Low T3 Syndrome Is Associated With High Mortality in Hospitalized Patients With Heart Failure

Is Low-free Triiodothyronine (fT3) Associated with Increased Morbidity in Patients Admitted to Coronary Care Units?

BACKGROUND

The effects of thyroid hormone on patients hospitalized in coronary intensive care units are still controversial.

OBJECTIVE

We retrospectively examined thyroid hormone levels and their impact on cardiovascular morbidity in patients admitted to coronary intensive care units.

METHODS

A total of 208 (Female/Male; 46.6%/53.4%) patients without any history of thyroid disease were enrolled and screened. Patients with specific heart disease and existing thyroid hormone parameters were included in the study. Low triiodothyronine syndrome is characterized by reduced serum total or free T3 (fT3) concentrations in normal free T4 (fT4) and TSH levels.

RESULTS

The common diagnosis of the patients in the coronary care unit is acute coronary syndrome (n = 59, 28.2 %) and heart failure (n = 46, 23.3%). Patients were divided into two groups according to left ventricular ejection fraction percentages (LVEF ≤39% vs LVEF ≥40%). Plasma fT3 levels were significantly correlated with low LVEF (≤39%) (p =0.002). fT3 (r = -0.183, p =0.013) and hospitalization etiology (r = -0.161, p =0.023) were also the most critical parameters affecting the length of hospitalization.

CONCLUSION

Low fT3 was associated with reduced ejection fraction and prolonged hospitalization, which may lead to potential morbidities in HF patients and may be useful in risk stratification and treatment strategies.

Long-term prognostic value of thyroid hormones in left ventricular noncompaction

PURPOSE

Thyroid function is closely related to the prognosis of cardiovascular diseases. This study aimed to explore the predictive value of thyroid hormones for adverse cardiovascular outcomes in left ventricular noncompaction (LVNC).

METHODS

This longitudinal cohort study enrolled 388 consecutive LVNC patients with complete thyroid function profiles and comprehensive cardiovascular assessment. Potential predictors for adverse outcomes were thoroughly evaluated.

RESULTS

Over a median follow-up of 5.22 years, primary outcome (the combination of cardiovascular mortality and heart transplantation) occurred in 98 (25.3%) patients. For secondary outcomes, 75 (19.3%) patients died and 130 (33.5%) patients experienced major adverse cardiovascular events (MACE). Multivariable Cox analysis identified that free triiodothyronine (FT3) was independently associated with both primary (HR 0.455, 95%CI 0.313-0.664) and secondary (HR 0.547, 95%CI 0.349-0.858; HR 0.663, 95%CI 0.475-0.925) outcomes. Restricted cubic spline analysis illustrated that the risk for adverse outcomes increased significantly with the decline of serum FT3. The LVNC cohort was further stratified according to tertiles of FT3 levels. Individuals with lower FT3 levels in the tertile 1 group suffered from severe cardiac dysfunction and remodeling, resulting in higher incidence of mortality and MACE (Log-rank P < 0.001). Subgroup analysis revealed that lower concentration of FT3 was linked to worse prognosis, particularly for patients with left atrial diameter ≥ 40 mm or left ventricular ejection fraction ≤ 35%. Adding FT3 to the pre-existing risk score for MACE in LVNC improved its predictive performance.

CONCLUSION

Through the long-term investigation on a large LVNC cohort, we demonstrated that low FT3 level was an independent predictor for adverse cardiovascular outcomes.

Update on clinical and experimental management of diabetic cardiomyopathy: addressing current and future therapy

Diabetic cardiomyopathy (DCM) is a severe secondary complication of type 2 diabetes mellitus (T2DM) that is diagnosed as a heart disease occurring in the absence of any previous cardiovascular pathology in diabetic patients. Although it is still lacking an exact definition as it combines aspects of both pathologies - T2DM and heart failure, more evidence comes forward that declares DCM as one complex disease that should be treated separately. It is the ambiguous pathological phenotype, symptoms or biomarkers that makes DCM hard to diagnose and screen for its early onset. This re-view provides an updated look on the novel advances in DCM diagnosis and treatment in the experimental and clinical settings. Management of patients with DCM proposes a challenge by itself and we aim to help navigate and advice clinicians with early screening and pharmacotherapy of DCM.

Organ injury and its management in heart failure: Liver, kidney, and thyroid gland dysfunction

Heart failure is hemodynamically characterized as congestion and/or end-organ hypoperfusion, and is associated with increased morbidity and mortality. Underlying pathophysiology, such as neuro-hormonal activation, exacerbates heart failure and leads to functional deterioration of other organs. We have been conducting clinical research to study the pathophysiology of heart failure and discover prognostic factors. In this review article, we report the results and implications of our clinical research on heart failure.

Low T3 syndrome as a predictor of poor prognosis in peripheral T-cell lymphomas

PURPOSE

The purpose of the study was to evaluate the prognostic value of low T3 syndrome in peripheral T-cell lymphomas (PTCLs).

METHODS

One hundred and seventy-four patients of newly diagnosed PTCLs were enrolled in the study. We performed statistical analysis based on the clinical data collected.

RESULTS

Thirty-Six (20.69%) patients had low T3 syndrome at first admission. Results suggested that the patients with higher score of ECOG PS, International Prognostic Index (IPI) and Prognostic Index for T-cell lymphoma (PIT), bone marrow involvement and lower level of albumin tended to develop low T3 syndrome. The median progression-free survival (PFS) and overall survival (OS) were 10 months and 36 months, respectively, for all patients. Pre-existing low T3 syndrome was in correlation with worse PFS and OS. Patients with low T3 syndrome showed worse PFS (4 months vs 13 months, P = 0.0001) and OS (7 months vs 83 months, P < 0.0001) than patients without low T3 syndrome. IPI and PIT, respectively, combined with low T3 syndrome improved the ability to predict OS and PFS of PTCLs.

CONCLUSIONS

The study indicated that low T3 syndrome may be a good candidate for predicting prognosis of peripheral T-cell lymphomas.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Low T3 syndrome predicts more adverse events in patients with hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a common cardiac genetic disorder that clinically manifests with sudden death and progressive heart failure. Moreover, thyroid dysfunction is associated with increased cardiovascular morbidity and mortality risks. Therefore, this study aimed to clarify whether thyroid hormones could serve as an independent predictor of adverse events in patients with HCM.

