Hyperthyroidism Associated Cardiomyopathy

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The thyroid gland is located in the neck and plays a very important role in regulating the body’s rate of metabolism. Hyperthyroidism is a disorder characterized by the overproduction of thyroid hormone and a subsequent increase in the metabolic rate. This is a fairly common disease in older cats. Although the thyroid gland enlarges, it is usually a nonmalignant change (benign). Less than 2% of hyperthyroid cases involve a malignancy.

Many organs are affected by this disease, including the heart. The heart is stimulated to pump faster and more forcefully; eventually, the heart enlarges to meet the increased demand for blood flow. The increased pumping pressure leads to a greater output of blood and, as a result, high blood pressure. About 80% of cats with hyperthyroidism have high blood pressure.

Contributing Factors

Advanced age is the main factor that increases a cat’s risk for hyperthyroidism. Environmental and dietary risk factors have been investigated and may play a role in predisposing cats to hyperthyroidism, though the specific mechanisms are not known.

No individual breed is known to be at increased risk, although Siamese cats appear to have a 10-fold lower risk of developing hyperthyroidism than other breeds.

Clinical Signs

The typical cat with hyperthyroidism is middle-aged or older; on average affected cats are about 12 years of age. The most consistent finding with this disorder is a loss of weight secondary to an increased rate of metabolism. To compensate for this, a cat will develop an increased appetite; some of these cats develop a ravenous appetite and will literally eat anything in sight! Despite the increased intake of food, most cats gradually lose weight. The weight loss may be so gradual that some owners will not even realize it has occurred. Affected cats usually drink more water and urinate at an increased rate. There may be periodic soft stool or diarrhea, and their coat may be unkempt. In some cats, anorexia develops as the disease progresses.

Two secondary complications of this disease can be significant. These include:

  • Hypertension (high blood pressure): Hypertension develops as a consequence of the increased pumping pressure of the heart. In some cats, blood pressure can become so high that retinal hemorrhage or detachment will occur and result in sudden blindness.
  • Thyrotoxic Cardiomyopathy (a form of heart disease): The heart problems develop because the heart must enlarge and thicken to meet the increased metabolic demands. Both of these problems are reversible with appropriate treatment of the disease.

Causes

A specific cause has not been identified. The possible role of dietary iodine continues to be investigated as a dietary influence on development of hyperthyroidism.

Diagnosis

In most instances, diagnosis of this disease is relatively straightforward. One of the first things to happen is an increase in size of one or both thyroid lobes. If they can be palpated (felt) during the physical exam, the disease is very likely. The first blood test that is performed measures the level of one of the thyroid hormones, called thyroxine (or T4). Usually, the T4 level is so high that there is no question as to the diagnosis. Occasionally, a cat suspected of having hyperthyroidism will have T4 levels within the upper range of normal cats. When this occurs, a second test, called a T3 Suppression Test, is performed. If this is not diagnostic, a thyroid scan may be performed, or the T4 could be measured again in a few weeks.

Treatment Options

Fewer than 2% of these cats have cancerous growths of the thyroid gland, as a result, treatment is usually very successful. There are three choices for treatment; any one of them could be the best choice in certain situations. Many factors must come into consideration when choosing the best therapy for an individual cat.

When possible, tests are conducted before adopting any form of treatment. These tests are necessary to evaluate the overall health of the cat and predict the chances for complications. Tests include blood work and urinalysis, radiographs, an EKG and a cardiac ultrasound.

  1. Radioactive Iodine: The most effective way to destroy all of the abnormal tissue is with radioactive iodine therapy. It causes no damage to normal thyroid tissue or to the nearby parathyroid gland. This requires 5-7 days of hospitalization at a veterinary hospital licensed to administer radiation therapy.
  2. Surgery: Surgical removal of the affected thyroid lobe(s) is also very effective. Because hyperthyroid cats are usually over 8 years of age, there is a degree of risk involved. However, if the cat is otherwise healthy, the risk need not be considered significant. If the disease involves both lobes of the thyroid gland, two surgeries may be required. If surgery is the treatment method chosen, the cat is usually treated with an anti-thyroid medication for several weeks prior to the operation. During that time, the ravenous appetite should subside and the cat will probably gain weight. Some cats also have a very fast heart rate and high blood pressure; these problems can be managed with medication before surgery. After one to two weeks, another T4 level is measured. The cat is generally hospitalized for one night following surgery and returns home feeling quite well. It should eat normally after returning home.
  3. Oral medication: Administration of an oral drug, methimazole, can control the effects of the overactive thyroid gland. Some cats have reactions to the drug, but that number is fairly small (less than 20%). However, the side effects may begin as late as six months after the beginning of treatment and can include vomiting, lethargy, anorexia, fever, and anemia. Methimazole does not destroy the abnormal thyroid tissue, but rather ties up the excess thyroid hormone. As a result, the drug must be given for the remainder of the cat’s life. Periodic blood tests must be carried out to keep the dosage regulated. This type of treatment is appropriate for the cat that is a poor surgical risk due to other health problems. As stated above, it may also be used for a few weeks to stabilize the cat that is at increased surgical risk because of cardiac complications. Recurrence of the disease is a possibility in some cats.Recurrence is uncommon after radioactive iodine therapy. It is however a possibility following surgery if appropriate margins were not attained on the abnormal thyroid cells. If those remaining cells grow, the disease may recur. However, this occurs less than 10% of the time and usually after 2-4 years. Another possibility is that one side of the thyroid gland was normal at the time of surgery so it was not removed. Then, months or years later, it may become abnormal.

Prognosis

Many owners of cats with hyperthyroidism are hesitant to have radiation therapy or surgery because of their cat’s advanced age. The outcome following both surgery and radiation therapy is usually very positive, and most cats have a very good chance of returning to an excellent state of health for many years.

Prevention

There are no known preventive measures, but middle-aged and geriatric cats should all receive a complete physical examination by a veterinarian every 6-12 months.

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