Awareness and Knowledge of Saudi Community about Cardiac Complications Resulting from Hyperthyroidism

Background: The misconceptions about thyroid disorders and the associated complications in many counties are a considerable concern. Thyroid disorders are amongst worldwide common endocrine disorders. Based on the World Health Organization, more than 190 million individuals have iodine deficiency disorders. Most importantly, hyperthyroidism alters the cardiovascular (CV) hemodynamic. Methods: A cross-sectional observational survey study that was carried out in Saudi Arabia using an online self-prepared questionnaire including socio-demographic data, disease manifestations, diagnosis, family history, and question regarding hyperthyroidism and CV complications. That was distributed, via a link to Google form, to the general public. Only completed surveys were included in the analysis. Data were represented in the form of frequencies (number of responders) and valid percentages for categorical variables. ANOVA test was utilized to compare means between different subgroups. All P values < 0.05 were considered statistically significant. Result: A total of 641 participants took part in this study and achieved a mean score of 4.7 (SD 1.5) of the total score obtainable regarding hyperthyroidism. Out of them, 51.3% did not perform thyroid hormones investigation or having family history of thyroid disorders (46.8%). Adequate knowledge was seen regarding the occurring of heart diseases as a complication of hyperthyroidism (80.5%) and preventing CV disease by treating hyperthyroidism (88.6%). 68.8% did not know which heart complications result from hyperthyroidism. There was a statistically significant relationship between the level of knowledge and age (p<0.001), sex (p=0.004), undergoing previous thyroid investigations (p=0.003) and being diagnosed with previous thyroid disease (p<0.001). Nationality and education had no significant effect on the knowledge level of the participants. Conclusion: In this study, the overall level of Knowledge about thyroid disorders in the community was limited. Better knowledge was found about CV complications of hyperthyroidism. Educational programs will have a positive influence of awareness on thyroid troubles and will help in early diagnosis of these disorders and prevent CV diseases.


Definition and epidemiology
Thyroid disorders are amongst worldwide common endocrine disorders. Based on the World Health Organization, more than 190 million individuals have iodine deficiency disorders [1] .
Hyperthyroidism prevalence is approximately 1.3% and it varies by age, sex, race/ethnicity, and geographically through variations in dietary iodine intake [2,3] . Hyperthyroidism is 5 times more common in females than males and increases in older women [4] . In younger women, Graves' disease is seen more frequently, whereas in older women, toxic nodular goiter is seen more. Similarly, hyperthyroidism is more common in smokers [5] . Most importantly, hyperthyroidism alters the cardiovascular (CV) hemodynamics. CV manifestations are common in patients with hyperthyroidism [8] . Thyroid hormone has effects on myocardium, the peripheral circulation, and sympathetic nervous system [9] . Also, hyperthyroidism is associated with multiple CV disease such as atrial fibrillation, heart failure, pulmonary hypertension, and angina [10] . CV signs and symptoms can be corrected by treating hyperthyroidism. Congestive heart failure can be avoided by an early and effective management of hyperthyroidism [10] .

Diagnosis and detection
Thyroid disorders are frequently under-diagnosed. There are several factors affecting early diagnosis and detection of hyperthyroidism. One of these factors is the poor knowledge and lack of awareness about these diseases which can lead patients to go undiagnosed [11] . Furthermore, there is limited data on the knowledge and awareness among cardiac complications resulting from hyperthyroidism patients [12] .
In light of the above, the present study aimed to determine the degree of knowledge of hyperthyroidism and the associated CV disorders among the Saudi population to develop awareness and educational measures for assisting in the early diagnosis of such disorders and prevent CV complications.

Study design
This cross-sectional study is a questionnaire-based assessment of general population in Saudi Arabia distributed during 2020, to evaluate and their level of knowledge and their awareness of CV complications of hyperthyroidism. All individuals who agreed to participate from all age groups and both sexes were included in the study.

Data collected
A self-prepared questionnaire was developed. The questionnaire was divided into four parts: 1. Demographic characteristics including age, gender, nationality, residency, and educational level. 2. Questions regarding family history and previous diagnosis of thyroid diseases. 3. Questions regarding knowledge of hyperthyroidism, discontinuation of hyperthyroidism drugs and the extent of the relationship of hyperthyroidism to heart diseases.

Sample size
The sample size was estimated using the Raosoft calculator with a confidence level of 95%; a sample size of 641.

Statistical methodology
Data were statistically described in terms of frequencies (number of cases) and valid percentages for categorical variables. Comparison of two means between the groups was done using One-way analysis of variance (ANOVA). P values less than 0.05 were considered statistically significant. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 21 for Microsoft Windows.

Ethical considerations:
During the research activities, each studied participant was informed about the study topic and objectives with stressing from our team on confidentiality of the collected data and sample results, and also on getting a written consent to share in the study.

Demographic data:
A total of 641 individuals were contributed in the study. Approximately one third of the response aged from 20 to 29 (35.1%) then from 40 to 49 (29.3%). Out of them, 501 (78.2%) were female. Ninety-six percent of the participants were Saudi. The majority of participants had Bachelor degree (68.5%). Majority of participants were from Jeddah (53.8%). Demographics, education, nationality and residency characteristics of the participants are presented in table 1.

Thyroid investigations
Participants were asked about their thyroid hormone investigations. Fifty-one percent of them did not perform thyroid hormones investigation. From those who performed thyroid analysis, the highest motive to perform analysis was to ensure general health (21.4%). Only 8.3% of participants were diagnosed by a doctor of hyperthyroidism. Out of those who were diagnosed with thyroid troubles, the highest percentage was diagnosed at age from 20 to 29 years old (2.4%). More details are shown in table 2. Moreover, the overall mean knowledge score regarding thyroid disorders was 4.7 (SD 1.5). Table 3 presents the descriptive statistics of the knowledge regarding thyroid disease.