METHODS

The cohort consisted of 782 patients with HCM who had thyroid hormones baseline data and were admitted to the Affiliated Hospital of Jiaxing University. Patients were divided into two groups according to serum levels of free triiodothyronine (fT3): the normal fT3 and low triiodothyronine (T3) syndrome groups. Low T3 syndrome was defined as fT3 < 2.43 pmol/L with a normal thyroid-stimulating hormone (TSH) level. Patients whose TSH levels were abnormally high or abnormally low were excluded from this study. The primary endpoint was the occurrence of sudden cardiac death (SCD) events, and the secondary endpoint was a composite of worsening heart failure (WHF) events, including heart failure death, cardiac decompensation, hospitalization for heart failure, and HCM-related stroke. The Kaplan-Meier and Cox regression were performed for the survival analysis.

RESULTS

After a median follow-up of 52 months, 75 SCD events and 134 WHF events were recorded. The Kaplan-Meier survival curves showed that the cumulative incidence of SCD events and WHF events were significantly higher in patients with low T3 syndrome (log-rank p = .02 and log-rank p = .001, respectively). Furthermore, multivariate Cox regression analysis demonstrated that low T3 syndrome is a strong predictor of SCD events and WHF events (adjusted hazard ratio [HR: 1.53, 95% confidence interval [CI]: 1.13-2.24, p < .01; HR: 3.87, 95% CI: 2.91-4.98, p < .001, respectively).

CONCLUSIONS

Low T3 syndrome is highly prevalent among patients with HCM and was independently associated with an increased risk of SCD events and WHF events. The routine assessment of serum fT3 levels may provide risk stratification in this population.

Association between dynamic fluctuations in triiodothyronine levels and prognosis among critically ill patients within comprehensive intensive care units

Objective

Decrease in free thyroid hormone T3 (FT3) can be used as an independent prognostic indicator for the risk of death in ICUs. However, FT3 as a predictive marker is hindered by its accuracy. The study introduces the concept of dynamic FT3 data as a means to bolster the value of FT3 as a prognostic tool. Therefore, the aim of this study is to investigate the prognostic value of dynamic FT3 evolution in a comprehensive ICU setting, analyze the consistency between dynamic FT3 changes and variations in disease severity, and explore the feasibility of FT3 as an objective indicator for real-time clinical treatment feedback.

Methods

Employing a single-center prospective observational study, FT3 measurements were taken on multiple days following enrollment, corresponding clinical data were collected. To investigated the pattern of dynamic changes of FT3,its prognostic significance in forecasting the risk of 28-day mortality, the alignment between dynamic FT3 changes and variations in the Sequential Organ Failure Assessment (SOFA) score.

Results

The survival group exhibited higher last FT3 levels compared to the lowest point (p<0.05), while the death group did not show statistically significant differences (p>0.05). The study also identifies the optimal correlation between FT3 and SOFA score at day 5 (optimal correlation coefficient -0.546).The ROC curve for FT3 at day 5 yielded an optimal AUC of 0.88, outperforming the SOFA score. The study categorizes FT3 curve patterns,Kaplan-Meier survival analysis of these patterns highlighted that the descending-type curve was significantly associated with increased risk of death (P<0.001). Additionally, the research explores the consistency between changes in FT3 and SOFA scores. While overall consistency rates were modest, subgroup analyses unveiled that greater disease severity led to higher consistency rates.

Conclusions

This study introduces the concept of dynamic FT3 changes to augment its prognostic utility in comprehensive ICU settings. The research identifies day 5 as the optimal time point for predictive efficacy, the descending FT3 curve as indicative of poor prognosis. While overall consistency with SOFA scores is modest, the correlation strengthens with greater disease severity.

Low T3 syndrome as a predictor of poor outcomes in patients with follicular lymphoma

The aim of this study was to investigate the prognostic value of low T3 syndrome in follicular lymphoma (FL). A total of 221 FL patients with detailed serum thyroid hormone levels and other complete clinical data were enrolled. Baseline features associated with low T3 syndrome were analyzed and balanced by propensity score matching. Univariate and multivariate regression analyses were performed to determine independent risk factors for progression-free survival (PFS) and overall survival (OS). A receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to assess the predictive accuracy of FL international prognostic index FLIPI-1/FLIPI-2 and low T3 syndrome. A total of 22 patients (10.0%) had low T3 syndrome at diagnosis, which was associated with poor PFS and OS in the rituximab era. It is an independent prognostic factor for PFS and OS. Low T3 syndrome and FLIPI-1/FLIPI-2 significantly increased the AUC of PFS and OS compared to FLIPI-1/FLIPI-2 alone. Low T3 is a risk factor for POD24. In conclusion, low T3 syndrome may be a good candidate for predicting the prognosis of CLL in future clinical practice. Our study demonstrates that low T3 syndrome is associated with poorer survival outcomes in FL patients.

Thyroid Hormone and Heart Failure: Charting Known Pathways for Cardiac Repair/Regeneration

Heart failure affects more than 64 million people worldwide, having a serious impact on their survival and quality of life. Exploring its pathophysiology and molecular bases is an urgent need in order to develop new therapeutic approaches. Thyroid hormone signaling, evolutionarily conserved, controls fundamental biological processes and has a crucial role in development and metabolism. Its active form is L-triiodothyronine, which not only regulates important gene expression by binding to its nuclear receptors, but also has nongenomic actions, controlling crucial intracellular signalings. Stressful stimuli, such as acute myocardial infarction, lead to changes in thyroid hormone signaling, and especially in the relation of the thyroid hormone and its nuclear receptor, which are associated with the reactivation of fetal development programmes, with structural remodeling and phenotypical changes in the cardiomyocytes. The recapitulation of fetal-like features of the signaling may be partially an incomplete effort of the myocardium to recapitulate its developmental program and enable cardiomyocytes to proliferate and finally to regenerate. In this review, we will discuss the experimental and clinical evidence about the role of the thyroid hormone in the recovery of the myocardium in the setting of heart failure with reduced and preserved ejection fraction and its future therapeutic implications.

