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Raho EM, Antonioni A, Cotta Ramusino N, Jubea D, Gragnaniello D, Franceschetti P, Penitenti F, Daniele A, Zatelli MC, Naccarato M, Traluci I, Pugliatti M, Padroni M. Cerebral Venous Thrombosis during Thyrotoxicosis: Case Report and Literature Update. J Pers Med 2023; 13:1557. [PMID: 38003871 PMCID: PMC10672691 DOI: 10.3390/jpm13111557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare cause of stroke, particularly in young adults. Several known thrombophilic conditions may lead to an increased CVT risk. Interestingly, few cases in the literature have reported an association between CVT and thyrotoxicosis. Here, we describe the case of a young woman with CVT and concomitant thyrotoxicosis, without any other known prothrombotic conditions. We also performed a literature review of CVT cases and hyperthyroidism, searching for all articles published in peer-reviewed journals. We identified 39 case reports/case series concerning patients with CVT associated with thyrotoxicosis, highlighting, in most cases, the association with additional known prothrombotic factors. We then discussed the possible mechanisms by which hyperthyroidism could underlie a pro-coagulative state resulting in CVT. Thyroid disease might be a more common prothrombotic risk factor than expected in determining CVT. However, in most cases, a coexistence of multiple risk factors was observed, suggesting a multifactorial genesis of the disorder. We hope that this work may alert clinicians to consider thyrotoxicosis as a potential risk factor for CVT, even in patients who apparently have no other pro-coagulative conditions.
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Affiliation(s)
- Emanuela Maria Raho
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Annibale Antonioni
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
- Doctoral Program in Translational Neurosciences and Neurotechnologies, University of Ferrara, 44121 Ferrara, Italy
| | - Niccolò Cotta Ramusino
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Dina Jubea
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Daniela Gragnaniello
- Neurology Unit, Neurosciences and Rehabilitation Department, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Paola Franceschetti
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Francesco Penitenti
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Andrea Daniele
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | | | - Ilaria Traluci
- Neuroradiology Unit, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Maura Pugliatti
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Marina Padroni
- Neurology Unit, Neurosciences and Rehabilitation Department, Ferrara University Hospital, 44124 Ferrara, Italy
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Gamal Y, Badawy A, Ali AM, Farghaly HS, Metwalley KA, Gaber N, Allam MT, Farouk Y. Endothelial dysfunction in children with newly diagnosed Graves' disease. Eur J Pediatr 2023:10.1007/s00431-023-04919-z. [PMID: 37022495 PMCID: PMC10257599 DOI: 10.1007/s00431-023-04919-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 04/07/2023]
Abstract
The most frequent cause of hyperthyroidism in children is Graves' disease (GD). Vascular endothelium is a specific target of thyroid hormone. The purpose of this study is to assess flow-mediated dilatation (FMD)% and serum von Willebrand factor (vWF) levels in children with newly diagnosed GD to reflect the extent of endothelial dysfunction in those children. In this study, 40 children with newly discovered GD and 40 children who were healthy served as the control group. Both patients and controls had anthropometric assessment, as well as measurements of fasting lipids, glucose, insulin, high-sensitivity C-reactive protein (hs-CRP), TSH, and free thyroxine (FT4 and FT3), thyrotropin receptor antibodies TRAbs and vWF. Noninvasive ultrasound was utilized to quantify the carotid arteries' intima-media thickness and the brachial artery's FMD. Patients reported significantly reduced FMD response and greater vWF and hs-CRP levels compared to controls (P = 0.001 for each). In multivariate analysis, we reported that vWF was significantly correlated with TSH (OR 2.5, 95% CI 1.32-5.32, P = 0.001), FT3 (OR 3.4, 95% CI 1.45-3.55, P = 0.001), TRAb (OR 2.1, 95% CI 1.16-2.23, P = 0.01), and FMD% (OR 4.2, 95% CI 1.18-8.23, P = 0.001). Conclusions: Children with newly diagnosed GD have endothelial dysfunction, which is shown by impaired FMD and increased vWF. These findings support the idea that GD may need to be treated as soon as possible. What is Known: • Graves' disease is the most common cause of hyperthyroidism in children. • vWF is a reliable marker for detection of vascular endothelial dysfunction. What is New: • Children with newly diagnosed Graves' disease may have endothelial dysfunction as reflected by impairment of FMD and raised vWF level. • Measurement of vWF level in children with newly diagnosed Graves' disease can be used for early detection of endothelial dysfunction.
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Affiliation(s)
- Yasser Gamal
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Ahlam Badawy
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Ali
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hekma Saad Farghaly
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Noha Gaber
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Momtaz Thabet Allam
- Department of Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Yasser Farouk
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
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3
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Links MH, Lefrandt JD, Lisman T, van der Boom T, Lukens MV, Meijer K, Links TP, Zandee WT. Fluctuations in Thyroid Hormone Levels During Initial Treatment for Differentiated Thyroid Carcinoma are Associated with Changes in Hemostasis: A Prospective Cohort Study. Thyroid 2023; 33:203-213. [PMID: 36322715 DOI: 10.1089/thy.2022.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: During treatment for differentiated thyroid carcinoma (DTC), patients go from euthyroidism to severe hypothyroidism to subclinical hyperthyroidism induced by thyroid hormone suppression therapy (THST). Severe hypothyroidism may induce a tendency toward bleeding, whereas hyperthyroidism is thrombogenic. Therefore, treatment for DTC may increase the risk of bleeding during thyroid hormone withdrawal, and thrombosis during THST. This study aims to provide prospective analysis of changes in the hemostatic system from euthyroidism to hypothyroidism, and during THST, in patients treated for DTC. Methods: This is a secondary study in a larger Dutch prospective cohort. Consecutive samples were obtained from 20 patients (18 female [90%]; median age 48 [interquartile range 35.8-56.5] years) throughout their treatment for DTC during euthyroidism (n = 5), severe hypothyroidism (n = 20), and THST (n = 20). We measured selected hemostatic proteins and C-reactive protein (CRP), performed functional tests of hemostasis (a thrombin generation test and a plasma-based clot lysis test), and assessed markers of in vivo activation of hemostasis (thrombin-antithrombin complexes, plasmin-antiplasmin [PAP] complexes, and D-dimer levels). Results: During hypothyroidism, the majority of measured parameters did not change. During THST, plasma levels of nearly all measured hemostatic proteins were higher than during hypothyroidism. Additionally, CRP significantly increased from 1.3 (0.5-3.3) to 3.2 (1.3-5.1) mg/L during THST (p < 0.01). Ex vivo thrombin generation increased from 626.0 (477.0-836.3) to 876.0 (699.0-1052.0) nM × min (p = 0.02), and ex vivo clot lysis time increased from 60.6 (55.6-67.4) to 76.0 (69.7-95.0) minutes during THST (p < 0.01). PAP levels reduced from 266.5 (211.8-312.0) to 192.0 (161.0-230.0) μg/L during THST (p < 0.01); other markers of in vivo activation of coagulation remained unaffected. Conclusions: During THST-induced hyperthyroidism, a shift toward a more hypercoagulable and hypofibrinolytic state occurred. However, in vivo activation of hemostasis did not increase. The rise in CRP levels suggests the presence of a low-grade inflammation in patients during THST. Both a hypercoagulable and hypofibrinolytic state and a low-grade inflammation are associated with an increased risk of cardiovascular diseases (CVD). Therefore, the subtle changes found during THST could potentially play a role in the pathogenesis of CVD as observed in DTC patients. Clinical Trial Registration: This study is part of a larger clinical trial registered at the Netherlands Trial Register (NTR ID 7228).
