RESUMEN
The prevalence of diabetic retinopathy (DR), and associated morbidity is high in the Asia-Pacific region. Emerging evidence suggests a potential role for fenofibrate in the prevention of progression of DR, especially in patients with cardiovascular risk, and pre-existing mild-to-moderate DR. Fenofibrate has also been found to reduce maculopathy, and the need for laser treatment in these patients. Considering these benefits of fenofibrate, a group of experts from the fields of endocrinology and ophthalmology convened in May 2017, to discuss on the the mechanism of action, and clinical efficacy of fenofibrate in DR. The findings from key clinical studies on fenofibrate in DR were reviewed by the experts, and consensus statements were derived to define the role of fenofibrate in the prevention and treatment of DR. The statements were rated based on the GRADE criteria. An algorithm was also developed for the screening and treatment of DR in patients with type 2 diabetes (T2D), and the place of fenofibrate was defined in the algorithm. The expert recommendations, and the algorithm provided in this review will serve as a guide to the clinicians to reconsider the adjunctive use of fenofibrate for preventing the progression of DR in selected T2D patients.
RESUMEN
Thyrotoxicosis is associated with cardiac dysfunction; more commonly, left ventricular dysfunction. However, in recent years, there have been more cases reported on right ventricular dysfunction, often associated with pulmonary hypertension in patients with thyrotoxicosis. Three cases of thyrotoxicosis associated with right ventricular dysfunction were presented. A total of 25 other cases of thyrotoxicosis associated with right ventricular dysfunction published from 1994 to 2017 were reviewed along with the present 3 cases. The mean age was 45 years. Most (82%) of the cases were newly diagnosed thyrotoxicosis. There was a preponderance of female gender (71%) and Graves' disease (86%) as the underlying aetiology. Common presenting features included dyspnoea, fatigue and ankle oedema. Atrial fibrillation was reported in 50% of the cases. The echocardiography for almost all cases revealed dilated right atrial and or ventricular chambers with elevated pulmonary artery pressure. The abnormal echocardiographic parameters were resolved in most cases after rendering the patients euthyroid. Right ventricular dysfunction and pulmonary hypertension are not well-recognized complications of thyrotoxicosis. They are life-threatening conditions that can be reversed with early recognition and treatment of thyrotoxicosis. Signs and symptoms of right ventricular dysfunction should be sought in all patients with newly diagnosed thyrotoxicosis, and prompt restoration of euthyroidism is warranted in affected patients before the development of overt right heart failure. LEARNING POINTS: Thyrotoxicosis is associated with right ventricular dysfunction and pulmonary hypertension apart from left ventricular dysfunction described in typical thyrotoxic cardiomyopathy.Symptoms and signs of right ventricular dysfunction and pulmonary hypertension should be sought in all patients with newly diagnosed thyrotoxicosis.Thyrotoxicosis should be considered in all cases of right ventricular dysfunction or pulmonary hypertension not readily explained by other causes.Prompt restoration of euthyroidism is warranted in patients with thyrotoxicosis complicated by right ventricular dysfunction with or without pulmonary hypertension to allow timely resolution of the abnormal cardiac parameters before development of overt right heart failure.