The Free Triiodothyronine/Free Thyroxine Ratio Is Associated with Frailty in Older Adults: A Longitudinal Multisetting Study

Background: Various models have been proposed to predict frailty, including those based on clinical criteria and phenotypes. However, a simple biomarker associated with frailty has been not yet identified. The aim of this study is to evaluate the relationship between free triiodothyronine (fT3)/free thyroxine (fT4) ratio value and the degree of frailty among three different cohorts of older individuals: (1) acutely ill hospitalized patients, (2) nursing-home (NH) residents, and (3) home-dwelling centenarians. Methods: We performed a secondary analysis of de-identified patient-level data from two prospective observational studies on acutely hospitalized older patients (Geriatric Acute Unit [GAU]), and home-dwelling centenarians (CENT), and a retrospective-prospective observational study on older NH residents. Demographic characteristics, along with a 30-items Frailty Index (FI) and serum thyrotropin, fT3 and fT4 measurements were obtained. Results: Six hundred fifteen individuals (aged 86.4 ± 8.9 years; 55.1% females) were included in the study, including 298 (48.5%) GAU, 250 (40.6%) NH, and 67 (10.9%) CENT. A significant inverse relationship between fT3/fT4 ratio and FI values was observed (ρ_s = -0.17 [confidence interval; CI: -0.092 to 0.252], p < 0.001), and this was confirmed by logistic multivariate analysis (β = -0.44, odds ratio [OR]: 0.64 [CI: 0.47-0.87], p < 0.001) (after adjustment for age, sex, and cohorts). Moreover, a progressively decreased mortality risk was associated with rising fT3/fT4 ratio (OR 0.60 [CI: 0.44-0.80] β = -0.51, p < 0.001]. Conclusions: The fT3/fT4 ratio value was inversely correlated with frailty degree and mortality risk in a large cohort of older individuals, including centenarians, regardless of their sex and clinical condition. fT3/fT4 ratio value could represent an easily measured independent biochemical marker of frailty degree in older people.

The effectiveness of thyroid hormone replacement therapy on heart failure and low T3-syndrome: An updated systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to conduct a systematic review and meta-analysis evaluating the role of thyroid hormone therapy in patients with heart failure (HF) and low triiodothyronine (T3) syndrome (LT3S).

METHODS

The electronic databases PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, Wanfang Database, and China Biology Medicine disc (CBMdisc) were systematically searched to identify eligible studies published before November 27, 2021. The mean difference was pooled for RCTs using a random-effects model.

RESULTS

The meta-analysis showed that thyroid hormone treatment improved the left ventricular ejection fraction (weighted mean difference [WMD] 5.61, 95% confidence interval [CI]: 4.38 to 6.85^, I² = 63.12%, P^<0.01). The cardiac output improved with thyroid hormone therapy (WMD 0.65, 95% CI: 0.42 to 0.89, I² = 84.28%, P^<0.01). The E/A in the thyroid hormone group was also improved compared to the control group (WMD 0.29, 95% CI: 0.15 to 0.42^, I² = 95.08%, P^<0.01). The left ventricular diastolic dysfunction was decreased with thyroid hormone treatment (WMD -5.17, 95% CI: -7.47 to -2.88, I² = 90.18%, P^<0.01). The brain natriuretic peptide decreased with thyroid hormone treatment (standardized mean difference [SMD] -1.49, 95% CI: -2.15 to -0.84, I² = 90.18%, P^<0.01). Noradrenaline decreased with thyroid hormone therapy (WMD -349.86, 95% CI: -401.05 to -298.67^, I² = 0%, P^<0.01). Free T3 increased with thyroid hormone treatment (SMD 2.18, 95% CI: 0.75 to 2.60^, I² = 98.20%, P^<0.01).

CONCLUSION

This meta-analysis showed that thyroid hormone replacement therapy was effective in patients with HF and LT3S.

Increases in Hepatokine Selenoprotein P Levels Are Associated With Hepatic Hypoperfusion and Predict Adverse Prognosis in Patients With Heart Failure

Background

Although multiorgan networks are involved in the pathophysiology of heart failure (HF), interactions of the heart and the liver have not been fully understood. Hepatokines, which are synthesized and secreted from the liver, have regulatory functions in peripheral tissues. Here, we aimed to clarify the clinical impact of the hepatokine selenoprotein P in patients with HF.

Methods and Results

This is a prospective observational study that enrolled 296 participants consisting of 253 hospitalized patients with HF and 43 control subjects. First, we investigated selenoprotein P levels and found that its levels were significantly higher in patients with HF than in the controls. Next, patients with HF were categorized into 4 groups according to the presence of liver congestion using shear wave elastography and liver hypoperfusion by peak systolic velocity of the celiac artery, which were both assessed by abdominal ultrasonography. Selenoprotein P levels were significantly elevated in patients with HF with liver hypoperfusion compared with those without but were not different between the patients with and without liver congestion. Selenoprotein P levels were negatively correlated with peak systolic velocity of the celiac artery, whereas no correlations were observed between selenoprotein P levels and shear wave elastography of the liver. Kaplan‐Meier analysis demonstrated that patients with HF with higher selenoprotein P levels were significantly associated with increased adverse cardiac outcomes including cardiac deaths and worsening HF.

Conclusions

Liver‐derived selenoprotein P correlates with hepatic hypoperfusion and may be a novel target involved in cardiohepatic interactions as well as a useful biomarker for predicting prognosis in patients with HF.

Value of FT3/FT4 Ratio in Prognosis of Patients With Heart Failure: A Propensity-Matched Study

Aims

Abnormal thyroid hormone secretions can alter the manifestation and prognosis of cardiovascular disease. To assess the effect of the free triiodothyronine (FT3)/free thyroxine (FT4) ratio on the prognosis of patients with heart failure (HF), we performed a propensity-matched study on patients with well-balanced baseline characteristics.

Methods

Overall, 8,887 patients with HF were divided into two groups according to the FT3/FT4 ratio. Propensity scores were calculated from each patient. A cohort comprising 2,164 pairs with high or low ratios and with 34 well-balanced baseline characteristics was then assembled. The endpoints were Cardiovascular (CV) mortality and all-cause mortality. The correlation between FT3/FT4 ratio and prognosis was assessed using matched Cox regression analyses. The mean follow-up was 3.3 years.

Results

In the full pre-match cohort, 3,710 (41.7%) patients died, with 2,581 (29.0%) cases of CV mortality. In the matched-pair cohort, all-cause mortality occurred in 923 (1,238/10,000 person-years of follow-up) patients with a high ratio and 1,036 (1,484/10,000 person-years) patients with a low ratio, resulting in a matched HR of 0.841 (95% CI: 0.769-0.919; P < 0.001). For CV mortality, the result was 638 (856/10,000 person-years) and 714 (1,023/10,000 person-years) patients, respectively, resulting in a matched HR of 0.844 (95% CI: 0.759-0.940; P < 0.001). Subgroup analysis revealed that a low FT3/FT4 ratio had a greater predictive value for all-cause and CV mortality in elderly or male patients and in patients with coronary artery disease (CAD), hypertension, diabetes mellitus, HFmrEF, or HFpEF.

Conclusions

A low FT3/FT4 ratio is valuable for predicting CV mortality and all-cause mortality in patients with HF.

Thyroid function and age-related decline in kidney function in older Chinese adults: a cross-sectional study

Background

Thyroid function may be a factor affecting kidney function in the general population. Kidney and thyroid function vary with age; therefore, the association between thyroid function and decreased kidney function in older adults may be different from that in younger adults and remains controversial. This study aimed to estimate the association between normal-range thyroid function and age-related decline in kidney function in older Chinese adults.

