Detecting a Thyroid Disorder in the Patient at Risk for Cardiovascular Disease

E. Chester Ridgway, MD
Head for the Division of Endocrinology, Metabolism and Diabetes
University of Colorado Hospital
Denver, CO

A 62-year-old female comes to see you because a local screening program carried out in her neighborhood revealed that she had an elevated cholesterol level. The patient is generally well, except for known hypertension that has been treated with Vasotec^® 20 mg/d for the last 8 years. The patient denies any previous knowledge of an elevated cholesterol or abnormal lipid panel. She has never had a myocardial infarction or chest pain. She eats a regular diet, which includes fish 3 times per week. She has had trouble with weight gain and loss in the past as a result of multiple diets. She currently weights 170 lb, which is 10 lb over her usual weight of 160 lb. Her family history is significant; her father died at 52 of a myocardial infarction and her mother is being treated for hypertension and osteoporosis at age 85. She has one brother, age 58, who has had a myocardial infarction and 3 sisters, one of whom has diabetes mellitus. The patient smokes one pack per day. She has no previous history of kidney disease, pulmonary disorder, diabetes, or thyroid problems. She denies previous kidney stones, and other than her difficulties with weight and mild fatigue, she has never had heat or cold intolerance and has never been told she had a goiter.  

On examination, her blood pressure was 152/98 mm Hg, and her pulse was 68 beats per minute. She weighed 170 lb. She appeared healthy but was slightly obese, and her carotid arteries were without a bruit. She had no thyromegaly. Her lungs exhibited a slight prolongation of the expiratory phase. The cardiac exam revealed an S4 gallop rhythm but no murmurs. Her abdomen was slightly obese with no organomegaly, and her legs were without edema. Her skin was dry but warm, and the reflexes were normal.  

A fasting metabolic panel, chest X-ray, and electrocardiogram (EKG) were performed. The chest X-ray was negative except for mild hyperinflation of both bases. The EKG showed a normal sinus rhythm, a slight lowering of the ST and T-wave amplitudes, and no evidence of a recent myocardial infarction. Sodium was 142 mEq/L, potassium was 3.8 mEq/L, bicarbonate was 25 mEq/L, and chloride was 104 mEq/L. The BUN was 12, creatinine 1.1 mg/dL, and calcium was 8.9 mg/dL. A fasting lipid panel revealed that her cholesterol was 242 mg/dL, high-density lipoprotein (HDL) cholesterol was 50 mg/dl, and low-density lipoprotein (LDL) cholesterol was 130 mg/dL.