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Affiliation(s)
- Mirthe H Links
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Joop D Lefrandt
- Division of Vascular Medicine, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Trynke van der Boom
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Michaël V Lukens
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Karina Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter T Zandee
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Dodson MW, Cirulis MM, Li H, Yue Z, Brown LM, Elliott CG. Frequency of Thrombotic Risk Factors in Patients with Chronic Thromboembolic Pulmonary Hypertension and Acute Pulmonary Embolism: A Case-Control Study. Clin Appl Thromb Hemost 2022; 28:10760296211073277. [PMID: 35000431 PMCID: PMC8744163 DOI: 10.1177/10760296211073277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious complication of acute pulmonary embolism (PE) which remains underdiagnosed. A better understanding of risk factors for CTEPH would improve our ability to predict which PE survivors are at risk. Several medical conditions-including malignancy, splenectomy, thyroid hormone supplementation, the presence of an intravascular device, inflammatory bowel disease, osteomyelitis, and non-O blood group-have been associated with increased risk of CTEPH, primarily in studies comparing patients with CTEPH to individuals with non-thrombotic conditions. Because many of these conditions increase thrombosis risk, it remains unclear whether their association with CTEPH reflects a general effect on thrombosis risk, or a specific effect on the risk of developing CTEPH as an outcome of thrombosis. We performed a case-control study comparing the frequencies of these conditions in patients with CTEPH versus patients with acute PE who did not develop CTEPH. The conditions studied were equally frequent in the CTEPH and PE cohorts, although there was a trend towards an increased frequency of splenectomy and non-O blood group among the CTEPH cohort. Thus, other than the possible exceptions of splenectomy and non-O blood group, the investigated medical conditions do not appear likely to increase the risk of CTEPH as an outcome of acute PE, and thus are unlikely to be useful in predicting CTEPH risk among PE survivors.
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Affiliation(s)
- Mark W Dodson
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - Meghan M Cirulis
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - Haojia Li
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Zhang Yue
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lynette M Brown
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - C Gregory Elliott
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
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5
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Kim K, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Sung JH, Pak HN, Lee MH, Lip GY, Joung B. Increased risk of ischemic stroke and systemic embolism in hyperthyroidism-related atrial fibrillation: A nationwide cohort study. Am Heart J 2021; 242:123-131. [PMID: 34480879 DOI: 10.1016/j.ahj.2021.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND We aimed to evaluate the long-term risk of ischemic stroke/systemic embolism of hyperthyroidism-related AF. METHODS This retrospective population-based cohort study included records of 1,034,099 atrial fibrillation patients between 2005 and 2016 from the Korean National Health Insurance Service database. After exclusion, we identified 615,724 oral anticoagulation-naïve patients aged ≥18 years with new-onset non-valvular atrial fibrillation, of whom 20,773 had hyperthyroidism-related atrial fibrillation. After 3:1 propensity score matching, ischemic stroke and systemic embolism occurrences were compared between hyperthyroidism-related and non-hyperthyroidism-related ("nonthyroidal") atrial fibrillation patients. RESULTS After exclusion, we identified 615,724 oral anticoagulation-naïve AF patients of whom 20,773 had hyperthyroidism-related AF. Median follow-up duration was 5.9 years. Hyperthyroidism-related AF patients had significantly higher risks of ischemic stroke and systemic embolism than nonthyroidal AF patients (1.83 vs 1.62 per 100-person year, hazard ratio[HR], 1.13; 95% confidence interval[CI], 1.07 to 1.19; P < 0.001). This risk was 36% higher in hyperthyroidism-related than in nonthyroidal AF patients within 1 year of atrial fibrillation diagnosis (3.65 vs 2.67 per 100-person year, HR, 1.36; 95% CI, 1.24 - 1.50; P < 0.001). This difference was also observed in the CHA2DS2-VASc score subgroup analysis. The risk of ischemic stroke and systemic embolism significantly decreased in patients treated for hyperthyroidism (HR, 0.64; 95% CI, 0.58 to 0.70; P < 0.001). CONCLUSIONS Hyperthyroidism-related AF patients have high risks of ischemic stroke and systemic embolism like nonthyroidal AF, especially when initially diagnosed. This risk is reduced by treating hyperthyroidism.