Methods

A total of 15,653 adults, of whom 23.2% (N = 3624) were older adults (age≧65 years), were collected at the Health Management Center of the First Affiliated Hospital of Nanjing Medical University from January 2018 to January 2020. Basic demographic information was collected by a physician-administered questionnaire. The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula. Trends in thyroid function with age were shown by means of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) in subgroups every ten years. The association between kidney function and thyroid function was estimated by multiple linear regression using β value and by multivariable logistic regression models using odds ratios (OR) after adjusting for age, gender, body mass index, and serum urine acid.

Results

In the older population, TSH tended to increase with age and FT3 tended to decrease, whereas FT4 was relatively stable. eGFR decreased significantly with increasing TSH (β = -0.081) and decreasing FT3 (β = 0.083) concentrations. Compared with those in the lowest quartile of FT3 (3.10–4.47 pmol/L), the prevalence of eGFR < 75 ml/min/1.73m² decreased significantly by 22.0% for those with FT3 of 4.47–4.81 pmol/L, 27.6% for those with FT3 of 4.82–5.20 pmol/L, and 34.9% for those with FT3 of 5.21–6.8 pmol/L in older individuals (P for trend < .001). The OR was 1.315 (P: 0.025) in subjects with high-normal TSH, using low-normal TSH as a reference. The prevalence of reduced kidney function was not significantly associated with FT4 within the reference range. Similar results were found in association between the prevalence of eGFR < 60 ml/min/1.73m² and thyroid function.

Conclusions

This study demonstrated a significant association between kidney function and thyroid function, particularly FT3, in the older population. Clinicians may need to pay more attention to the assessment and follow-up of kidney function in older individuals with low-normal FT3 and high-normal TSH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02904-z.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Association of thyroid function, within the euthyroid range, with cardiovascular risk: The EPIPorto study

BACKGROUND

Thyroid hormones are important modulators of cardiovascular function. Both hypothyroidism and hyperthyroidism are known to contribute to an increased cardiovascular risk. It remains uncertain whether thyroid hormones level within the euthyroid range are associated with cardiometabolic risk. We aimed to evaluate the association between thyroid function levels within the euthyroid range and cardiovascular risk in a population-based cohort.

METHODS

Eight hundred thirty-five subjects aged ≥45 years from the EPIPorto population-based cohort were included. We excluded participants with TSH, free T4 (FT4), or free T3 (FT3) outside of the reference range, or with previous cardiovascular or thyroid disease. The associations between thyroid function, cardiovascular risk factors and the 10-year estimated risk of cardiovascular events (using SCORE2 and SCORE2-OP) were evaluated in linear and logistic regression models, crudely and adjusting for age, sex, BMI, diabetes, and smoking.

RESULTS

The mean age of the participants was 61.5 (SD 10.5) years and 38.9% were men. Eleven percent of the participants had diabetes, 47.8% had dyslipidemia, and 54.8% had hypertension. The mean body mass index (BMI) was 27.4 (SD 4.6) kg/m², and the median (percentile25-75) 10-year risk of cardiovascular events was 5.46% (2.92, 10.11). Participants with higher BMI, larger waist circumference and higher hs-CRP had higher levels of FT3 and FT3/FT4 ratio. Lower FT3/FT4 ratio and higher FT4 levels were associated with higher prevalence of diabetes and more adverse lipid profile. Higher TSH, lower FT3 and lower FT3/FT4 ratio were associated with lower eGFR. Lower FT3, lower FT3/FT4 ratio and higher FT4 were associated with an increased 10-year risk of cardiovascular events.

CONCLUSIONS

In a population-based study, variations of thyroid function within the euthyroid range were associated with cardiovascular risk factors. On one hand, individuals with higher BMI, larger waist circumference and higher hs-CRP had higher levels of FT3 and FT3/FT4 ratio. On the other hand, a decreased conversion of T4 to T3 (lower FT3, lower FT3/FT4 ratio and/or higher FT4) was associated with a higher prevalence of diabetes, a more adverse lipid profile, a lower eGFR and an increased 10-year risk of cardiovascular events.

High-TSH Subclinical Hypothyroidism Is Associated With Postoperative Mortality in Acute Type A Aortic Dissection

BACKGROUND

Subclinical hypothyroidism can negatively affect the cardiovascular system and increase the risk of mortality, especially for individuals with thyroid-stimulating hormone (TSH) levels above 10 mU/L. We investigated the relationship between high-TSH subclinical hypothyroidism and postoperative mortality in acute type A aortic dissection (ATAAD) patients.

METHOD

We enrolled 146 patients with ATAAD who underwent aortic surgery in Beijing Anzhen Hospital from July 2016 to November 2018. Thyroid hormone levels were obtained before surgery, and participants were divided into a ≥10mU/L TSH level group and a <10mU/L level group. Cox proportional hazard regression and subgroup analysis were conducted to examine the association of preoperative high-TSH subclinical hypothyroidism with postoperative mortality.

RESULT

Participants with preoperative high-TSH (≥10mU/L) subclinical hypothyroidism tended to have longer hospitalization stays after surgery [16.0 (IQR 11.0-21.0) days vs 12.5 (IQR 8.0-16.0) days, P=0.001]. During the first 30 days after operation, 15 of 146 patients died (10.3%); during a median of 3.16 (IQR 1.76-4.56) years of follow-up, 24 patients died (16.4%). Cox proportional hazard regression showed that preoperative high-TSH subclinical hypothyroidism was independently associated with 30-day mortality (HR=6.2, 95% CI, 1.7-22.0, P=0.005) and postoperative mortality after adjusting for age, sex, BMI, hypertension, ejection fraction, diabetes and history of PCI (HR=3.4, 95% CI, 1.4-8.0, P=0.005).

CONCLUSION

This study showed that preoperative high-TSH subclinical hypothyroidism was an independent predictor of postoperative mortality in ATAAD patients who underwent aortic surgery.

Low Triiodothyronine Syndrome Increased the Incidence of Acute Kidney Injury After Cardiac Surgery

Background

Acute kidney injury (AKI) is a severe complication of cardiac surgery. This study was designed to explore the association between the preoperative low T3 syndrome and cardiac surgery-associated acute kidney injury (CSA-AKI).

Methods

This was a retrospective single-center study. Data on 784 patients undergoing elective coronary artery bypass grafting (CABG) or valve surgery were collected from January 2016 to July 2019. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines. The effect of preoperative low T3 syndrome (fT3 < 3.5pmol/L) on the risk of the postoperative AKI was analyzed in a logistic regression model.

