Hypothyroidism v PPM

66-year-old lady for TKR – initial preop 2019


  • IHD – Normal stress echo 2020. No angina. 
  • AF
  • MVP
  • Asthma


  • Bradycardia – 45bpm. Fatigued, no syncope.
  • Discussed at cardiology meeting.
    • Referred to own cardiologist
    • Recommended PPM
  • Bilateral pitting peripheral oedema. Complaining of orthopnoea and PND. 
  • DASI – 3.97, limited by fatigue
  • Echo 2020. 
    • dilated cardiomyopathy
    • severely dilated LV and LA
    • MR with prolapse 
    • Severe AS
  • Returned to clinic this week for PPM insertion
  • Thyroid function checked: 
    • TSH = 8 hypothyroidism.
    • on thyroxine but not checked regularly
  • Echo repeated due to oedema, orthopnoea, and PND:
    • Normal Aortic Valve. No stenosis!


Does patient need PPM?

  • Likely that symptoms be attributed to hypothyroidism
  • Imperative that hypothyroidism is addressed first


  • Medication compliance issue should be considered
  • Timescale for expected changes with treatment of hypothyroidism.
    • weeks for improvement of symptoms 
    • 3 months for biochemical changes
  • Important to look at clinical picture as well as biochemistry when making decisions regarding fitness for surgery 
  • Current clinic guidelines for TFT’s:
    • ‘Monitoring is usually performed serially by GP. Consider testing peri-operatively if not done within 12 months if stable disease or sooner if frequent medication changes required/new cardiac arrhythmias/or signs and symptoms of thyroid disease.’ www.perioptalk.org
  • If request TFT’s will only get TSH value and need to request T3/T4 separately if required or if TSH abnormal

Aortic Stenosis?

  • Need to revisit cardiac imaging – possibility of error with previous echo regarding documented AS
  • Discuss at Cardiology MDT – ideal place to consolidate this information and facilitate liaison with regular cardiologist


  • Postpone for 6 weeks
  • Cardiology MDT 
  • Review perioperative guidelines for Thyroid Function testing