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Ellervik C, Mora S, Kuś A, Åsvold B, Marouli E, Deloukas P, Sterenborg RB, Teumer A, Burgess S, Sabater-Lleal M, Huffman J, Johnson AD, Trégouet DA, Smith NL, Medici M, DeVries PS, Chasman DI, Kjaergaard AD. Effects of Thyroid Function on Hemostasis, Coagulation, and Fibrinolysis: A Mendelian Randomization Study. Thyroid 2021; 31:1305-1315. [PMID: 34210154 PMCID: PMC8558080 DOI: 10.1089/thy.2021.0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Untreated hypothyroidism is associated with acquired von Willebrand syndrome, and hyperthyroidism is associated with increased thrombosis risk. However, the causal effects of thyroid function on hemostasis, coagulation, and fibrinolysis are unknown. Methods: In a two-sample Mendelian randomization (MR) study with genome-wide association variants, we assessed causality of genetically predicted hypothyroidism (N = 134,641), normal-range thyrotropin (TSH; N = 54,288) and free thyroxine (fT4) (N = 49,269), hyperthyroidism (N = 51,823), and thyroid peroxidase antibody positivity (N = 25,821) on coagulation (activated partial thromboplastin time, von Willebrand factor [VWF], factor VIII [FVIII], prothrombin time, factor VII, fibrinogen) and fibrinolysis (D-dimer, tissue plasminogen activator [TPA], plasminogen activator inhibitor-1) from the CHARGE Hemostasis Consortium (N = 2583-120,246). Inverse-variance-weighted random effects were the main MR analysis followed by sensitivity analyses. Two-sided p < 0.05 was nominally significant, and p < 0.0011[ = 0.05/(5 exposures × 9 outcomes)] was Bonferroni significant for the main MR analysis. Results: Genetically increased TSH was associated with decreased VWF [β(SE) = -0.020(0.006), p = 0.001] and with decreased fibrinogen [β(SE) = -0.008(0.002), p = 0.001]. Genetically increased fT4 was associated with increased VWF [β(SE) = 0.028(0.011), p = 0.012]. Genetically predicted hyperthyroidism was associated with increased VWF [β(SE) = 0.012(0.004), p = 0.006] and increased FVIII [β(SE) = 0.013(0.005), p = 0.007]. Genetically predicted hypothyroidism and hyperthyroidism were associated with decreased TPA [β(SE) = -0.009(0.024), p = 0.024] and increased TPA [β(SE) = 0.022(0.008), p = 0.008], respectively. MR sensitivity analyses showed similar direction but lower precision. Other coagulation and fibrinolytic factors were inconclusive. Conclusions: In the largest genetic studies currently available, genetically increased TSH and fT4 may be associated with decreased and increased synthesis of VWF, respectively. Since Bonferroni correction may be too conservative given the correlation between the analyzed traits, we cannot reject nominal associations of thyroid traits with coagulation or fibrinolytic factors.
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Affiliation(s)
- Christina Ellervik
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Data and Data Support, Region Zealand, Sorø, Denmark
- Address correspondence to: Christina Ellervik, MD, PhD, Department of Laboratory Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine; Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Aleksander Kuś
- Department of Internal Medicine, Academic Center for Thyroid Diseases; Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Bjørn Åsvold
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eirini Marouli
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Panos Deloukas
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rosalie B.T.M. Sterenborg
- Department of Internal Medicine, Academic Center for Thyroid Diseases; Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander Teumer
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Stephen Burgess
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Maria Sabater-Lleal
- Genomics of Complex Diseases Group, Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona, Spain
- Cardiovascular Medicine Unit, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jennifer Huffman
- Scientific Director for Genomics Research, Center for Population Genomics, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Andrew D. Johnson
- National Heart, Lung and Blood Institute's The Framingham Heart Study, Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, Framingham, Massachusetts, USA
| | - David-Alexandre Trégouet
- INSERM U1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Nicolas L. Smith
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Kaiser Permamente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, Washington, USA
| | - Marco Medici
- Department of Internal Medicine, Academic Center for Thyroid Diseases; Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul S. DeVries
- Department of Epidemiology, Human Genetics, and Environmental Sciences, Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Daniel I. Chasman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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7
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Katić J, Katić A, Katić K, Duplančić D, Lozo M. CONCURRENT DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM ASSOCIATED WITH HYPERTHYROIDISM: A CASE REPORT. Acta Clin Croat 2021; 60:314-316. [PMID: 34744284 PMCID: PMC8564842 DOI: 10.20471/acc.2021.60.02.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
Abstract
Numerous disorders of coagulation and fibrinolysis have been reported in patients with thyroid diseases, especially with hyperthyroidism. Most articles are focused on deep vein thrombosis risk, however, few of them describe association between hyperthyroidism and pulmonary embolism. We report a case of a 43-year-old woman with long-term uncontrolled hyperthyroidism complicated by venous thromboembolism. The potential mechanisms could be endothelial dysfunction, decreased fibrinolytic activity, and increased levels of coagulation factors. Thyroid evaluation should be recommended in patients with unprovoked venous thromboembolic events.
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Affiliation(s)
| | - Ana Katić
- 1Department of Cardiology, Split University Hospital Centre, Split, Croatia; 2University of Split School of Medicine, Split, Croatia; 3Department of Ophthalmology, Split University Hospital Centre, Split, Croatia
| | - Karla Katić
- 1Department of Cardiology, Split University Hospital Centre, Split, Croatia; 2University of Split School of Medicine, Split, Croatia; 3Department of Ophthalmology, Split University Hospital Centre, Split, Croatia
| | - Darko Duplančić
- 1Department of Cardiology, Split University Hospital Centre, Split, Croatia; 2University of Split School of Medicine, Split, Croatia; 3Department of Ophthalmology, Split University Hospital Centre, Split, Croatia
| | - Mislav Lozo
- 1Department of Cardiology, Split University Hospital Centre, Split, Croatia; 2University of Split School of Medicine, Split, Croatia; 3Department of Ophthalmology, Split University Hospital Centre, Split, Croatia
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8
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Abstract
OBJECTIVES Cats with hyperthyroidism have been reported to develop thromboembolism, with and without echocardiographic abnormalities consistent with hyperthyroidism. The objective of this study was to compare platelet function in cats with hyperthyroidism with euthyroid age-matched cats. We hypothesized that cats with hyperthyroidism have shortened collagen and adenosine diphosphate (C-ADP) closure times as measured with the platelet function analyzer (PFA-100) in comparison with healthy, age-matched controls. METHODS Sixteen hyperthyroid and nine euthyroid healthy cats >7 years of age were recruited from the hospital population. Platelet function, measured using the C-ADP closure times by the PFA-100, and platelet count were measured in healthy euthyroid cats and cats with hyperthyroidism. RESULTS Mean ± SD closure times were not significantly different between control (66.3 ± 9.6 s) and hyperthyroid cats (65.9 ± 11.5 s; P = 0.75). The mean ± SD closure times of hyperthyroid cats that either were untreated or received methimazole for ⩽3 weeks (n = 6; mean 68.5 ± 15.4 s) was not different than that of cats treated for >3 weeks (n = 10; mean 64.3 ± 8.9 s; P = 0.57). The mean automated platelet count was higher in the hyperthyroid group than in the control group (P = 0.023). CONCLUSIONS AND RELEVANCE Platelet function, as measured by closure time under high shear conditions using C-ADP as an agonist, was not affected by hyperthyroidism in this group of cats. Further research is needed to determine if a hypercoagulable state exists in hyperthyroid cats and the potential roles platelets and von Willebrand factor may have.