Results

There were 171 (21.8%) patients developing AKI. Preoperative T3 and FT3 levels were lower in patients with AKI than in those without AKI (P < 0.001). The incidence of postoperative AKI was higher in patients with low T3 syndrome than in those without (31.0% vs 19.8%; P = 0.003). Multivariate logistic regression analysis showed that low T3 syndrome was an independent risk factor for CSA-AKI patients (OR = 1.609, 95% CI: 1.033–2.504; P = 0.035), after adjusting for confounding factors, such as age, albumin, and uric acid. Subgroup analyses showed that preoperative low T3 syndrome also increased incidence of CSA-AKI in those with high risk factors, such as age ≧60 yrs (OR: 1.891, 95% CI: 1.183–3.022, P = 0.008), hypertension (OR: 2.104, 95% CI: 1.218–3.3.635, P = 0.008), and hyperuricemia (OR: 2.052, 95% CI: 1.037–4.06, P = 0.039).

Conclusion

Low T3 syndrome independently increases the risk of CSA-AKI. Patients with low T3 syndrome should be considered at higher risk and be evaluated before cardiac surgery.

Effect of levothyroxine replacement therapy in patients with subclinical hypothyroidism and chronic heart failure: A systematic review

BACKGROUND

Chronic heart failure (CHF) affects the health care system with high social and economic costs due to recurrent hospital admissions or frequent ambulatory reassessments. Subclinical hypothyroidism (SCH) is commonly observed in patients with CHF and negatively affects myocardial function and remodeling and, ultimately, increases the risk of hospitalizations and all-cause and cardiovascular (CV) mortality. The role of levothyroxine replacement on relevant CV outcomes in patients with SCH and CHF is unclear.

OBJECTIVE

To assess the effect of levothyroxine (compared to placebo or no treatment) on the incidence of all-cause and CV mortality, major adverse CV events, and heart failure in patients with SCH and CHF.

METHODS

PubMed/MEDLINE, Cochrane Library, and ClinicalTrial.gov were searched for randomized clinical trials, non-randomized observational, multicentric, and comparative studies. No language restrictions were included. After duplicate removal, articles were screened and extracted for the synthesis according to a hierarchical strategy that included title, abstract, and full-text appraisal. The risk of bias was assessed by RoB2 and ROBIN-I tools. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to rate the quality of evidence and grade the strength of recommendations.

RESULTS

Two trials were included in the systematic review with considerable indirectness and inaccuracy that down-graded the level of evidence.

DISCUSSION

No evidence supports the use of levothyroxine for treating SCH in CHF due to the lack of reliable and well-designed clinical trials.

CONCLUSION

CV outcome and dose-response trials are needed to understand better the role of levothyroxine replacement treatment for a safer prescription in this clinical setting.

Low triiodothyronine levels correlate with high B-type natriuretic peptide levels in patients with heart failure

Thyroid hormone metabolism can be closely associated with cardiovascular disorders. We examined the relationship between low triiodothyronine (T3) levels and heart failure status, including B-type natriuretic peptide (BNP) levels, in 625 patients with cardiovascular disorders who underwent cardiac catheterization. A multiple regression analysis revealed that the left ventricular ejection fraction (LVEF), hemoglobin (Hb) levels, sex (male), free T3 (FT3) levels, and estimated glomerular filtration rate (eGFR) were significantly negatively associated with the log BNP value, while age was significantly positively associated with the log BNP value (P < 0.001 each). Furthermore, the log BNP and age were significantly negatively associated with the FT3 levels, while the Hb and body mass index (BMI) were significantly positively associated with the FT3 levels (P < 0.001 each). Theoretically constructed structure equation modeling (SEM) revealed an inverse association between FT3 and BNP (β = −0.125, P = 0.002), and the same relationship remained in the patient group with normal-range BNP values (β = −0.198, P = 0.008). We demonstrated a significant relationship between high BNP and low serum FT3 levels, and this relationship remained significant in patients with normal BNP levels. These results indicate that low T3 is associated with high plasma BNP levels rather than worsening of hemodynamics.

Clinical Significance of Low-Triiodothyronine Syndrome in Patients Requiring Non-Surgical Intensive Care - Triiodothyronine Is a Comprehensive Prognostic Marker for Critical Patients With Cardiovascular Disease

Background: Low-triiodothyronine (T₃) syndrome is a known complication in intensive care unit (ICU) patients, but the underlying mechanisms and prognostic impact are unclear.

Methods and Results: This study retrospectively enrolled 2,976 patients who required care in the ICU. Of these patients, 2,425 were euthyroid and were divided into normal (n=1,666; free T₃ [FT₃] ≥1.88 µIU/L) and low-FT₃ (n=759; FT₃ <1.88 µIU/L) groups. Multivariate logistic regression analysis revealed that prognostic nutritional index >46.03 (odds ratio [OR] 2.392; 95% confidence interval [CI] 1.904–3.005), age (per 1-year increase; OR 1.022; 95% CI 1.013–1.031), creatinine (per 0.1-mg/dL increase; OR 1.019; 95% CI 1.014–1.024), and C-reactive protein (per 1-mg/dL increase; OR 1.123; 95% CI 1.095–1.151) were independently associated with low FT₃. Survival rates (within 365 days) were significantly lower in the low-FT₃ group. A multivariate Cox regression model showed that low FT₃ was an independent predictor of 365-day mortality (hazard ratio 1.785; 95% CI 1.387–2.297). Low-T₃ syndrome was significantly more frequent in patients with non-cardiovascular than cardiovascular diseases (73.5% vs. 25.8%). Prognosis was significantly poorer in the low-FT₃ than normal group for patients with cardiovascular disease, particularly those with acute coronary syndrome and acute heart failure.

Conclusions: Low-T₃ syndrome was associated with aging, inflammatory reaction, malnutrition, and renal insufficiency and could lead to adverse outcomes in patients admitted to a non-surgical ICU.

