Reversible congestive heart failure in severe hypocalcemia

Cardiovascular status in chronic hypoparathyroidism: a systematic cross-sectional assessment in 168 patients

OBJECTIVE

Long-term complications such as renal diseases are well known in patients with chronic hypoparathyroidism (hypoPT), but risk of cardiovascular comorbidity remains less clear. This study comprehensively assessed cardiovascular parameters in hypoPT compared to matched controls.

DESIGN

Cross-sectional cohort study involving 168 patients with chronic hypoPT.

METHODS

Patients underwent electrocardiograms, blood pressure measurements, and echocardiography. A 1:3 propensity score matching was performed with individuals from the German population-based Study of Health in Pomerania (SHIP-TREND) and the "Characteristics and Course of Heart Failure Stages A-B" (STAAB) cohort.

RESULTS

HypoPT showed significantly higher systolic (128 vs 125 mm Hg, P = .02) and diastolic blood pressures (83 vs 77 mm Hg, P < .01). Intake of antihypertensives was similar between groups. The QTc interval was markedly prolonged (438 vs 420 ms, P < .01) with QTc interval prolongation occurring significantly more frequently in hypoPT (24% vs 6%, P < .01). Interestingly, echocardiography revealed significantly lower left ventricular mass index (28 vs 43 g/m2.7, P < .01) and less frequent left ventricular hypertrophy (7%% vs 41%, P < .01) in hypoPT but comparable left ventricular ejection fraction (P = .48). HypoPT patients had higher prevalence of mitral (20 vs 0%, P < .01) and aortic valve stenoses (7 vs 2%, P < .01). Comparison with STAAB confirmed the increased prevalence of arterial hypertension and reduced myocardial mass indices.

CONCLUSIONS

Patients with hypoPT exhibit a higher prevalence of QTc interval prolongation despite established therapy and an increased incidence of hypertension. Conversely, echocardiography revealed lower left ventricular mass and less frequent left ventricular hypertrophy in hypoPT, but higher prevalence of valve stenosis. Regular monitoring of hypertension, QTc interval prolongation, and valve stenosis is recommended to reduce the risk of cardiovascular diseases.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05585593.

Hypocalcemia as a cause of reversible heart failure: A case report and review of the literature

Introduction

In both pediatric and adult populations, hypocalcemia-induced heart failure is an extremely rare presentation. The aim of the current study is to report a case of reversible heart failure caused by severe hypocalcemia resulting from hypoparathyroidism, which was resolved by correcting the serum calcium level.

Case report

A 29-year-old female presented with orthopnea, dyspnea on mild exertion, and bilateral lower limb swelling. She had a positive Trousseau's sign. Vital signs were stable except for tachycardia. On chest auscultation, there were bilateral basal fine inspiratory crackles. She was immediately treated as a case of pulmonary edema with intravenous furosemide and oxygen therapy. Subsequent treatment for correcting the hypocalcemia was then initiated.

Discussion

Hypocalcemia has been proven to influence cardiac function, resulting in lower cardiac contractility as determined by decreased left ventricular work index, stroke index, and cardiac index. In rare circumstances, the clinical, biochemical (elevation of cardiac enzymes), electrocardiographic, and echocardiographic data may lead to an incorrect diagnosis of an acute ischemic attack.

Conclusion

Hypocalcemia as a possible factor leading to heart failure should be considered in the differential diagnosis of all individuals with congestive heart failure.

[Hormones and The Heart - Clinical Cases]

The heart is closely connected with the endocrine system. On the one hand, the heart is an endocrine organ itself and produces several hormones like atrial and brain natriuretic peptides. On the other hand, cardiac structures are targets of many hormones like catecholamines, thyroid hormones, and corticosteroids. Therefore, many endocrine diseases come with cardiac symptoms. In this article, we describe three instructive clinical cases of patients with hormonal disorders that mimicked cardiovascular disease. Furthermore, we shortly discuss useful diagnostic and treatment algorithms. All cases emphasize the value of interdisciplinary management of patients with cardiac symptoms.