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Affiliation(s)
- Elizabeth C Hiebert
- Department of Small Animal Clinical Sciences, Virginia–Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
| | - David L Panciera
- Department of Small Animal Clinical Sciences, Virginia–Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
| | - Katie M Boes
- Department of Biomedical Sciences and Pathobiology, Virginia–Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
| | - Lara Bartl
- Department of Small Animal Clinical Sciences, Virginia–Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
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9
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Elhassan AEE, Ali MOK, Bougaila A, Abdelhady M, Abuzaid H. Hyperthyroidism as a Precipitant Factor for Cerebral Venous Thrombosis: A Case Report. J Investig Med High Impact Case Rep 2020; 8:2324709620949309. [PMID: 32787455 PMCID: PMC7427011 DOI: 10.1177/2324709620949309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVT) is an uncommon yet serious condition. While CVT has many known precipitants and etiologies, hyperthyroidism as a precipitant of CVT is not well understood. This study reported a case of a 41-year-old male with a 4-year history of hyperthyroidism presented with seizure. Consequently, a diagnosis of superior sagittal sinus thrombosis was confirmed by computed tomography and magnetic resonance (MR) venograms. Extensive investigations yielded no apparent underlying cause, but laboratory findings were consistent with uncontrolled hyperthyroidism. The patient improved rapidly following anticoagulation. Follow-up MR and MRV scans 2 months after treatment revealed full recanalization of the superior sagittal sinus. This case report highlighted hyperthyroidism, as a procoagulant condition, resulting specifically in superior sagittal sinus thrombosis.
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Bano A, Chaker L, de Maat MPM, Atiq F, Kavousi M, Franco OH, Mattace-Raso FUS, Leebeek FWG, Peeters RP. Thyroid Function and Cardiovascular Disease: The Mediating Role of Coagulation Factors. J Clin Endocrinol Metab 2019; 104:3203-3212. [PMID: 30938758 DOI: 10.1210/jc.2019-00072] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/27/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT Mechanisms linking high and high-normal thyroid function to increased cardiovascular risk remain unclear. Hypothetically, coagulation can play a role. OBJECTIVE To investigate (i) the association of thyroid function with coagulation factors and (ii) whether coagulation factors mediate the association of thyroid function with cardiovascular disease (CVD). DESIGN AND SETTING Rotterdam Study, a population-based prospective study. PARTICIPANTS AND MAIN OUTCOME MEASURES In 5918 participants (mean age, 69.1 years), we measured TSH, free T4 (FT4), and coagulation factors [von Willebrand factor antigen (VWF:Ag), ADAMTS13 activity, fibrinogen]. Participants were followed up for the occurrence of cardiovascular events and deaths. Associations of thyroid function with coagulation factors (standardized z scores) and CVD were assessed through linear regression and Cox proportional hazards models, adjusted for potential confounders. We performed causal mediation analyses to evaluate whether the effect of thyroid function on CVD is mediated by coagulation. RESULTS Higher FT4 levels were associated with higher VWF:Ag (β = 0.34; 95% CI = 0.22, 0.47), lower ADAMTS13 activity (β = -0.22; 95%CI = -0.35, -0.09), and higher fibrinogen (β = 0.26; 95% CI = 0.13, 0.39); 857 incident cardiovascular events and 690 cardiovascular deaths occurred. FT4 levels were positively associated with cardiovascular events and deaths. The effect of FT4 on incident cardiovascular events was minimally mediated by fibrinogen (1.6%) but not by VWF:Ag and ADAMTS13. VWF:Ag and fibrinogen together mediated 10.0% of the effect of FT4 on cardiovascular deaths. CONCLUSIONS Higher FT4 levels were associated with higher VWF:Ag, lower ADAMTS13 activity, and higher fibrinogen levels, indicating a procoagulant state. VWF:Ag and fibrinogen explained up to 10% of the link between FT4 and CVD.
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Affiliation(s)
- Arjola Bano
- Department of Internal Medicine, Netherlands Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Layal Chaker
- Department of Internal Medicine, Netherlands Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ferdows Atiq
- Department of Hematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Frank W G Leebeek
- Department of Hematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Netherlands Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
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11
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Zhang YM, Yang B, Sun XD, Zhang Z. Combined intravenous and intra-articular tranexamic acid administration in total knee arthroplasty for preventing blood loss and hyperfibrinolysis: A randomized controlled trial. Medicine (Baltimore) 2019; 98:e14458. [PMID: 30762760 PMCID: PMC6408055 DOI: 10.1097/md.0000000000014458] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 01/09/2019] [Accepted: 01/13/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability. However, blood loss and fibrinolytic activity, accounting for a poor prognosis following TKA operation, were relieved by fibrinolytic inhibitor tranexamic acid (TXA). For a better application of TXA function, we explored the effect of intravenous injection (IV) of TXA combined with intra-articular injection (IA) of TXA in patients after TKA. METHODS Patients admitted from Weifang People's Hospital from January 2015 to December 2016 who received TKA were injected with 20 mg/kg TXA by IV before TKA (n = 50), 3.0 g TXA by IA after TKA (n = 50), or combination of 20 mg/kg TXA by IV before TKA and 3.0 g TXA by IA after TKA (n = 50). Knee function was assessed using HSS, KSS, NASS, and ROM. In addition, the total blood loss (TBL), hidden blood loss (HBL), maximum hemoglobin (Hb) drop, fibrinolytic activity, as well as incidence of thromboembolism were measured. The patients were followed up for 6 months. The deadline for follow-up was June 2017 and the incidence of thromboembolism events within 6 months after operation was counted. RESULTS HSS, KSS, NASS scores, and ROM were elevated after patients receiving TKA. Patients received IV plus IA TXA has decreased TBL, HBL, and maximum Hb drop than those received IV TXA-alone and IA TXA-alone, with reductions in FDP and D-dimer, indicating that IV plus IA TXA injection is superior to prevent blood loss and hyperfibrinolysis during TKA. Age, sex, type of femoral prosthesis, and the injection method of TXA were risk factors for HBL of patients after receiving TKA. CONCLUSIONS The aforementioned results demonstrate that TKA is an effective surgery, and IV plus IA TXA injection functions more effectively in reducing blood loss and fibrinolytic activity in patients, which is a clinical factor of occult hemorrhage.