Prognostic role of hypothyroidism and low free-triiodothyronine levels in patients hospitalized with acute heart failure

Low thyroid function has been widely recognized as a potential cause of heart failure (HF), but the evidence about a possible association with in-hospital, all-cause mortality in patients with acute HF (AHF) is not consistent. This study sought to investigate the prevalence and prognostic role of hypothyroidism, overt and subclinical, and of low free-triiodothyronine (fT3) levels in patients hospitalized with AHF. We retrospectively analyzed consecutive 1018 patients who were hospitalized for AHF in a single academic medical center [Fondazione Policlinico A.Gemelli IRCCS, Rome, Italy] between January 1st 2016, and December 31st 2018. Patients were divided into three groups: normal thyroid function (n = 798), subclinical hypothyroidism (n = 105), and overt hypothyroidism (n = 115). The outcome was in-hospital, all-cause mortality. Patients were 81 years of age, 55% were females and nearly two-thirds of the patients were on New York Heart Association functional class III. The three most common cardiovascular comorbidities were coronary artery disease, hypertension, and atrial fibrillation with no differences across the three groups. Overall, 138 patients (14%) died during the hospital stay. The mortality rate was 27% among patients with overt hypothyroid, 17% among those with subclinical hypothyroidism, and 11% among euthyroid patients (p < 0.001). At a multivariate Cox regression model, overt hypothyroidism (HR 2.1, 95% CI 1.4-3.2) and fT3 levels < 1.8 pg/mL (HR 3.4, 95% CI 2.3-5.1) were associated with an increased likelihood of in-hospital death. No association was found with subclinical hypothyroidism. Among patients hospitalized with AHF, overt hypothyroidism and low fT3 levels are independent predictors of all-cause mortality during the hospital stay.

Combined use of low T3 syndrome and NT-proBNP as predictors for death in patients with acute decompensated heart failure

BACKGROUND

In patients with established HF, low triiodothyronine syndrome (LT3S) is commonly present, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a useful marker for predicting death. This study was aimed to evaluate the prognostic value of LT3S in combination with NT-proBNP for risk of death in patients with heart failure (HF).

METHODS

A total of 594 euthyroid patients hospitalized with acute decompensated HF were enrolled by design. Of these patients, 27 patients died during hospitalization and 100 deaths were identified in patients discharged alive during one year follow-up. Patients were divided into 2 groups on the base of the reference ranges of free T3 (FT3) levels: LT3S group (FT3 < 2.3pg/mL, n = 168) and non-LT3S group (FT3 ≥ 2.3pg/mL, n = 426).

RESULTS

In multivariable Cox regression, LT3S was significantly associated with 1 year all-cause mortality (adjusted hazard ratio, 1.85; 95 % confidence interval [CI], 1.21 to 2.82; P = 0.005), but not significant for in-hospital mortality (adjusted hazard ratio, 1.58; 95 % CI, 1.58 to 2.82; P = 0.290) after adjustment for clinical variables and NT-proBNP. Addition of LT3S and NT-proBNP to the prediction model with clinical variables significantly improved the C statistic for predicting 1 year all-cause mortality.

CONCLUSIONS

In patients with acute decompensated HF, the combination of LT3S and NT-proBNP improved prediction for 1 year all-cause mortality beyond established risk factors, but was not strong enough for in-hospital mortality.

Triiodothyronine maintains cardiac transverse-tubule structure and function

Subclinical hypothyroidism and low T3 syndrome are commonly associated with an increased risk of cardiovascular disease (CVD) and mortality. We examined effects of T3 on T-tubule (TT) structures, Ca²⁺ mobilization and contractility, and clustering of dyadic proteins. Thyroid hormone (TH) deficiency was induced in adult female rats by propyl-thiouracil (PTU; 0.025%) treatment for 8 weeks. Rats were then randomized to continued PTU or triiodo-L-thyronine (T3; 10 μg/kg/d) treatment for 2 weeks (PTU + T3). After in vivo echocardiographic and hemodynamic recordings, cardiomyocytes (CM) were isolated to record Ca²⁺ transients and contractility. TT organization was assessed by confocal microscopy, and STORM images were captured to measure ryanodine receptor (RyR2) cluster number and size, and L-type Ca²⁺ channel (LTCC, Ca_v1.2) co-localization. Expressed genes including two integral TT proteins, junctophilin-2 (Jph-2) and bridging integrator-1 (BIN1), were analyzed in left ventricular (LV) tissues and cultured CM using qPCR and RNA sequencing. The T3 dosage used normalized serum T3, and reversed adverse effects of TH deficiency on in vivo measures of cardiac function. Recordings of isolated CM indicated that T3 increased rates of Ca²⁺ release and re-uptake, resulting in increased velocities of sarcomere shortening and re-lengthening. TT periodicity was significantly decreased, with reduced transverse tubules but increased longitudinal tubules in TH-deficient CMs and LV tissue, and these structures were normalized by T3 treatment. Analysis of STORM data of PTU myocytes showed decreased RyR2 cluster numbers and RyR localizations within each cluster without significant changes in Ca_v1.2 localizations within RyR clusters. T3 treatment normalized RyR2 cluster size and number. qPCR and RNAseq analyses of LV and cultured CM showed that Jph2 expression was T3-responsive, and its increase with treatment may explain improved TT organization and RyR-LTCC coupling.

Ignoring a basic pathophysiological mechanism of heart failure progression will not make it go away

A link between heart failure (HF) and low thyroid hormone (TH) function has been known for over a century. Nonetheless, there is a general belief that TH treatment of patients with HF may not be worth the risk. This is largely based on two clinical trials where heart patients were treated with excessive doses of TH analogs, not actual THs. Further complicating the matter is the fact that normalization of THs in noncardiac patients can often be challenging. This issue is not going away as noted by a steady increase in TH-HF citations in recent years. In this article, we discuss what we know and how we may move the field forward.

Evaluation of Thyroid Function in Patients Hospitalized for Acute Heart Failure

BACKGROUND

Thyroid hormones (TH) are crucial for cardiovascular homeostasis. Recent evidence suggests that acute cardiovascular conditions, particularly acute heart failure (AHF), significantly impair the thyroid axis. Our aim was to evaluate the association of thyroid function with cardiovascular parameters and short- and long-term clinical outcomes in AHF patients.

METHODS

We performed a single-centre retrospective cohort study including patients hospitalized for AHF between January 2012 and December 2017. We used linear, logistic, and Cox proportional hazard regression models to analyse the association of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) with inpatient cardiovascular parameters, in-hospital mortality, short-term adverse clinical outcomes, and long-term mortality. Two models were used: (1) unadjusted, and (2) adjusted for age and sex.

RESULTS

Of the 235 patients included, 59% were female, and the mean age was 77.5 (SD 10.4) years. In the adjusted model, diastolic blood pressure was positively associated with TSH [β = 2.68 (0.27 to 5.09); p = 0.030]; left ventricle ejection fraction (LVEF) was negatively associated with FT4 [β = -24.85 (-47.87 to -1.82); p = 0.035]; and a nonsignificant trend for a positive association was found between 30-day all-cause mortality and FT4 [OR = 3.40 (0.90 to 12.83); p = 0.071]. Among euthyroid participants, higher FT4 levels were significantly associated with a higher odds of 30-day all-cause death [OR = 4.40 (1.06 to 18.16); p = 0.041]. Neither TSH nor FT4 levels were relevant predictors of long-term mortality in the adjusted model.

