Hipocalcemia causando insuficiência cardíaca / Hypocalcemia causing myocardial failure

RESUMO

Paciente do sexo feminino, de 39 anos, com insuficiência cardíaca refratária. Em 2/82 havia sido submetida a tireiodectomia lobar direita por bócio difuso hiperplásico e, em 8/84, a nova cirurgia tireiodiana para remoção de nódulo no lobo esquerdo. Um dia após, apresentou sinais de hipocalcemia, sendo diagnosticado hipoparatireoidismo secundário à ablação acidental das paraitreóides. Iniciou descompensação cardíaca esquerda culminando, sete meses após, com edema pulmonar agu-do. Nessa ocasião, apresentava cardiomegalia de grau II (ICT = 0,58), com predominância de câmaras esquerdas, confirmada pelo ecocardiograma que mostrava importante diminuição da contratilidade. O eletrocardiograma revelava aumento de intervalo QT (QTc = 0,55 s). A calcemia era de 5,0 mg/dl com calciúria de 28 mg/dia, fosfatemia de 4,8 mg/dl e fosfatúria de 214 mg/dia. Os níveis de hormônios tiretodianos (T3 e T4) estavam nos limites da normalidade, embora o TSH estivesse no início com valores aumentados. Foi tratada, inicialmente, com digital, diurético, vasodilatador, hormônio tireoidiano e cálcio oral. Somente logrou progressiva melhora hemodinâmica, quando doses mais elevadas de cálcio foram administradas, além da associação com a vitamina D3, normalizando a área cardíaca, estando hoje assintomática, somente em uso de hormônio tireoidiano, cálcio e vitamina D3

ABSTRACT

A 39 years-old female patient with refractory hears failure has been studied. On February, 1982 she was submitted to right lobar thyreoidectomy for remotion of the left thyreoidean lobe. Follow-ing the surgery, she had signs of hypocalcemia and the diagnosis of secondary hypoparathyreoidism and heart failure had been made. Seven months after she had acute pulmonary edema, cardiomegaly III (cardiothoracic index = 0.58) with predominant left atrial and left ventricular hypertrophy, which were confirmed by echocardiogram (ECO). The ECO also demonstrated low contractility of the left ventricle. The QT interval was increased on the electrocardiogram (QTc = 0.50 s), the calcium was 5.0 mg/dl with calciuria of 28 mg/ day; phosphatemia was 4.8 mg/dl and phosphaturia of 214 mg/day. The level of thyreoidean hormones (T3 and T4) were in the normal ranges despite the TSH was increased in the beginning of the disease. She was first treated with digitalis, diuretic and vasodilator drugs, thyreoidean hormone and oral calcium. She had progressive hemodynamic improvement when higher doses of calcium were given with D3 vitamin. The most significant result of this treatment was reduction of the heart size that come back to normal. At the present time patient is treated with thyreoidean hormone, calcium and D3 vitamin only