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Pepe J, Cipriani C, Curione M, Biamonte F, Colangelo L, Danese V, Cecchetti V, Sonato C, Ferrone F, Cilli M, Minisola S. Reduction of arrhythmias in primary hyperparathyroidism, by parathyroidectomy, evaluated with 24-h ECG monitoring. Eur J Endocrinol 2018; 179:117-124. [PMID: 29875287 DOI: 10.1530/eje-17-0948] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 06/01/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Hypercalcemia may induce arrhythmias. There are no data on the prevalence of arrhythmias in primary hyperparathyroidism (PHPT) in daily life. Aim of the study was to investigate both the prevalence of arrhythmias in patients with PHPT compared to controls and the impact of parathyroidectomy, evaluated by 24-h electrocardiogram (ECG) monitoring. DESIGN This is a randomized study. METHODS Twenty-six postmenopausal women with PHPT and 26 controls were enrolled. PHPT patients were randomized to two groups: 13 underwent parathyroidectomy (Group A) and 13 were followed up conservatively (Group B). After 6 months, patients were studied again. Each patient underwent mineral metabolism biochemical evaluation, bone mineral density measurement, standard ECG and 24-h ECG monitoring. RESULTS PHPT patients showed higher calcium and parathyroid hormone compared to controls and a higher prevalence of both supraventricular (SVBPs) and ventricular premature beats (VPBs) during 24-h ECG monitoring. Groups A and B showed no differences in mean baseline biochemical values and ECG parameters. Mean value of QTc in PHPT groups was in the normal range at baseline, but significantly shorter than controls. A negative correlation was found between QTc and ionized calcium levels (r = -0.48, P < 0.05). After parathyroidectomy, Group A had a significant reduction in SVPBs and VPBs compared to baseline and restored normal QTc. Group B showed no significant changes after a 6-month period. CONCLUSIONS The increased prevalence of SVPBs and VPBs is significantly reduced by parathyroidectomy, and it is mainly related to the short QTc caused by hypercalcemia.
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Affiliation(s)
- Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Mario Curione
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Federica Biamonte
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Luciano Colangelo
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Vittoria Danese
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Veronica Cecchetti
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Chiara Sonato
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Federica Ferrone
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Mirella Cilli
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University of Rome, Rome, Italy
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Pepe J, Cipriani C, Sonato C, Raimo O, Biamonte F, Minisola S. Cardiovascular manifestations of primary hyperparathyroidism: a narrative review. Eur J Endocrinol 2017; 177:R297-R308. [PMID: 28864535 DOI: 10.1530/eje-17-0485] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
| | - Chiara Sonato
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
| | - Orlando Raimo
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
| | - Federica Biamonte
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, 'Sapienza' University, Rome, Italy
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Cinamon U, Gavish D, Ovnat Tamir S, Goldfarb A, Ezri T. Effect of general anesthesia and intubation on parathyroid levels in normal patients and those with hyperparathyroidism. Head Neck 2017; 40:555-560. [PMID: 29130559 DOI: 10.1002/hed.25002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/26/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Induction of general anesthesia and endotracheal intubation may precipitate parathyroid hormone (PTH) elevation in patients with primary hyperparathyroidism (HPT). The purposes of this study were to revisit this observation and to study its impact in healthy patients. METHODS Patients with primary HPT who underwent parathyroidectomy were retrospectively studied. The PTH was sampled and compared: before, immediately after general anesthesia and endotracheal intubation, and 15 minutes after parathyroidectomy. Healthy adults who underwent elective operations were prospectively studied. The PTH was sampled before general anesthesia and endotracheal intubation, immediately after, and 15 minutes later. RESULTS Thirty-one patients, aged 28-89 years (mean 60.1 ± 13 years), were retrospectively studied. The PTH was significantly elevated after general anesthesia and endotracheal intubation (P = .014). Fifty patients, aged 21-86 years (mean 54 ± 15 years), were prospectively studied. The PTH elevation after general anesthesia and endotracheal intubation was not significant. CONCLUSION General anesthesia and endotracheal intubation causes an immediate, steep, and significant PTH elevation in patients with primary HPT but only a minor change in healthy adults. The difference may be attributed to an impaired adrenergic response in patients with primary HPT.