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12
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Davis PJ, Mousa SA, Schechter GP. New Interfaces of Thyroid Hormone Actions With Blood Coagulation and Thrombosis. Clin Appl Thromb Hemost 2018; 24:1014-1019. [PMID: 29742907 PMCID: PMC6714741 DOI: 10.1177/1076029618774150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Substantial clinical evidence indicates hyperthyroidism enhances coagulation and increases the risk of thrombosis. In vitro and clinical evidence implicate multiple mechanisms for this risk. Genomic actions of thyroid hormone as 3,5,3′-triiodo-L-thyronine (T3) via a nuclear thyroid hormone receptor have been implicated, but recent evidence shows that nongenomic mechanisms initiated at the receptor for L-thyroxine (T4) on platelet integrin αvβ3 are prothrombotic. The T4-initiated mechanisms involve platelet activation and, in addition, cellular production of cytokines and chemokines such as CX3CL1 with procoagulatory activities. These procoagulant actions of T4 are particulary of note because within cells T4 is not seen to be functional, but to be only a prohormone for T3. Finally, it is also possible that thyroid hormone stimulates platelet-endothelial cell interaction involved in local thrombus generation. In this brief review, we survey mechanisms by which thyroid hormone is involved in coagulation and platelet functions. It is suggested that the threshold should be lowered for considering the possibility that clinically significant clotting may complicate hyperthyroidism. The value of routine measurement of partial thromboplastin time or circulating D-dimer in patients with hyperthyroid or in patients treated with thyrotropin-suppressing dosage of T4 requires clinical testing.
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Affiliation(s)
- Paul J Davis
- 1 Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA.,2 Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Shaker A Mousa
- 1 Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA
| | - Geraldine P Schechter
- 3 Hematology Section, Medical Service, Washington Veterans Affairs Medical Center, Washington, DC, USA.,4 Department of Medicine, George Washington University, Washington, DC, USA
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13
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Elbers LPB, Fliers E, Cannegieter SC. The influence of thyroid function on the coagulation system and its clinical consequences. J Thromb Haemost 2018; 16:634-645. [PMID: 29573126 DOI: 10.1111/jth.13970] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 11/29/2022]
Abstract
Several studies indicate that low plasma levels of thyroid hormone shift the hemostatic system towards a hypocoagulable and hyperfibrinolytic state, whereas high levels of thyroid hormone lead to more coagulation and less fibrinolysis. Low levels of thyroid hormone thereby seem to lead to an increased bleeding risk, whereas high levels, by contrast, increase the risk of venous thromboembolism. Hypothyroidism leads to a higher incidence of acquired von Willebrand's syndrome and with increasing levels of free thyroxine, levels of fibrinogen, factor VIII and von Willebrand factor, amongst others, increase gradually, to the extent that they may lead to symptomatic venous thromboembolism in patients with hyperthyroidism. Here, we discuss the literature on the effect of thyroid hormone on the hemostatic system and the associated risk of bleeding and venous thromboembolism. Patients with hypothyroidism are at increased risk of developing bleeding complications, which could be relevant in patients undergoing invasive procedures. Furthermore, physicians should be aware of the possibility of hyperthyroidism as an underlying risk factor for venous thromboembolism, especially in unexplained cases. Clinical studies are needed to further investigate the significance for general practice of these findings. Besides the effects of hyperthyroidism on venous thromboembolism, its effects on embolism secondary to atrial fibrillation are described.
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Affiliation(s)
- L P B Elbers
- Department of Internal Medicine, MC Slotervaart, Amsterdam, the Netherlands
| | - E Fliers
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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14
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Ordookhani A, Motazedi A, Burman KD. Thrombosis in Thyroid Cancer. Int J Endocrinol Metab 2018; 16:e57897. [PMID: 29696039 PMCID: PMC5903374 DOI: 10.5812/ijem.57897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/26/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The number of studies on venous thromboembolism (VTE) and thyroid cancer is very scarce and existing data are contradictory. This paper reviews VTE in thyroid cancer. METHODS The following words were used for a comprehensive literature review using MEDLINE database: Blood coagulation factors; thyroid hormones; blood coagulation tests; venous thromboembolism; receptors thyroid hormone; hemostasis; fibrinolysis; bleeding; blood coagulation disorders; thyroid neoplasms; Thyroid cancer, papillary; Thyroid cancer, follicular; Thyroid carcinoma, anaplastic; Thyroid cancer, Hurthle cell; Familial medullary thyroid carcinoma; venous thrombosis; Pulmonary embolism; Blood coagulation factors. The studies, which include any changes in hemostasis and thyroid cancer were included and reviewed. RESULTS Although few studies have shown a possible increase in VTE occurrence in thyroid cancer in patients ≥ 60 years old and in proximity to cancer diagnosis, other studies could not find any difference compared to general population. New thyroid cancer classification excluding common subtype(s) with benign nature, may affect the results of the future studies on association of VTE and thyroid cancer. CONCLUSIONS Prospective studies on the occurrence of VTE in various types and severities of thyroid cancer and in different age groups are warranted, as the results would affect clinical practice on the necessity of usage of anticoagulants in some thyroid cancer groups.
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Affiliation(s)
- Arash Ordookhani
- MD, Endocrine Section, Department of Internal Medicine, Providence Hospital, Washington, DC, 20017
| | - Abbas Motazedi
- MD, Endocrine Section, Department of Internal Medicine, Providence Hospital, Washington, DC, 20017
| | - Kenneth D. Burman
- MD, Endocrine Section, MedStar Washington Hospital Center, Washington, DC, 20010
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15
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Zaane BV, Romualdi E, Brandjes D, Gerdes V, Squizzato A, Stuijver D. The effect of hyperthyroidism on procoagulant, anticoagulant and fibrinolytic factors. Thromb Haemost 2017; 108:1077-88. [DOI: 10.1160/th12-07-0496] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 08/10/2012] [Indexed: 11/05/2022]
Abstract
SummarySeveral coagulation and fibrinolytic parameters appear to be affected by thyroid hormone excess;however, the net effect on the haemostatic system remains unclear. We aimed to update our previous review and systematically summarise and meta-analyse the data by assessing the effects of thyrotoxicosis on the coagulation and fibrinolytic system in vivo. Data sources included MEDLINE (2006–2012), EMBASE (2006–2012), and reference lists. The sources were combined with our previous search containing studies from 1980–2006. Eligible studies were all observational or experimental studies. Two investigators independently extracted data and rated study quality. Weighted mean proportion and 95% confidence intervals were calculated and pooled using a fixed and a random-effects model. A total of 29 articles consisting of 51 studies were included, as in several articles more than one study was described. We included four intervention (before and after treatment in hyperthyroid patients), five cross-sectional (hyperthyroid subjects and euthyroid controls), and four experimental (before and after use of thyroid hormone in euthyroid subjects) medium/high quality studies for meta-analysis. We found that thyrotoxicosis shifts the haemostatic balance towards a hypercoagulable and hypofibrinolytic state with a rise in factors VIII and IX, fibrinogen, von Willebrand factor, and plasminogen activator inhibitor-1. This was observed in endogenous and exogenous thyrotoxicosis, and in subclinical as well as overt hyperthyroidism. We conclude that both subclinical and overt hyperthyroidism induce a prothrombotic state, which is therefore likely to be a risk factor for venous thrombosis.
