Acute decompensated heart failure secondary to thiamine deficiency: often a missed diagnosis

Editor – We read with great interest Saunders et al's excellent educational paper (Clin Med December 2010 pp 624–7) on malnutrition. Thiamine deficiency leads to dysfunction of cardiovascular system, commonly known as wet beriberi. This tends to present as acute decompensated heart failure and also with signs of hyperdynamic circulation.^1.2 Cardiac beriberi is usually missed in clinical practice because of the absence of classically described symptoms, such as pedal oedema/anasarca. It has been reported that these patients have ongoing myocardial damage with troponin rise.³ Patients in the high risk group of thiamine deficiency are likely to be suffering from chronic alcoholism, social isolation or poor dietary intake, including elderly.⁴ As the body storage of thiamine is often small, with a high turnover rate and a half life of 10 to 18 days, high risk patients can enter into thiamine deficiency rapidly. Coexisting hypomagnesaemia, a likely result of chronic alcohol abuse, further aggravates the myocardial damaging effect of thiamine deficiency.⁵

These patients are likely to be diagnosed with idiopathic dilated cardiomyopathy as coronary angiography rules out ischaemic cardiomyopathy. From our experience, erythrocyte transketolase levels are under requested for patients presenting with heart failure.

Treatment of such patients includes usual heart failure management and aggressive replenishment of thiamine. This has been shown to have dramatic response to haemodynamic state in a few hours.^1,2

We suggest that thiamine deficiency should be excluded in malnourished patient's presenting with acute decompensated heart failure.