Hypocalcaemic cardiomyopathy: a description of two cases and a literature review

Hypocalcaemic cardiomyopathy is a rare form of dilated cardiomyopathy. The authors here present two cases in which symptomatic dilated cardiomyopathy was the result of severe hypocalcaemia. First, we report about a 26‐year‐old woman with primary hypoparathyroidism and then about a 74‐year‐old man with secondary hypoparathyroidism following a thyroidectomy. In both cases, the left ventricular systolic function improved after calcium supplementation. In the first case, a lack of compliance led to a repeated decrease of both serum calcium level and left ventricular systolic function. The authors also present a comprehensive summary of all cases of hypocalcaemic dilated cardiomyopathy that have been described in literature to date. The mean age of the affected patients was 48.3 years, of which 62% were female patients. The most common causes of hypocalcaemic cardiomyopathy are primary hypoparathyroidism (50%) and post‐thyroidectomy hypoparathyroidism (26%). In the post‐thyroidectomy subgroup, the median time for the development of hypocalcaemic cardiomyopathy is 10 years (range: 1.5 months to 36 years). Hypocalcaemic cardiomyopathy leads to heart failure with reduced ejection fraction in 87% of patients. Generally, the most common complications of hypoparathyroidism and/or hypocalcaemia are cerebral calcifications, cognitive deficit, and cataracts. Once calcium supplementation is administered, the disease has a good prognosis and, in most individuals, a significant improvement (21%) or even normalization (74%) of the left ventricular systolic function occurs.

A rare and reversible case of heart failure-Hypocalcemia due to hypoparathyroidism

Physicians should look more carefully for the potential reversible causes of acute heart failure, namely hypoparathyroidism. The recovery of left ventricular function with the treatment of hypoparathyroidism underlines the importance of calcium and the reversibility of this type of cardiomyopathy.

Electrolyte Disorders as Triggers for Takotsubo Cardiomyopathy

A 56-year-old woman presented with cognitive impairment, confusion and slowed speech, muscle cramps and peripheral paraesthesia preceded by vomiting. Blood tests revealed severe hypokalaemia, hyponatremia, hypomagnesemia and hypocalcaemia. Following a diagnosis of Takotsubo cardiomyopathy based on ultrasonography, the patient was treated with electrolyte supplementation and recovered within 48h. When heart failure is suspected, electrolyte abnormalities should be carefully ruled out as they can affect cardiac function.

Theoretical overview of clinical and pharmacological aspects of the use of etelcalcetide in diabetic patients undergoing hemodialysis

Etelcalcetide is the first intravenous calcimimetic agent authorized for the treatment of secondary hyperparathyroidism (sHPT) in patients undergoing hemodialysis in Europe, the US, and Japan. The relationship between sHPT and diabetes resides on complex, bidirectional effects and largely unknown homeostatic mechanisms. Although 30% or more patients with end-stage renal disease are diabetics and about the same percentage of those patients suffer from sHPT associated with hemodialysis, no data on the specificities of the use of etelcalcetide in such patients are available yet. Regarding pharmacokinetic interactions, etelcalcetide may compete with oral hypoglycemics recommended for use in patients undergoing hemodialysis and insulins detemir and degludec, causing unexpected hypocalcemia or hypoglycemia. More importantly, hypocalcemia, a common side effect of etelcalcetide, may cause decompensation of preexisting cardiac insufficiency in diabetic patients or worsen dialysis-related hypotension and lead to hypotension-related cardiac events, such as myocardial ischemia. In diabetic patients, hypocalcemia may lead to dangerous ventricular arrhythmias, as both insulin-related hypoglycemia and hemodialysis prolong QT interval. Patients with diabetes, therefore, should be strictly monitored for hypocalcemia and associated effects. Due to an altered parathormone activity in this patient group, plasma calcium should be the preferred indicator of etelcalcetide effects. Until more clinical experience with etelcalcetide is available, the clinicians should be cautious when using this calcimimetic in patients with diabetes.