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16
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Verkleij C, van Zaane B, Squizzato A, Brandjes D, Büller H, Meijers J, Gerdes V, Stuijver D. Thrombin-activatable fibrinolysis inhibitor in hypothyroidism and hyperthyroxinaemia. Thromb Haemost 2017. [DOI: 10.1160/th12-07-0525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryEndocrine disorders affect both the coagulation and fibrinolytic systems, and have been associated with the development of cardiovascular diseases. Thrombin-activatable fibrinolysis inhibitor (TAFI) is a link between coagulation and the fibrinolytic system. The aim of this study was to determine the effect of thyroid hormone excess and deficiency on TAFI levels and function. The effect of hyperthyroxinemia on TAFI was studied in healthy volunteers who were randomised to receive levothyroxine or no medication for 14 days in a crossover design. The effect of hypothyroidism on TAFI was studied in a multicentre observational cohort study. Blood was drawn before treatment of patients with newly diagnosed hypothyroidism and when euthyroidism was achieved. Plasma clot-lysis times, activated TAFI (TAFIa)-dependent prolongation of clot-lysis and TAFI levels were measured. Thyroid hormone excess resulted in a hypofibrinolytic condition and in an enhanced TAFIa-dependent prolongation of clot lysis. A trend towards decreased plasma TAFI levels was observed in healthy volunteers who used levothyroxine. Hypothyroidism resulted in hyperfibrinolysis and a reduced TAFIa-dependent prolongation of clot lysis. In conclusion, alterations of TAFIa-dependent prolongation of clot lysis in patients with thyroid disorders may cause an impaired haemostatic balance. The disturbed haemostatic balance in patients with hyperthyroidism might make them prone to thrombosis, while the risk for bleeding may increase in patients with hypothyroidism.
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17
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Sjouke B, Elbers LPB, van Zaane B, Kastelein JJP, Hovingh GK, Gerdes VEA. Effects of Supra-Physiological Levothyroxine Dosages on Liver Parameters, Lipids and Lipoproteins in Healthy Volunteers: A Randomized Controlled Crossover Study. Sci Rep 2017; 7:14174. [PMID: 29074892 PMCID: PMC5658438 DOI: 10.1038/s41598-017-14526-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/04/2017] [Indexed: 11/13/2022] Open
Abstract
Eprotirome, a liver specific thyroid hormone agonist, was shown to induce significant increases in markers of liver injury along with a modest decrease in atherogenic lipids and lipoproteins. To get more insight into whether these effects on liver parameters were compound specific or the effect of mimicking thyrotoxicosis, we studied the effects of supra-physiological levothyroxine dosages on liver parameters, lipids and lipoproteins. We used data of a single-blinded, randomized controlled crossover trial. Herein, healthy volunteers received levothyroxine or no medication for 14 days. Thyroid hormone excess did not induce clinically relevant changes in liver parameters, while significant reductions in total cholesterol, low-density lipoprotein-cholesterol as well as apolipoprotein-B levels were observed in the intervention periods compared with the control periods. Supra-physiological thyroid hormone levels did not induce clinically relevant increases in markers of liver injury after 2 weeks of exposure, while it reduced total cholesterol, low-density lipoprotein cholesterol and apolipoprotein B levels. This suggests that the effects of eprotirome on liver parameters in previous studies were either off-target and compound specific or due to drug-drug interaction at the level of the liver. The results of our study are relevant for the development of novel thyroid hormone agonists to reduce atherogenic lipoproteins.
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Affiliation(s)
- Barbara Sjouke
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Laura P B Elbers
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands. .,Department of Internal Medicine, Slotervaart Hospital, PO box 90440, 1006 BK, Amsterdam, The Netherlands.
| | - Bregje van Zaane
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands.,Department of Internal Medicine, Slotervaart Hospital, PO box 90440, 1006 BK, Amsterdam, The Netherlands
| | - John J P Kastelein
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Victor E A Gerdes
- Department of Vascular Medicine, Academic Medical Center, PO box 22660, 1100 DD, Amsterdam, The Netherlands.,Department of Internal Medicine, Slotervaart Hospital, PO box 90440, 1006 BK, Amsterdam, The Netherlands
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19
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Ordookhani A, Burman KD. Hemostasis in Overt and Subclinical Hyperthyroidism. Int J Endocrinol Metab 2017; 15:e44157. [PMID: 29201071 PMCID: PMC5702470 DOI: 10.5812/ijem.44157] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/24/2017] [Accepted: 03/14/2017] [Indexed: 11/29/2022] Open
Abstract
CONTEXT There are contradictory results on the effect of hyperthyroidism on hemostasis. Inadequate population-based studies limited their clinical implications, mainly on the risk of venous thromboembolism (VTE). The present review focuses on hemostatic changes in overt and subclinical hyperthyroidism. METHODS A systematic literature search was conducted employing MEDLINE database. The following words were used for the search: Hyperthyroidism; thyrotoxicosis; Graves disease; goiter, nodular; hemostasis; blood coagulation factors; blood coagulation disorders; venous thromboembolism; bleeding; fibrinolysis. The articles that were related to hyperthyroidism and hemostasis are used in this manuscript. RESULTS Hyperthyroidism, either overt or subclinical, renders a hypercoagulable state, although there are several studies with contradictory findings in the literature. Hypercoagulability may be caused by an increase in the level of various coagulation factors such as factor (F) VIII, FX, FIX, von Willebrand F (vWF), and fibrinogen, while hypofibrinolysis by changes in coagulation parameters such as a decrease in plasmin and plasmin activator or an increase in α2-antiplasmin, plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor. CONCLUSIONS Although many reports are in favor of a hypercoagulable state in overt hyperthyroidism but this finding at the biochemical level and its clinical implication, on the occurrence of VTE, has yet to be confirmed.