Overall Knowledge of hyperthyroidism
In Table 4, the differences in the level of knowledge in relation to the demographic characteristics of the respondents as well as the previous history of thyroid diseases were discussed in details. It was found that the knowledge of the participants was statistically significant with variables such as; gender (p=0.004), age (p<0.001), undergoing previous thyroid investigations (p<0.003), and being diagnosed with thyroid disease (p<0.001). Meanwhile nationality and educational level did not show a significant difference when compared to the overall knowledge score (all p>0.05).

Discussion
Thyroid disorders are amongst the most underdiagnosed health problems, and the lack of community knowledge about the disease is considered an issue [11] . Awareness can benefit many individuals who have thyroid disease and are unaware of their problem [13] .
Very little is known about the level of knowledge about hyperthyroidism and its complications on CV system [12] . Most of the studies were conducted on the knowledge of the all thyroid diseases (hypo and hyperthyroidism) or on hypothyroidism alone, the risk factors and the diagnosis [11,12,14] .
In this cross-sectional study, it was designed to determine the degree of knowledge of hyperthyroidism and its CV complications, the diagnosis and past medical history among the Saudi community to develop awareness programs for tackling the problem of early detection of hyperthyroidism disorders.
In the current study, we provide information on patterns of community-based level of awareness among Saudi population regarding thyroid disorders. The total number of participants was 641 among which 78.2% were females. The respondents were classified into 7 age groups; most of them were in the 20 to 29 (35.1%) years old group. 68.5% of the respondents had Bachelor degree.
In the present study, we also analyzed the family history of thyroid disorders. Nearly half of participants did not have family history of thyroid disorders (46.8 %), while family history of hyperthyroidism were the lowest reported thyroid disorders than hypothyroidism. Similarly to our results, in other studies conducted, Saudi Arabia; 52.1 to 59.3% of individuals did not have a family history of thyroid diseases [14,15] . Hyperthyroidism was the least disease detected (12.5%). In another study conducted at India, only 18% of respondents had a family history of thyroid disorders (hyper or hypothyroidism) [11] .
As seen in our study, our participants have a limited level of the overall knowledge regarding thyroid disorders where the overall mean knowledge score was 4.7 (SD 1.5). Poor knowledge of thyroid troubles is a concern in Saudi Arabia and in many countries [11,12,14,15] . Unlike women in Selangor, most of them have good knowledge and awareness [16] .
The findings of the study further indicated adequate general knowledge regarding what is hyperthyroidism (74.6%), and unintentional weight loss as a symptom of hyperthyroidism (67.4%). Our results were in accordance with another study conducted among Saudi people [12] . Loss of weight despite good appetite is a symptom of hyperthyroidism (79.7%). In contrary to our results concerning high awareness about not stopping using hyperthyroidism medication without consulting a doctor (76.1%) and stopping them in pregnancy (76.4%), 27 % of respondents among the Riyadh population thought that stopping treatment of hyperthyroidism when the investigations were normal and in pregnancy due to harm of the fetus [15] .
Knowledge of cardiac complications resulting from hyperthyroidism is an important aspect. Most of conducted studies that assessed the community knowledge of thyroid diseases, did not evaluate the CV complications. As seen in our study, a better knowledge of the CV complications was reported. The current study showed 80.5% agreed on the occurring of heart diseases as a complication of hyperthyroidism; nevertheless, 68.8% of them did not know which cardiac complications could result from hyperthyroidism. The number of participants increased (88.6%) who believed that treating hyperthyroidism could prevent CV disease. Our results were better than another study conducted among Saudi people [12] . Only 59% believed that thyroid dysfunction results in cardiac diseases.
In our study, moderate knowledge was found regarding hyperthyroidism is being genetically transmitted (55.2%). Different reported knowledge was found among Saudi population. In one study, 42.1% thought it is genetic [12] and among Riyadh population, only 19.3% though thyroid dysfunction can be genetically transmitted [15] . At the same time, a general poor knowledge in the present study was found regarding symptoms of hyperthyroidism.
Study results further exhibited that there was an association between some of socio-demographic characteristics and level of knowledge and awareness of hyperthyroidism such as gender, age group and undergoing previous thyroid investigations and being diagnosed with thyroid disease.
Our results were in consistent with Alyahya, A., et al., study in 2021 conducted in Eastern Province, Saudi Arabia [14] . They reported that having a previous history of thyroid disease, those undergoing thyroid tests and being female had a significant value on better knowledge of thyroid disease. Additionally, in accordance to our results, Canaris et al. study conducted in Michigan, showed an association higher level between that a higher level of knowledge about the thyroid troubles and the prevalence of these disorders [13] . On the other hand, Almuzaini et al showed that age and gender had no significant effect on the knowledge level of thyroid troubles [12] .
Furthermore, the current study shows that there is no significant difference between educational level and overall knowledge score. Similarly, Almuzaini et al revealed that education was not significantly associated with the level of knowledge of the participants [12] .

International Journal of Innovative Research in Medical Science (IJIRMS)
Our results show a limited knowledge and awareness among Saudi population regarding hyperthyroidism which may delay the diagnosis. However, more knowledge was seen regarding CV complications resulting from hyperthyroidism. Educational programs and on thyroid disorders and CV complications for the general population is needed.

Ethics approval
Institutional research ethics board approval was acquired before conducting any study-related procedures. A statement was included at the beginning of the questionnaire clarifying that the participation in this study is voluntary and that collected data will be anonymous and will only be used for this study.