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Zwijnenburg RD, de Groot NMS. Atrial fibrillation in adult congenital heart disease: Puzzling with the pieces. Heart Rhythm 2023; 20:1255-1256. [PMID: 37230407 DOI: 10.1016/j.hrthm.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Roxanne D Zwijnenburg
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Department of Microelectronics, Signal Processing Systems, Faculty of Electrical Engineering, mathematics and computer sciences, Delft University of Technology, Delft, The Netherlands.
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Joyce TR, Joyce JJ, Gleva MJ, Ferns SJ. Presentation and Prognosis of Excessive Asymptomatic Atrial Ectopy in Children and Adolescents With Structurally and Functionally Normal Hearts. Am J Cardiol 2023; 192:160-165. [PMID: 36807132 DOI: 10.1016/j.amjcard.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 02/21/2023]
Abstract
Excessive premature atrial complexes (PACs) in pediatric patients with a structurally normal heart are presumed to be benign and self-resolving, but no studies have confirmed this. Adults with excessive PACs, however, are at increased risk for future sustained atrial arrhythmias and cardiovascular morbidity and mortality. Therefore, we sought to evaluate the clinical course of frequent PACs in asymptomatic children. Patients < 21 years old with numerous asymptomatic PACs (>50/24 hours) were retrospectively selected over a 10-year period. Demographics, clinical characteristics, and results of cardiovascular testing were tabulated. Two groups were defined: those with a significant (>20%) reduction in burden of atrial ectopy versus those with an insignificant (<20%) reduction or increase. Of 6,902 patients, 343 patients (5%) met criteria. Initial median age was 8.3 (interquartile range [IQR] 4.1 to 14) years with comparable male:female ratio. Follow-up Holters were performed on 188 patients (54.8%) at a median interval of 2.2 (IQR 1.3 to 3.6) years. Overall, there was a significant decrease in atrial ectopy burden from 4.2% (IQR 1.9 to 6.5) down to 0.5% (IQR 0.01 to 2.3), with 166 patients (88.3%), demonstrating a decrease of over 20%. Five percent had a small increase, and 6% had an insignificant decrease. None developed cardiac symptoms or sustained supraventricular tachydysrhythmia. Male gender, athletic participation, and discontinuation of stimulant medications were the chief predictors for a reduction of PAC burden on follow-up. Atrial triplets at presentation were associated with a 5.4% increase. In conclusion, this study confirms that excessive asymptomatic childhood PACs with structurally normal hearts are rare and short-term to medium-term prognosis is benign.
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Affiliation(s)
- Thomas R Joyce
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Jacksonville Pediatric and Adult Congenital Cardiology, Jacksonville, Florida
| | - James J Joyce
- Jacksonville Pediatric and Adult Congenital Cardiology, Jacksonville, Florida; Wolfson Children's Hospital, Jacksonville, Florida
| | - Marye J Gleva
- Washington University School of Medicine, St. Louis, Missouri
| | - Sunita J Ferns
- Wolfson Children's Hospital, Jacksonville, Florida; University of Florida School of Medicine, Jacksonville, Florida.
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van Schie MS, Veen D, Kharbanda RK, Heida A, Starreveld R, van Schaagen FRN, Bogers AJJC, Taverne YJHJ, de Groot NMS. Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation. Int J Cardiol 2022; 363:71-79. [PMID: 35705170 DOI: 10.1016/j.ijcard.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Danny Veen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF.
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Affiliation(s)
- Bianca J J M Brundel
- Department of Physiology, Amsterdam University Medical Centers, VU Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
| | - Xun Ai
- Department of Physiology and Cell Biology, College of Medicine/Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - Myrthe F Kuipers
- AFIPonline.org, Atrial Fibrillation Innovation Platform, Amsterdam, Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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van Wijk SW, Su W, Wijdeveld LFJM, Ramos KS, Brundel BJJM. Cytoskeletal Protein Variants Driving Atrial Fibrillation: Potential Mechanisms of Action. Cells 2022; 11:416. [PMID: 35159226 PMCID: PMC8834312 DOI: 10.3390/cells11030416] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/15/2022] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
The most common clinical tachyarrhythmia, atrial fibrillation (AF), is present in 1-2% of the population. Although common risk factors, including hypertension, diabetes, and obesity, frequently underlie AF onset, it has been recognized that in 15% of the AF population, AF is familial. In these families, genome and exome sequencing techniques identified variants in the non-coding genome (i.e., variant regulatory elements), genes encoding ion channels, as well as genes encoding cytoskeletal (-associated) proteins. Cytoskeletal protein variants include variants in desmin, lamin A/C, titin, myosin heavy and light chain, junctophilin, nucleoporin, nesprin, and filamin C. These cytoskeletal protein variants have a strong association with the development of cardiomyopathy. Interestingly, AF onset is often represented as the initial manifestation of cardiac disease, sometimes even preceding cardiomyopathy by several years. Although emerging research findings reveal cytoskeletal protein variants to disrupt the cardiomyocyte structure and trigger DNA damage, exploration of the pathophysiological mechanisms of genetic AF is still in its infancy. In this review, we provide an overview of cytoskeletal (-associated) gene variants that relate to genetic AF and highlight potential pathophysiological pathways that drive this arrhythmia.