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Affiliation(s)
- Arash Ordookhani
- Endocrine Section, Department of Internal Medicine, Providence Hospital, Washington, DC, 20017
| | - Kenneth D. Burman
- Endocrine Section, MedStar Washington Hospital Center, Washington, DC, 20010
- Corresponding author: Kenneth D. Burman, Endocrine Section, MedStar Washington Hospital Center, Washington, DC, 20010, E-mail:
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Pietzner M, Engelmann B, Kacprowski T, Golchert J, Dirk AL, Hammer E, Iwen KA, Nauck M, Wallaschofski H, Führer D, Münte TF, Friedrich N, Völker U, Homuth G, Brabant G. Plasma proteome and metabolome characterization of an experimental human thyrotoxicosis model. BMC Med 2017; 15:6. [PMID: 28065164 PMCID: PMC5220622 DOI: 10.1186/s12916-016-0770-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 12/15/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Determinations of thyrotropin (TSH) and free thyroxine (FT4) represent the gold standard in evaluation of thyroid function. To screen for novel peripheral biomarkers of thyroid function and to characterize FT4-associated physiological signatures in human plasma we used an untargeted OMICS approach in a thyrotoxicosis model. METHODS A sample of 16 healthy young men were treated with levothyroxine for 8 weeks and plasma was sampled before the intake was started as well as at two points during treatment and after its completion, respectively. Mass spectrometry-derived metabolite and protein levels were related to FT4 serum concentrations using mixed-effect linear regression models in a robust setting. To compile a molecular signature discriminating between thyrotoxicosis and euthyroidism, a random forest was trained and validated in a two-stage cross-validation procedure. RESULTS Despite the absence of obvious clinical symptoms, mass spectrometry analyses detected 65 metabolites and 63 proteins exhibiting significant associations with serum FT4. A subset of 15 molecules allowed a robust and good prediction of thyroid hormone function (AUC = 0.86) without prior information on TSH or FT4. Main FT4-associated signatures indicated increased resting energy expenditure, augmented defense against systemic oxidative stress, decreased lipoprotein particle levels, and increased levels of complement system proteins and coagulation factors. Further association findings question the reliability of kidney function assessment under hyperthyroid conditions and suggest a link between hyperthyroidism and cardiovascular diseases via increased dimethylarginine levels. CONCLUSION Our results emphasize the power of untargeted OMICs approaches to detect novel pathways of thyroid hormone action. Furthermore, beyond TSH and FT4, we demonstrated the potential of such analyses to identify new molecular signatures for diagnosis and treatment of thyroid disorders. This study was registered at the German Clinical Trials Register (DRKS) [DRKS00011275] on the 16th of November 2016.
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Affiliation(s)
- Maik Pietzner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Beatrice Engelmann
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
| | - Tim Kacprowski
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
| | - Janine Golchert
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
| | - Anna-Luise Dirk
- Medical Clinic I, University of Lübeck, Experimental and Clinical Endocrinology, Ratzeburger Allee 160, Zentralklinikum (Haus 40), 23538 Lübeck, Germany
| | - Elke Hammer
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
| | - K. Alexander Iwen
- Medical Clinic I, University of Lübeck, Experimental and Clinical Endocrinology, Ratzeburger Allee 160, Zentralklinikum (Haus 40), 23538 Lübeck, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Henri Wallaschofski
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
- Private Practice Endocrinology, Krämpferstraße 6, 99094 Erfurt, Germany
| | - Dagmar Führer
- Department of Endocrinology and Metabolism, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Thomas F. Münte
- Department of Neurology, University of Lübeck, Ratzeburger Allee 169, 23538 Lübeck, Germany
| | - Nele Friedrich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
- Research Centre for Prevention and Health, Glostrup University Hospital, Nordre Ringvej 57, 2600 Glostrup, Denmark
| | - Uwe Völker
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
- ZIK-FunGene (Zentrum für Innovationskompetenz - Funktionelle Genomforschung), Greifswald, Germany
| | - Georg Homuth
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt University Greifswald, Friedrich-Ludwig-Jahn-Straße 15a, D-17475 Greifswald, Germany
- ZIK-FunGene (Zentrum für Innovationskompetenz - Funktionelle Genomforschung), Greifswald, Germany
| | - Georg Brabant
- Medical Clinic I, University of Lübeck, Experimental and Clinical Endocrinology, Ratzeburger Allee 160, Zentralklinikum (Haus 40), 23538 Lübeck, Germany
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Benavides Bermúdes JM, Vivas Diaz JJ, Jaramillo Trujillo G, Bernal Torres W. Trombosis venosa profunda en un paciente con hipertiroidismo de novo. Presentación de caso. REPERTORIO DE MEDICINA Y CIRUGÍA 2017. [DOI: 10.1016/j.reper.2017.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Benavides Bermúdes JM, Vivas Diaz JJ, Jaramillo Trujillo G, Bernal Torres W. Trombosis venosa profunda en un paciente con hipertiroidismo de novo. Presentación de caso. REPERTORIO DE MEDICINA Y CIRUGÍA 2017; 26:44-49. [DOI: https:/doi.org/10.1016/j.reper.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Dekkers OM, Horváth-Puhó E, Cannegieter SC, Vandenbroucke JP, Sørensen HT, Jørgensen JOL. Acute cardiovascular events and all-cause mortality in patients with hyperthyroidism: a population-based cohort study. Eur J Endocrinol 2017; 176:1-9. [PMID: 27697972 DOI: 10.1530/eje-16-0576] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/28/2016] [Accepted: 10/03/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Several studies have shown an increased risk for cardiovascular disease (CVD) in hyperthyroidism, but most studies have been too small to address the effect of hyperthyroidism on individual cardiovascular endpoints. Our main aim was to assess the association among hyperthyroidism, acute cardiovascular events and mortality. DESIGN It is a nationwide population-based cohort study. Data were obtained from the Danish Civil Registration System and the Danish National Patient Registry, which covers all Danish hospitals. We compared the rate of all-cause mortality as well as venous thromboembolism (VTE), acute myocardial infarction (AMI), ischemic and non-ischemic stroke, arterial embolism, atrial fibrillation (AF) and percutaneous coronary intervention (PCI) in the two cohorts. Hazard ratios (HR) with 95% confidence intervals (95% CI) were estimated. RESULTS The study included 85 856 hyperthyroid patients and 847 057 matched population-based controls. Mean follow-up time was 9.2 years. The HR for mortality was highest in the first 3 months after diagnosis of hyperthyroidism: 4.62, 95% CI: 4.40-4.85, and remained elevated during long-term follow-up (>3 years) (HR: 1.35, 95% CI: 1.33-1.37). The risk for all examined cardiovascular events was increased, with the highest risk in the first 3 months after hyperthyroidism diagnosis. The 3-month post-diagnosis risk was highest for atrial fibrillation (HR: 7.32, 95% CI: 6.58-8.14) and arterial embolism (HR: 6.08, 95% CI: 4.30-8.61), but the risks of VTE, AMI, ischemic and non-ischemic stroke and PCI were increased also 2- to 3-fold. CONCLUSIONS We found an increased risk for all-cause mortality and acute cardiovascular events in patients with hyperthyroidism.
