Evaluation of subclinical coronary atherosclerosis in mild asymptomatic primary hyperparathyroidism patients

Chapter 3: Impact of primary hyperparathyroidism

At present, primary hyperparathyroidism is most often discovered in an asymptomatic patient, but can sometimes be revealed by a renal or bone complications. In all cases, a full work-up is recommended, with assessment of renal function (glomerular filtration rate), 24-hour calciuria, screening for risk factors for lithiasis, and renal and urinary tract imaging (ultrasound or CT scan) to look for stones or nephrocalcinosis. Bone densitometry, with measurements of the spine, femur and radius, is the recommended reference test for demineralization. Standard X-rays of the spine or other imaging techniques are recommended for the detection of asymptomatic vertebral fracture. Neurocognitive manifestations, reduced quality of life or cardiovascular manifestations should not be routinely screened for, as they are not currently consensual criteria for surgical indications.

Beyond the Heart: The Predictive Role of Coronary Artery Calcium Scoring in Non-Cardiovascular Disease Risk Stratification

Coronary artery calcium scoring (CACS), a non-invasive measure of coronary atherosclerosis, has significantly enhanced cardiovascular (CV) risk assessment and stratification in asymptomatic individuals. More recently, a higher score for CAC has been associated with an increased risk of non-CV diseases and all-cause mortality. This review consolidated evidence supporting the role of CAC in assessing non-CV diseases, emphasizing its potential in early diagnosis and prognosis. We observed a strong association between CACS and non-CV diseases, viz., chronic obstructive pulmonary disease, pulmonary embolism, pneumonia, diabetes, chronic kidney disease, osteoporosis, metabolic dysfunction-associated steatotic liver disease, nephrolithiasis, stroke, dementia, malignancies, and several autoimmune diseases. Also, CAC may aid in evaluating the risk of CV conditions developing secondary to the non-CV diseases mentioned earlier. Further evidence from prospective studies, intervention trials, and population-based behavioral studies is needed to establish CAC cutoff values and explore preventative care applications, facilitating their broader integration into healthcare practices.

Cardiovascular and metabolic status in patients with primary hyperparathyroidism: a single-center experience

Introduction

Cardiovascular diseases (CVD) and metabolic disorders (MD) have retained leading positions in the structure of morbidity and mortality for many years. Primary hyperparathyroidism (PHPT) is also associated with a greater incidence of CVD and MD. The aim of the present study was to describe the prevalence and structure of CVD and MD in hospitalized patients with PHPT and to search for possible associations between these pathologies.

Methods

838 patients with a verified PHPT were included in the study. The studied cohort was divided into 2 groups according to their age at the time of admission: patients aged 18 to 49 years (group A, n = 150); patients aged 50 years and older (group B, n = 688).

Results

There were no significant differences between two groups in parameters of calcium-phosphorus metabolism. Obesity was diagnosed in 24.2% of patients in group A and in 35.9% in group B. Type 2 diabetes mellitus was more common in older patients (14.4% in group B vs. 2.6% in group A). Arterial hypertension, ischemic heart disease, chronic heart failure and brachiocephalic arteries atherosclerosis were more frequent in older patients, occurring in 79.1%, 10.8%, 8.4%, and 84% of cases respectively. The cutoff points that increased the risk of CVD detection turned out to be age above 56 years, eGFR below 92 ml/min/1.73m2, BMI above 28.3 kg/m2.

Discussion

The present study demonstrated a high incidence of some CVD, as well as disorders of lipid, carbohydrate and purine metabolism in patients with PHPT.