CONCLUSIONS

Thyroid function in AHF patients is associated with blood pressure and LVEF during hospitalization. FT4 might be useful as a biomarker of short-term adverse outcomes in these patients.

Lower levels of triiodothyronine are associated with poor hemodynamic profile and all-cause mortality in heart failure

Background: We aimed to assess the association of triiodothyronine (T3) hormone with invasive hemodynamic parameters and all-cause mortality in heart failure with reduced ejection fraction (HFrEF). Results: About 483 HFrEF patients were enrolled. Patients with the lowest T3 tertile had advanced New York Heart Association (NYHA) classes, had higher uric acid, brain natriuretic peptide. T3 level had a positive correlation with cardiac index (CI) and a negative correlation with pulmonary vascular resistance and pulmonary capillary wedge pressure. Adjusted with NYHA III-IV classes, uric acid, aspartate aminotransferase and CI, T3 level was found to be an independent predictor of all-cause mortality. In Kaplan-Meier analysis, the lowest T3 tertile had the lowest survival function. Conclusion: Free T3 is positively correlated with CI and negatively correlated with pulmonary vascular resistance and pulmonary capillary wedge pressure in patients with HFrEF. Lower levels of T3 seems to be a poor prognostic factor in this particular patient population.

Low Free Triiodothyronine as a Predictor of Poor Prognosis in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries

BACKGROUND

Low free triiodothyronine (fT3) level is strongly associated with poor prognosis in various patient populations. However, the role of fT3 in the risk of clinical outcomes in myocardial infarction with non-obstructive coronary arteries (MINOCA) has not been studied. Our study aimed to evaluate the association between low fT3 levels and the clinical outcomes of MINOCA patients.

METHODS

A total of 218 MINOCA patients without a history of thyroid disease were enrolled in the study. Demographic, baseline clinical data, thyroid hormones, and other biochemical parameters were assessed in all patients. According to the fT3 levels, the present study was classified into two groups: the low fT3 group (fT3<3.5 pmol/L) and the normal fT3 group (fT3 3.5-6.5 pmol/L). The endpoint of the study was major adverse cardiac events (MACE).

RESULTS

Fifty-nine patients were in the low fT3 group and 159 patients were in the normal fT3 group. Over the two years of follow-up, 36 MACE have occurred. The occurrence of MACE was higher in the low fT3 group compared with normal fT3 group (25.4% vs 13.2%; P=0.031). Kaplan-Meier survival curves showed a significantly increased risk of MACE in patients with low fT3 (log-rank P=0.027). Multivariable logistic regression analysis stated that high fT3 was independently associated with lower risk of MACE after two years of follow up (OR, 0.623; 95% CI, 0.399- 0.972; P=0.037).

CONCLUSION

Low fT3 levels were significantly associated with increased risk of MACE in patients with MINOCA. This finding suggests that the fT3 levels may serve as a potential biomarker in risk stratification of MINOCA patients.

Association Between Low T3 Syndrome and Poor Prognosis in Adult Patients With Acute Myocarditis

BACKGROUND

This study aims to investigate the role of free triiodothyronine (fT3) in predicting poor prognosis of adult patients with acute myocarditis.

METHODS

A total of 173 consecutive adult patients with acute myocarditis completed thyroid function evaluations. They were divided into two groups according to fT3 levels: low fT3 group (n = 54, fT3 < 3.54 pmol/liter) and normal fT3 group (n = 119, fT3 ≥ 3.54 pmol/liter). The primary endpoint was major adverse cardiac events (MACE).

RESULTS

During the 3.5 ± 2.8 years follow-up, the rate of MACE was 29.6% versus 3.5% in low fT3 group versus normal fT3 group, respectively (P < 0.0001). Long-term at 8 years MACE-free survival were lower in low fT3 group versus normal fT3 group (52.9% versus 92.3%, log-rank P < 0.0001), respectively. Univariate Cox analysis showed that left ventricular ejection fraction (LVEF) < 50% [hazard ratio (HR) 10.231, 95% confidence interval (CI): 3.418-30.624, P < 0.0001) and low fT3 level (HR 0.360, 95% CI: 0.223-0.582, P < 0.0001) were strongest two predictors of MACE. After adjustment for traditional risk predictors, the prognostic value of fT3 status was still significant (HR 0.540, 95% CI: 0.316-0.922, P = 0.024). Compared with normal fT3 group, those in low fT3 group were at a much higher risk of MACE (HR 5.074, 95% CI: 1.518-16.964, P = 0.008).

CONCLUSIONS

Low T3 syndrome was a strong predictor of poor prognosis in adult patients with acute myocarditis. These findings suggest that fT3 level could serve as a biomarker for risk stratification in acute myocarditis patients.

Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure

Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.

Modification of cardiac thyroid hormone deiodinases expression in an ischemia/reperfusion rat model after T3 infusion

The deiodinases regulate the activation and inactivation of Thyroid hormones (TH), in both physiological and pathological conditions. The three deiodinases, DIO1, DIO2 and DIO3, have different catalytic role and cellular and tissue distribution. Aim of this study is to evaluate a rat model of regional ischemia/reperfusion (I/R), the modification of cardiac main function after the administration of 6 µg/kg/day of triiodothyronine (T3), and the associated to DIO1, DIO2 and DIO3 gene expression. We also aim to study DIO1 and DIO2 protein levels in different left ventricular regions after an ischemic event. Four groups of rats were studied: sham-operated, sham-operated + T3, I/R rats and I/R rats + T3. DIO1, DIO2 and DIO3 expression were evaluated in I/R region (AAR: area-at-risk) and in a more distant region from ischemic wound (RZ: remote zone). In I/R group, circulating free-T3 (FT3) levels were significantly decreased with respect to basal values, whereas in I/R + T3 rats, FT3 levels were comparable to basal values. In AAR of I/R + T3 rats, DIO1 and DIO2 gene expression significantly increased with respect to sham. In RZ, DIO1 and DIO3 gene expression was significantly lower in sham and I/R rats when compared to I/R + T3. In sham + T3 group, DIO1 and DIO2 gene expression was not detectable, whereas DIO3 was significantly higher than in the other three groups. The present study gives interesting new insights on DIO1, DIO2 and DIO3 in the ischemic heart and their role in relation to T3-mediated amelioration of cardiac function and structure.

BNP as a New Biomarker of Cardiac Thyroid Hormone Function

Background

Cardiac re-expression of fetal genes in patients with heart failure (HF) suggests the presence of low cardiac tissue thyroid hormone (TH) function. However, serum concentrations of T3 and T4 are often normal or subclinically low, necessitating an alternative serum biomarker for low cardiac TH function to guide treatment of these patients. The clinical literature suggests that serum Brain Natriuretic Peptide (BNP) levels are inversely associated with serum triiodo-L-thyronine (T3) levels. The objective of this study was to investigate BNP as a potential serum biomarker for TH function in the heart.