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Affiliation(s)
| | | | | | | | - Bianca J. J. M. Brundel
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (S.W.v.W.); (W.S.); (L.F.J.M.W.); (K.S.R.)
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Novel insights in pathophysiology of postoperative atrial fibrillation. JTCVS OPEN 2021; 6:120-129. [PMID: 36003566 PMCID: PMC9390318 DOI: 10.1016/j.xjon.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/29/2022]
Abstract
Objectives Atrial extrasystoles are usually benign; however, they can also trigger atrial fibrillation. It is most likely that if atrial extrasystoles provoke a larger amount of conduction disorders and a greater degree of endo-epicardial asynchrony, the risk of postoperative atrial fibrillation increases. To test this hypothesis, we investigated the effect of programmed atrial extrasystoles on endo-epicardial conduction and postoperative atrial fibrillation. Methods Twelve patients (58% male, age 68 ± 7 years) underwent simultaneous endo-epicardial mapping (256 electrodes) of the right atrium during sinus rhythm and programmed atrial extrasystoles provoked from the right atrial free wall. Areas of conduction block were defined as conduction delays of ≥12 milliseconds and endo-epicardial asynchrony as activation time differences of exact opposite electrodes of ≥15 milliseconds. Results Endo-epicardial mapping data of all programmed atrial extrasystoles were analyzed and compared with sinus rhythm (median preceding cycle length = 531 milliseconds [345-787] and median sinus rhythm cycle length = 843 milliseconds [701-992]). All programmed atrial extrasystoles were aberrant (severe, moderate, and mildly aberrant, respectively, n = 6, 3, and 3) and had a mean prematurity index of 50.1 ± 11.9%. The amount of endo-epicardial asynchrony (1% [1-2] vs 6.7 [2.7-16.9], P = .006) and conduction block (1.4% [0.6-2.6] vs 8.5% [4.2-10.4], P = .005) both increased during programmed atrial extrasystoles. Interestingly, conduction block during programmed atrial extrasystoles was more severe in patients (n = 4, 33.3%) who developed postoperative atrial fibrillation (5.1% [2.9-8.8] vs 11.3% [10.1-12.1], P = .004). Conclusions Atrial conduction disorders and endo-epicardial asynchrony, which play an important role in arrhythmogenesis, are enhanced during programmed atrial extrasystoles compared with sinus rhythm. The findings of this pilot study provide a possible explanation for enhanced vulnerability for postoperative atrial extrasystoles to induce postoperative atrial fibrillation in patients after cardiac surgery.
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Waldmann V, Khairy P. Pathophysiology, Risk Factors, and Management of Atrial Fibrillation in Adult Congenital Heart Disease. Card Electrophysiol Clin 2021; 13:191-199. [PMID: 33516397 DOI: 10.1016/j.ccep.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A confluence of clinical and epidemiologic factors has provoked a steep increase in the prevalence of atrial fibrillation in adults with congenital heart disease. Atrial fibrillation is the most common presenting arrhythmia. Much remains to be unraveled about the mitigating role congenital heart disease, residual hemodynamic defects, surgical ramifications, and shunts and cyanosis on new-onset and recurrent atrial fibrillation in this population. Catheter ablation is increasingly performed for atrial fibrillation. This synopsis provides an overview of current knowledge on atrial fibrillation in adults with congenital heart disease, addresses clinical management, and discusses knowledge gaps and areas for future research.