Cardiovascular Risk in Patients with Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders characterized by parathyroid hormone (PTH)-dependent hypercalcemia. Cardinal features include low trauma fractures, nephrolithiasis, and chronic kidney disease. Several experimental studies established that parathyroid hormone exerts actions on the cardiovascular (CV) system, including vasodilatation and positive inotropic and chronotropic effects. Observational studies, especially in severe cases, report a higher prevalence of hypertension, diabetes mellitus, lipid abnormalities, endothelial dysfunction, arrhythmias, and left ventricular hypertrophy in patients with PHPT, while the risk of CV events seems to be increased in severe cases. However, the effect of surgery is inconsistent on CV abnormalities and, more importantly, on CV disease (CVD) events, especially in mild cases. In the current review, we describe the available evidence linking PHPT and CVD, as well as the effect of surgical management and pharmacological treatment on CVD manifestations in patients with PHPT. Based on the current evidence, CVD is not considered an indication for surgery.

Impact of parathyroidectomy on cardiovascular risk in primary hyperparathyroidism: A narrative review

AIMS

Primary hyperparathyroidism (PHPT), one of the most frequent endocrine disorders, is not only associated with bone and kidney disorders but also with increased cardiovascular risk. This cardiovascular risk is not part of the indication for surgery owing to discordant evidence of the effects of parathyroidectomy (PTX), especially in mild PHPT which is the most common presentation of PHPT. This literature review focuses on the effects of PTX on the cardiovascular risk in PHPT. The MEDLINE database was searched via the PubMed interface, selecting relevant articles published after 1990 in English.

DATA SYNTHESIS

In the most recent series, PTX appeared to have a positive impact on cardiovascular morbidity and mortality. Surgery improves arterial hypertension, markers of glucose homeostasis, vascular and cardiac remodeling and electrocardiographic impairments due to classical PHPT. However, the results of surgery on mild PHPT are conflicting.

CONCLUSIONS

PTX seems to improve cardiovascular risk in patients presenting the classical form of PHPT. This improvement is correlated with preoperative serum calcium and/or PTH level, depending on the cardiovascular risk factor. However, many aspects of this improvement are not fully understood. Future studies should assess the effects of PTX on nocturnal hypertension, cardiac morphology and functions. The results for mild PHPT are conflicting owing to the limited size of the cohorts included in studies and the lack of randomized trials. Surgery is not currently recommended for patients presenting mild PHPT based on the cardiovascular risk and more studies are needed to better understand the interest of PTX on cardiovascular outcomes.

Coronary artery disease is more severe in patients with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism is associated with an increased cardiovascular mortality, but mechanisms underlying this association are unclear. The goal of this study was to evaluate coronary artery calcifications via the coronary calcification score in primary hyperparathyroidism patients, to compare with control subjects, and to identify risk factors for high to intermediate risk coronary calcification scores (coronary calcification score >100).

METHOD

Cross-sectional study of primary hyperparathyroidism patients without a history of coronary artery disease, diabetes, or severe, chronic kidney disease. Coronary calcification scores were compared with a cohort of population-based control subjects.

RESULTS

The mean coronary calcification score was 120 ± 344 in 130 primary hyperparathyroidism patients. The coronary calcification score was >100 in 27 patients (21%). When compared with control subjects, the percentage of positive coronary calcification scores was similar in primary hyperparathyroidism patients (53% vs 50%); however, positive coronary calcification scores were at the 67^th percentile of the control subjects cohort (P < .001). In multivariable regression, patient age (1.1; 1.1-1.2; P < .001), patients in the mild normocalcemic primary hyperparathyroidism group (5.1; 1.1-22.6; P = .037), and the need for antihypertensive medications (6.1; 1.8-20.9; P < .001) remained independent predictors for a coronary calcification score >100.

CONCLUSION

Positive coronary calcification scores were greater in primary hyperparathyroidism patients than in population-based control subjects. These study data may provide new criteria for parathyroidectomy in patients with primary hyperparathyroidism.

Primary hyperparathyroidism

In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.