Comparative Safety and Effectiveness of Denosumab Versus Zoledronic Acid in Patients With Osteoporosis: A Cohort Study

Limited head-to-head comparative safety and effectiveness data exist between denosumab and zoledronic acid in real-world healthcare. We aimed to examine the safety and effectiveness of denosumab compared to zoledronic acid with regard to risk of serious infection and cardiovascular disease (CVD) and osteoporotic fracture. We conducted a cohort study using claims data (2009-2013) from a US commercial insurance plan database. We included patients aged ≥50 years who were newly initiated on denosumab or zoledronic acid. The primary outcomes were (1) hospitalization for serious infection; (2) composite CVD endpoint including myocardial infarction, stroke, coronary revascularization, and heart failure; and (3) nonvertebral osteoporotic fracture including hip, wrist, forearm, and pelvic fracture. To control for potential confounders, we used 1:1 propensity score (PS) matching. Cox proportional hazards models compared the risk of serious infection, CVD, and osteoporotic fracture within 365 days after initiation of denosumab versus zoledronic acid. After PS matching, a total of 2467 pairs of denosumab and zoledronic acid initiators were selected with a mean age of 63 years and 96% were female. When compared with zoledronic acid, denosumab was not associated with an increased risk of serious infection (HR 0.81; 95% confidence interval [CI], 0.55 to 1.21) or CVD (HR 1.11; 95% CI, 0.60 to 2.03). Similar results were obtained for each component of CVD. The risk of osteoporotic fracture was also similar between groups (HR 1.21; 95% CI, 0.84 to 1.73). This large population-based cohort study shows that denosumab and zoledronic acid have comparable clinical safety and effectiveness with regard to the risk of serious infection, CVD, and osteoporosis fracture within 365 days after initiation of medications. © 2016 American Society for Bone and Mineral Research.

Paraneoplastic hypocalcemia-induced heart failure in advanced breast cancer: A case report and literature review

Hypocalcemia is an uncommon clinical symptom of patients with malignant tumors, and a number of factors may be involved in its development. The present study describes the case of a 67-year-old Caucasian female, presenting with severe refractory hypocalcemia and heart failure. The patient was subsequently diagnosed with breast cancer and bone metastases. The paraneoplastic origin of the syndrome was confirmed by its complete resolution once the tumor responded to specific antineoplastic treatments, comprising weekly paclitaxel and aromatase inhibitor administration. The present case report suggested the need for greater awareness of the possibility of paraneoplastic hypocalcemia in breast cancer patients, and suggested that this condition may also contribute to the occurrence of heart failure. The mechanisms potentially responsible for this event were discussed and a brief review of the literature presented.

Use of recombinant human parathyroid hormone in hypocalcemic cardiomyopathy

Hypocalcemia secondary to hypoparathyroidism is a rare cause of congestive heart failure. However, its early recognition and treatment lead to significant improvement in cardiac function. We report a middle-aged woman presenting with symptoms of heart failure with a serum calcium level of 3.7 mg/dl and a serum inorganic phosphate level of 17.6 mg/dl 22 years after subtotal thyroidectomy. Besides calcium and calcitriol supplementation, she was the first patient with severe hypocalcemic cardiomyopathy to be given off-label recombinant human parathyroid hormone (PTH) because of an elevated serum calcium-phosphate product. We discuss the management and outcome of the patient and then present a brief review of similar previously reported cases. We also describe the pivotal role of calcium ion and the potential role of PTH in maintaining myocardial contractility, effective natriuresis, and possible pathogenic mechanisms contributing to heart failure secondary to hypocalcemia and hypoparathyroidism.

Vitamin D deficiency in patients with congestive heart failure: mechanisms, manifestations, and management

Recent research suggests that vitamin D may play a role in cardiovascular (CV) health. Although its exact role is still debated and is a matter of controversy, vitamin D deficiency has been linked to increased prevalence of CV risk factors and events. Factors that predispose persons with congestive heart failure (CHF) to hypovitaminosis D include nutritional deficiency, decreased skin production, reduced intestinal absorption, and hepatorenal disease. It is possible that low vitamin D can in turn aggravate CHF. The extent of deficiency can be severe enough to cause hypocalcemia, secondary hyperparathyroidism, osteomalacia, and decreased bone density. No clear data exist showing improvement in CV clinical outcomes with vitamin D replacement. Screening is advocated in most patients, although benefits of replacement are most likely to accrue in those with severe lack or with abnormalities of calcium-parathyroid-bone metabolism. According to current guidelines and research, vitamin D goals of >20 ng/ml in most patients with CHF and >30 ng/ml in those with secondary hyperparathyroidism seem to be appropriate to aim for. Further research is needed to fully unravel the association among CV risk, CHF and hypovitaminosis D, and translate this knowledge into clinically meaningful management recommendations.