventricular repolarization: decreased serum thyrotropin levels are associated with short rate-adjusted QT intervals. J Clin Endocrinol Metab. 2006; 91: 4938–4942.

Van Noord C, Van der Deure WM, Sturkenboom MC, Straus SM, Hofman A. High free thyroxine levels are associated with QTc prolongation in males. J Endocrinol. 2008; 198: 253–260.

Qari FA. Hypothyroidism Associated with Echocardiographic Abnormalities. Internal Medicine: Intern Med. 2017; 7(2):237

Cappola AR, Fried LP, Arnold AM. Thyroid Status, Cardiovascular Risk, and Mortality in Older Adults. JAMA. 2006;295(9):1033–1041. doi:10.1001/jama.295.9.1033

Soliman EZ, Backlund JYC, Bebu I, Orchard TJ, Zinman B, Lachin JM, et al, the DCCT/EDIC Research Group. Electrocardiographic Abnormalities and Cardiovascular Disease Risk in Type1 Diabetes: The Epidemiology of Diabetes Interventions and Complications (EDIC) Study. Diabetes Care Jun 2017, 40 (6) 793-799; DOI: 10.2337/dc16-2050.

Merce J, Ferras S, Oltra C, Sanz E, Vendrell J, Simon I. Cardiovascular abnormalities in hyperthyroidism: a prospective Doppler echocardiographic study. Am J Med. 2005; 118: 126–133.

Udovcic M, Pena RH, Patham B, Tabatabai L, Kansara A. Hypothyroidism and the Heart. Methodist Debakey Cardiovasc J. 2017;13(2):55–59. doi:10.14797/mdcj-13-2-55

Mitchell AL, Pearce SH: How should we treat patients with low serum thyrotropin concentrations? Clin Endocrinol (Oxf) 2010; 72:292-296.

Biondi B, Kahaly GJ: Cardiovascular involvement in patients with different causes of hyperthyroidism. Nat Rev Endocrinol 2010; 6:431-443.



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