Cardiovascular manifestations of primary hyperparathyroidism: a narrative review

Data on cardiovascular disease in primary hyperparathyroidism (PHPT) are controversial; indeed, at present, cardiovascular involvement is not included among the criteria needed for parathyroidectomy. Aim of this narrative review is to analyze the available literature in an effort to better characterize cardiovascular involvement in PHPT. Due to physiological effects of both parathyroid hormone (PTH) and calcium on cardiomyocyte, cardiac conduction system, smooth vascular, endothelial and pancreatic beta cells, a number of data have been published regarding associations between symptomatic and mild PHPT with hypertension, arrhythmias, endothelial dysfunction (an early marker of atherosclerosis), glucose metabolism impairment and metabolic syndrome. However, the results, mainly derived from observational studies, are inconsistent. Furthermore, parathyroidectomy resulted in conflicting outcomes, which may be linked to several potential biases. In particular, differences in the methods utilized for excluding confounding co-existing cardiovascular risk factors together with differences in patient characteristics, with varying degrees of hypercalcemia, may have contributed to these discrepancies. The only meta-analysis carried out in PHPT patients, revealed a positive effect of parathyroidectomy on left ventricular mass index (a predictor of cardiovascular mortality) and more importantly, that the highest pre-operative PTH levels were associated with the greatest improvements. In normocalcemic PHPT, it has been demonstrated that cardiovascular risk factors are almost similar compared to hypercalcemic PHPT, thus strengthening the role of PTH in the cardiovascular involvement. Long-term longitudinal randomized trials are needed to determine the impact of parathyroidectomy on cardiovascular diseases and mortality in PHPT.

Evaluation of coronary calcium score in patients with normocalcemic primary hyperparathyroidism

RATIONALE

Given that the diagnosis of primary hyperparathyroidism (PHPT) is given at an increasingly less-symptomatic phase, and the literature data on the cardiovascular risk of patients with normocalcemic primary hyperparathyroidism (NPHPT) are controversial, the coronary calcium score (CCS), which is correlated with coronary artery disease, may be useful for clarifying the association between cardiovascular risk and NPHPT.

OBJECTIVE

This research aims to describe the CCS and the clinical and laboratory variables of patients with NPHPT compared with a control group and to verify the presence of an association between NPHPT and CCS.

STUDY POPULATION AND METHODS

A questionnaire on anthropometric data (weight, height, waist circumference, and blood pressure) was used, laboratory examinations (estimations of glucose, glycated hemoglobin [HbA1c], total cholesterol [TC] and its fractions, triglycerides, creatinine, calcium, parathyroid hormone, and 25-OH vitamin D) were conducted, and computerized tomography was carried out to measure the CCS in 13 patients diagnosed with NPHPT and 16 controls.

RESULTS

There was no association between NPHPT and altered CCS (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.05-1.26; p=0.095). Differences between the case and control groups were found in terms of body mass index (BMI) (26.97 kg/m² vs 31.53 kg/m², respectively; p=0.044), HbA1c (5.59% vs 6.62%; p=0.000), and TC (188.07 mg/dL vs 220.64 mg/dL; p=0.088). After adjustment for potential confounders, no statistical significance was observed for the association between changes in CCS and presence of NPHPT (adjusted OR: 1.64; 95% CI: 0.1-26.43; p=0.726).

CONCLUSION

No association was found between the CCS and the presence of NPHPT.

Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop

OBJECTIVE

This report summarizes data on traditional and nontraditional manifestations of primary hyperparathyroidism (PHPT) that have been published since the last International Workshop on PHPT.

PARTICIPANTS

This subgroup was constituted by the Steering Committee to address key questions related to the presentation of PHPT. Consensus was established at a closed meeting of the Expert Panel that followed.

EVIDENCE

Data from the 5-year period between 2008 and 2013 were presented and discussed to determine whether they support changes in recommendations for surgery or nonsurgical follow-up.

CONSENSUS PROCESS

Questions were developed by the International Task Force on PHPT. A comprehensive literature search for relevant studies was undertaken. After extensive review and discussion, the subgroup came to agreement on what changes in the recommendations for surgery or nonsurgical follow-up of asymptomatic PHPT should be made to the Expert Panel.