Methods

Two animal models of thyroid hormone deficiency: (1) 8-weeks of propyl thiouracil-induced hypothyroidism (Hypo) in adult female rats were subsequently treated with oral T3 (10 μg/kg/d) for 3, 6, or 14 days; (2) HF induced by coronary artery ligation (myocardial infarction, MI) in adult female rats was treated daily with low dose oral T3 (5 μg/kg/d) for 8 or 16 wks.

Results

Six days of T3 treatment of Hypo rats normalized most cardiac functional parameters. Serum levels of BNP increased 5-fold in Hypo rats, while T3 treatment normalized BNP by day 14, showing a significant inverse relationship between serum BNP and free or total T3 concentrations. Myocardial BNP mRNA was increased 2.5-fold in Hypo rats and its expression was decreased to normal values by 14 days of T3 treatment. Measurements of hemodynamic function showed significant dysfunction in MI rats after 16 weeks, with serum BNP increased by 4.5-fold and serum free and total T3 decreased significantly. Treatment with T3 decreased serum BNP while increasing total T3 indicating an inverse correlation between these two biologic factors (r ² = 0.676, p < 0.001). Myocardial BNP mRNA was increased 5-fold in MI rats which was significantly decreased by T3 over 8 to 16 week treatment periods.

Conclusions

Results from the two models of TH dysfunction confirmed an inverse relationship between tissue and serum T3 and BNP, such that the reduction in serum BNP could potentially be utilized to monitor efficacy and dosing of T3 treatment. Thus, serum BNP may serve as a reliable biomarker for cardiac TH function.

B-type natriuretic peptide is associated with post-discharge stroke in hospitalized patients with heart failure

Aims

Recently, B‐type natriuretic peptide (BNP) has been attracting attention as a predictor of stroke in patients with atrial fibrillation or those with prior stroke experience. However, the association between BNP and stroke has not been examined in patients with chronic heart failure (CHF). In the current study, we assessed whether BNP is associated with future occurrence of stroke in patients with CHF.

Methods and results

We prospectively studied 1803 consecutive patients who were admitted for decompensated HF and assessed the predictive value of circulating BNP levels for occurrence of post‐discharge stroke.

A total of 69 (3.8%) patients experienced a stroke (the stroke group) during the post‐discharge follow‐up period of a median of 1150 days. The stroke group showed a higher CHADS₂ score. With respect to past medical history, the stroke group had a higher prevalence of arterial hypertension, atrial fibrillation, prior stroke, and chronic kidney disease. Echocardiographic parameters showed no significant differences between the two groups. In contrast, BNP levels were significantly higher in the stroke group than in the non‐stroke group (452.1 vs. 222.7 pg/mL, P < 0.001). Multivariate Cox proportional hazard analysis indicated that BNP levels were independently associated with post‐discharge stroke (hazard ratio 2.636, 95% confidence interval 1.595–4.357, P < 0.001). The survival classification and regression tree analysis revealed that the accurate cut‐off point of BNP in predicting post‐discharge stroke was 187.7 pg/mL. We added high BNP level (BNP ≥ 180 pg/mL) as one point to CHADS₂ score. The BNP‐added CHADS₂ score was compared with CHADS₂ score alone by using c‐statistics. The areas under the curve of CHADS₂ score, BNP, and BNP‐added CHADS₂ score were 0.698, 0.616, and 0.723, respectively. The predictive value of BNP‐added CHADS₂ score was higher compared with those of CHADS₂ score (P = 0.026).

Conclusions

The assessment of BNP may predict the occurrence of stroke in CHF patients used alone or in combination with established CHADS₂ score.

Relation of Low Triiodothyronine Syndrome Associated With Aging and Malnutrition to Adverse Outcome in Patients With Acute Heart Failure

Low triiodothyronine (T3) syndrome has recently been evaluated as a prognostic marker of acute heart failure (AHF). However, in which cases low T3 syndrome typically leads to adverse outcomes remain unclear. Of 1,432 AHF patients screened, 1,190 were enrolled. Euthyroidism was present in 956 patients (80.3%), who were divided into 2 groups: the normal group (n = 445, FT3 ≥1.88 µIU/L) and low-FT3 group (n = 511, FT3 <1.88 µIU/L). The survival rates and event-free rates within 365 days were significantly lower in the low-FT3 group than in the normal group. A multivariate Cox regression model showed that the low-FT3 group was an independent predictor of 365-day mortality (hazard ratio [HR] 1.429, 95% confidence interval [CI] 1.013 to 2.015) and HF events (HR 1.349, 95% CI 1.047 to 1.739). The multivariate logistic regression analysis revealed that age (per 10-year old increase, odds ratio [OR]: 1.186, 95% CI: 1.046 to 1.345) and prognostic nutritional index (PNI; per 1-point increase, OR: 1.067, 95% CI: 1.046 to 1.089) were independently associated with the low-FT3 group. The prognosis in patients with a low PNI and over 75 years old, including all-cause death within 365 days, was significantly poorer in the low-FT3 group than in the normal group. In conclusion, adverse outcomes were predicted by the presence of low T3. AHF patients with low T3 syndrome are strongly associated with aging and malnutrition. Low T3 syndrome complicated with older age and malnutrition is likely to lead to adverse outcomes in patients with AHF.

Cardioprotection and Thyroid Hormones in the Clinical Setting of Heart Failure

Ischemic heart disease is the main cause of morbidity and mortality worldwide and is becoming more widespread with population aging. Cardioprotection is a dynamic process characterized by mechanisms related to myocardial damage and activation of protective factors. Targeting these processes could be attractive as a new therapeutic strategy in the evolution of post-ischemic heart failure (HF). In this context, the role of thyroid hormone (TH)-mediated cardioprotection is supported by a number of findings regarding the modulation of neuroendocrine systems, inflammatory and oxidative stress status, pro-survival intracellular pathways, and epigenetic factors, its effects on cardiac angiogenesis, structure, and function and on the preservation of mitochondrial function and morphology, and its beneficial effects on cell growth and redifferentiation. Moreover, the numerous effects of TH on the heart involve genomic mechanisms, which include cardiac differentiation during the perinatal period and non-genomic action, directed toward the maintenance of cardiovascular homeostasis. This evidence suggests that there is an opportunity to treat HF patients with TH. This review is mainly focused on the clinical evidence of the role of the thyroid system in the complex setting of HF.