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Affiliation(s)
- Victor Waldmann
- Electrophysiology and Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, Université de Paris, 20 Rue Leblanc, 75015 Paris, France
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Zhang Y, Sun YM, Xu YJ, Zhao CM, Yuan F, Guo XJ, Guo YH, Yang CX, Gu JN, Qiao Q, Wang J, Yang YQ. A New TBX5 Loss-of-Function Mutation Contributes to Congenital Heart Defect and Atrioventricular Block. Int Heart J 2020; 61:761-768. [DOI: 10.1536/ihj.19-650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yan Zhang
- Department of Cardiology, Shanghai Jing'an District Central Hospital, Fudan University
| | - Yu-Min Sun
- Department of Cardiology, Shanghai Jing'an District Central Hospital, Fudan University
| | - Ying-Jia Xu
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Cui-Mei Zhao
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine
| | - Fang Yuan
- Department of Cardiology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine
| | - Xiao-Juan Guo
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Yu-Han Guo
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Chen-Xi Yang
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Jia-Ning Gu
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Qi Qiao
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
| | - Jun Wang
- Department of Cardiology, Shanghai Jing'an District Central Hospital, Fudan University
| | - Yi-Qing Yang
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
- Center for Complex Cardiac Arrhythmias of Minhang District, Shanghai Fifth People's Hospital, Fudan University
- Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University
- Central Laboratory, Shanghai Fifth People's Hospital, Fudan University
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Lanters EAH, Teuwen CP, Hokken T, Rohde S, Haitsma DB, Zijlstra F, Jordaens LJLM, de Groot NMS. Early markers of atrial fibrillation recurrence after pulmonary vein isolation. J Arrhythm 2020; 36:304-310. [PMID: 32256879 PMCID: PMC7132191 DOI: 10.1002/joa3.12307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postprocedural atrial extrasystole (AES) frequency predicts atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) in patients with paroxysmal AF. However, the predictive value of preprocedural AES frequency is unknown. We investigate whether preprocedural AES frequency is a feasible marker to predict (timing of) AF recurrence after PVI. METHODS Patients (N = 684) with paroxysmal or persistent AF undergoing first-time PVI were evaluated for (a) the frequency of AES/day on Holter recordings without AF prior to PVI, (b) AF episodes during the 90 days blanking period, and (c) AF recurrences afterward. The correlation between AES/day and both development and timing of AF recurrences was tested. RESULTS Preprocedural AES/day was similar in patients with paroxysmal (66 [20-295] AES/day) and persistent AF (115 [12-248] AES/day, P = .915). During the blanking period, 302 (44.2%) patients showed AF episodes. AF recurred in 379 (55.4%) patients at 203 (105-400) days after PVI. AF recurred more frequently in patients with persistent (N = 104 [69.3%]) than in patients with paroxysmal AF (N = 275 [51.5%], P < .001). Frequency of AES prior to PVI was not correlated with development (P = .203) or timing (P = .478) of AF recurrences. AF recurrences occurred both more frequently (P < .001) and earlier (P < .000) in patients with AF during the blanking period. CONCLUSION AES/day prior to PVI is not correlated with (timing of) AF during the blanking period or AF recurrences, and is therefore not a feasible marker for AF recurrences in patients with PAF. AF during the blanking period is correlated with AF recurrence.
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Affiliation(s)
- Eva A. H. Lanters
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | | | - Thijmen Hokken
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Sofie Rohde
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - David B. Haitsma
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Felix Zijlstra
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
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Waldmann V, Laredo M, Abadir S, Mondésert B, Khairy P. Atrial fibrillation in adults with congenital heart disease. Int J Cardiol 2019; 287:148-154. [DOI: 10.1016/j.ijcard.2019.01.079] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/12/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022]
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Korevaar TIM, Steegers EAP, Chaker L, Medici M, Jaddoe VWV, Visser TJ, de Rijke YB, Peeters RP. Thyroid Function and Premature Delivery in TPO Antibody-Negative Women: The Added Value of hCG. J Clin Endocrinol Metab 2017; 102:3360-3367. [PMID: 28911134 DOI: 10.1210/jc.2017-00846] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/15/2017] [Indexed: 02/04/2023]
Abstract
CONTEXT Human chorionic gonadotropin (hCG) stimulates thyroid function during pregnancy. We recently showed that thyroid autoimmunity severely attenuated the thyroidal response to hCG stimulation and that this may underlie the higher risk of premature delivery in thyroperoxidase antibody (TPOAb)-positive women. We hypothesized that a lower thyroidal response to hCG stimulation in TPOAb-negative women is also associated with a higher risk of premature delivery and preterm premature rupture of membranes (pPROM). DESIGN, SETTING, AND PARTICIPANTS Thyrotropin (TSH), free thyroxine (FT4), and hCG concentrations were available in 5644 TPOAb-negative women from a prospective cohort. We tested for interaction between TSH or FT4 and hCG in linear regression models for duration of pregnancy and logistic regression models for premature delivery/pPROM. Accordingly, analyses were stratified per TSH percentile (TSH ≥ 85th percentile) and hCG per 10,000 IU/L. RESULTS Women with high TSH and low hCG concentrations did not have a higher risk of premature delivery or pPROM, with protective effect estimates. In contrast, women with a high TSH concentration despite a high hCG concentration had twofold to 10-fold higher risk of premature delivery (Pdifference = 0.022) and an up to fourfold higher risk of pPROM (Pdifference = 0.079). hCG concentrations were not associated with premature delivery or pPROM. CONCLUSION In TPOAb-negative women with high-normal TSH concentrations, only women with high hCG concentrations had a higher risk of premature delivery or pPROM. These results suggest a lower thyroidal response to hCG stimulation is also associated with premature delivery in TPOAb-negative women and that an additional measurement of hCG may improve thyroid-related risk assessments during pregnancy.
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Affiliation(s)
- Tim I M Korevaar
- The Generation R Study Group, Erasmus Medical Center and/or Sophia Children's Hospital, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Erasmus Medical Center and/or Sophia Children's Hospital, 3015 GE Rotterdam, The Netherlands
| | - Layal Chaker
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Marco Medici
- The Generation R Study Group, Erasmus Medical Center and/or Sophia Children's Hospital, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Vincent W V Jaddoe
- The Generation R Study Group, Erasmus Medical Center and/or Sophia Children's Hospital, 3015 GE Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center and/or Sophia Children's Hospital, 3015 GE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Theo J Visser
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Yolanda B de Rijke
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Department of Clinical Chemistry, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
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