CONCLUSIONS

1) There are limited new data available on the natural history of asymptomatic PHPT. Although recognition of normocalcemic PHPT (normal serum calcium with elevated PTH concentrations; no secondary cause for hyperparathyroidism) is increasing, data on the clinical presentation and natural history of this phenotype are limited. 2) Although there are geographic differences in the predominant phenotypes of PHPT (symptomatic, asymptomatic, normocalcemic), they do not justify geography-specific management guidelines. 3) Recent data using newer, higher resolution imaging and analytic methods have revealed that in asymptomatic PHPT, both trabecular bone and cortical bone are affected. 4) Clinically silent nephrolithiasis and nephrocalcinosis can be detected by renal imaging and should be listed as a new criterion for surgery. 5) Current data do not support a cardiovascular evaluation or surgery for the purpose of improving cardiovascular markers, anatomical or functional abnormalities. 6) Some patients with mild PHPT have neuropsychological complaints and cognitive abnormalities, and some of these patients may benefit from surgical intervention. However, it is not possible at this time to predict which patients with neuropsychological complaints or cognitive issues will improve after successful parathyroid surgery.

Neurologic disorders of mineral metabolism and parathyroid disease

Disorders of mineral metabolism may cause neurologic manifestations of the central and peripheral nervous systems. This is because plasma calcium stabilizes excitable membranes in the nerve and muscle tissue, magnesium is predominantly intracellular and is required for activation of many intracellular enzymes, and extracellular magnesium affects synaptic transmission. This chapter reviews abnormalities in electrolytes and minerals which can be associated with several neuromuscular symptoms including neuromuscular irritability, mental status changes, cardiac and smooth muscle changes, etc.

Article Commentary: Nonclassical Symptoms of Primary Hyperparathyroidism and Their Response to Parathyroidectomy

An estimated 100,000 new patients are diagnosed with primary hyperparathyroidism (PHPT) each year in the United States.1 In the past, patients with PHPT typically presented with “stones, bones, abdominal groans, and psychic moans” but today patients often present with more subtle symptoms and physiologic changes associated with earlier stages of disease. Patients without the classic symptoms of PHPT are often referred to as “asymptomatic.” These patients frequently pose a conundrum for clinicians. Uncertainties remain as to which symptoms truly represent PHPT and which are related to comorbidities or the aging process. To address these uncertainties, we review most recent literature regarding the nonclassical manifestations of PHPT and their response to parathyroidectomy.

Coronary Calcification and Hormones

The pathogenesis of coronary artery calcification and its role in atherogenesis has not been completely understood but is a new focus of interest in experimental and clinical research. Various bioactive substances, including hormones, have been implicated in the process of arterial calcification. This review considers the relationship between coronary artery calcification and hormones. These hormones may become therapeutic targets for the prevention of arterial calcification.

Primary hyperparathyroidism: an update

PURPOSE OF REVIEW

Primary hyperparathyroidism (PHPT) is a constantly evolving disease. As more evidence on the cardiovascular and neuropsychiatric manifestations of apparently asymptomatic disease accumulates, and since medical therapeutic options and surgical indications are being further investigated, it is important to review this disease entity to gain a fresh, updated perspective on the current disease phenotype and treatment approach.

RECENT FINDINGS

The pathogenesis of PHPT has not been completely elucidated yet, but some potential culprits, such as gene mutations, growth factors, calcium sensing receptor antibodies, and chronic vitamin D deficiency are being identified. There is increasing evidence that even mild, asymptomatic PHPT is associated with some aspects of cardiovascular and neuropsychiatric dysfunction, but the clinical significance as well as the reversibility with parathyroidectomy of these abnormalities remain to be determined. Medical therapies such as bisphosphonates and calcimimetics are showing some promise in the treatment of PHPT, although surgery remains the only curative intervention. The indications for surgical intervention in patients with asymptomatic PHPT have been recently revised.

SUMMARY

Parathyroidectomy is the treatment of choice for patients with symptomatic PHPT and patients with asymptomatic PHPT who fulfill certain age, bone density, serum calcium, and creatinine criteria. Further research is needed to determine whether patients with prominent cardiovascular and neuropsychiatric manifestations would benefit from such intervention.