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Affiliation(s)
- Udi Cinamon
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Doron Gavish
- Department of Anesthesiology, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Sharon Ovnat Tamir
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Abraham Goldfarb
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Tiberiu Ezri
- Department of Anesthesiology, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel.,Outcomes Research Consortium, Cleveland, Ohio
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Sabljak VD, Zivaljevic VR, Milicic BR, Paunovic IR, Toskovic AR, Stevanovic KS, Tausanovic KM, Markovic DZ, Stojanovic MM, Lakicevic MV, Jovanovic MD, Diklic AD, Kalezic NK. Risk Factors for Intraoperative Hypertension during Surgery for Primary Hyperparathyroidism. Med Princ Pract 2017; 26:381-386. [PMID: 28399538 PMCID: PMC5768112 DOI: 10.1159/000475597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 04/10/2017] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To investigate the incidence and identify risk factors for the occurrence of intraoperative hypertension (IOH) during surgery for primary hyperparathyroidism (pHPT). SUBJECTS AND METHODS The study included 269 patients surgically treated between January 2008 and January 2012 for pHPT. IOH was defined as an increase in systolic blood pressure ≥20% compared to baseline values which lasted for 15 min. The investigated influence were demographic characteristics, surgical risk score related to physical status (based on the American Society of Anesthesiologists [ASA] classification), comorbidities, type and duration of surgery, and duration of anesthesia on IOH occurrence. The investigated factors were obtained from the patients' medical history, anesthesia charts, and the daily practice database. Logistic regression analysis was done to determine the predictors of IOH. RESULTS Of the 269 patients, 153 (56.9%) had IOH. Based on the univariate analysis, age, body mass index, ASA status, duration of anesthesia, and preoperative hypertension were risk factors for the occurrence of IOH. Multivariate analysis showed that independent predictors of IOH were a history of hypertension (OR = 2.080, 95% CI: 1.102-3.925, p = 0.024) and age (OR = 0.569, 95% CI: 0.360-0.901, p = 0.016). CONCLUSION In this study, a high percentage (56%) of the patients developed IOH during surgery for pHPT, which indicates that special attention should be paid to these patients, especially to the high-risk groups: older patients and those with a history of hypertension. Further, this study showed that advanced age and hypertension as a coexisting disease prior to parathyroid surgery were independent risk factors for the occurrence of IOH.
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Affiliation(s)
- Vera D. Sabljak
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Serbia
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
| | - Vladan R. Zivaljevic
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
- Center for Endocrine Surgery, Clinical Center of Serbia, Serbia
| | - Biljana R. Milicic
- Institute for Medical Informatics and Statistics, School of Dentistry, University of Belgrade, Serbia
| | - Ivan R. Paunovic
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
- Center for Endocrine Surgery, Clinical Center of Serbia, Serbia
| | - Anka R. Toskovic
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Serbia
| | | | | | - Dejan Z. Markovic
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Serbia
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
| | - Marina M. Stojanovic
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Serbia
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
| | - Mirko V. Lakicevic
- Department for Anesthesia and Resuscitation, Clinical Hospital Center Zemun, Belgrade, Serbia
| | | | - Aleksandar D. Diklic
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
- Center for Endocrine Surgery, Clinical Center of Serbia, Serbia
| | - Nevena K. Kalezic
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Serbia
- Department for Surgery and Anesthesiology, School of Medicine, University of Belgrade, Serbia
- *Prof. Nevena K. Kalezic, MD, PhD, Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Pasterova 2 St., RS-11000 Belgrade (Serbia), E-Mail
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Abstract
This review discusses recent findings on the clinical presentation, evaluation, medical and surgical management of primary hyperparathyroidism. Medical management includes the use of cinacalcet and bisphosphonates for bone loss and correction of vitamin D deficiency. Surgical updates reviewed recent studies on the preoperative localization of the disease, specifically, sestamibi scans, 4DCT and MRI. Focused parathyroidectomy continues to be the preferred surgical approach for a select group of patients, guided by intraoperative use of PTH and new technology, such as endoscopic and robotic platforms; however, there appears to be no difference in long-term success compared to the traditional approach.
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Affiliation(s)
- Zeina Habib
- a Mercy Hospital and Medical Center - Internal Medicine, Section of Endocrinology and Metabolism, 2525 S Michigan Ave, Chicago, IL 60616, USA
| | - Adam Kabaker
- b Loyola University - Surgery, Section of Endocrine Surgery, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Pauline Camacho
- c Loyola University - Endocrinology and Metabolism, 2160 S. First Avenue, Maywood, IL 60153, USA
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Alex G, Morris L, Pasieka J, Perrier N. Article Commentary: Nonclassical Symptoms of Primary Hyperparathyroidism and Their Response to Parathyroidectomy. Am Surg 2013. [DOI: 10.1177/000313481307900419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Gillian Alex
- Departments of Surgical Oncology and Endocrine Neoplasia and Hormonal Disorders, University of Texas M.D. Anderson Cancer Center, Houston, Texas; and the
| | - Lilah Morris
- Departments of Surgical Oncology and Endocrine Neoplasia and Hormonal Disorders, University of Texas M.D. Anderson Cancer Center, Houston, Texas; and the
| | - Janice Pasieka
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Nancy Perrier
- Departments of Surgical Oncology and Endocrine Neoplasia and Hormonal Disorders, University of Texas M.D. Anderson Cancer Center, Houston, Texas; and the
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