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Affiliation(s)
- Olaf M Dekkers
- Department of Clinical EpidemiologyAarhus University Hospital, Aarhus, Denmark
- Department of Clinical Endocrinology and Metabolism
- Department of Clinical EpidemiologyLeiden University Medical Centre, Leiden, The Netherlands
| | | | - Suzanne C Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical Centre, Leiden, The Netherlands
| | - Jan P Vandenbroucke
- Department of Clinical EpidemiologyAarhus University Hospital, Aarhus, Denmark
- Department of Clinical EpidemiologyLeiden University Medical Centre, Leiden, The Netherlands
| | | | - Jens Otto L Jørgensen
- Department of Endocrinology and Internal MedicineAarhus University Hospital Aarhus, Aarhus, Denmark
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Kyriakakis N, Lynch J, Ajjan R, Murray RD. The effects of pituitary and thyroid disorders on haemostasis: potential clinical implications. Clin Endocrinol (Oxf) 2016; 84:473-84. [PMID: 25753252 DOI: 10.1111/cen.12767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/09/2014] [Accepted: 03/03/2015] [Indexed: 12/22/2022]
Abstract
Disturbances of coagulation and fibrinolysis are usually multifactorial and growing evidence suggests that endocrinopathies modulate the haemostatic balance. The thrombotic alterations in endocrine disorders range from mild laboratory clotting abnormalities with little clinical significance to serious thrombotic and bleeding disorders directly related to hormonal disturbances. This literature review focuses on presenting the current data on the effects of thyroid and pituitary disorders on various parameters of the haemostatic system. With the exception of overt hypothyroidism which appears to cause a bleeding tendency, the rest of the endocrinopathies discussed in this review (subclinical hypothyroidism, hyperthyroidism, endogenous hypercortisolaemia, growth hormone deficiency, acromegaly, prolactinoma/hyperprolactinaemia and hypogonadotrophic hypogonadism) are associated with a hypercoagulable and hypofibrinolytic state, increasing the overall cardiovascular risk and thromboembolic potential in these patients. In most studies, the haemostatic abnormalities seen in endocrine disorders are usually reversible with successful treatment of the underlying condition and biochemical disease remission. High-quality studies on larger patient cohorts are needed to produce robust evidence on the effects of endocrine disorders and their therapeutic interventions on coagulation and fibrinolysis, as well as on the long-term mortality and morbidity outcomes in association with endocrine-related haemostatic imbalance. Given the rarity of some of the endocrine disorders, multicentre studies are required to achieve this target.
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Affiliation(s)
- Nikolaos Kyriakakis
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Julie Lynch
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ramzi Ajjan
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
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25
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Elbers LPB, Moran C, Gerdes VE, van Zaane B, Meijers J, Endert E, Lyons G, Chatterjee VK, Bisschop PH, Fliers E. The Hypercoagulable state in Hyperthyroidism is mediated via the Thyroid Hormone β Receptor pathway. Eur J Endocrinol 2016; 174:EJE-15-1249. [PMID: 26961801 PMCID: PMC7613030 DOI: 10.1530/eje-15-1249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hyperthyroidism is associated with a hypercoagulable state, but the underlying mechanism is unknown. Patients with resistance to thyroid hormone (RTH) due to defective thyroid hormone receptor β (TRβ) exhibit elevated circulating thyroid hormones (TH) with refractoriness to TH action in TRβ-expressing tissues. We tested the hypothesis that the hypercoagulable state in hyperthyroidism is mediated via the TRβ. DESIGN We conducted a cross-sectional study from November 2013 to January 2015 in 3 hospitals in the Netherlands and the United Kingdom. METHODS Patients with RTH due to defective TRβ (n=18), patients with hyperthyroidism (n=16) and euthyroid subjects (n=18) were included. TH concentrations and markers of coagulation and fibrinolysis were measured. Data are expressed as median [interquartile range]. RESULTS Free thyroxine (FT4) levels were slightly higher in hyperthyroid patients than in RTH patients (53.9 [30.5-70.0] and 34.9 [28.4-42.2]pmol/l, respectively, P=0.042). Both groups had raised FT4 levels compared to euthyroid subjects (14.0 [13.0-15.8] pmol/l, P≤0.001). Levels of von Willebrand factor (VWF), factor (F) VIII, fibrinogen, and D-dimer were significantly higher in hyperthyroid patients than in RTH patients (VWF 231 [195-296] vs. 111 [82-140]%, FVIII 215 [192-228] vs. 145 [97-158]%, fibrinogen 3.6 [3.0-4.4] vs. 2.8 [2.5-3.2]g/L, D-dimer 0.41 [0.31-0.88] vs. 0.20 [0.17-0.26]mg/L, respectively, P≤0.001), while there were no differences between RTH patients and euthyroid controls. CONCLUSIONS Parameters of coagulation and fibrinolysis were elevated in hyperthyroid patients compared to patients with RTH due to defective TRβ, whereas these parameters were not different between euthyroid controls and RTH patients, despite elevated FT4 concentrations in RTH patients. This indicates that the procoagulant effects observed in hyperthyroidism are mediated via the TRβ.
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Affiliation(s)
- Laura P B Elbers
- L Elbers, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Carla Moran
- C Moran, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Victor Ea Gerdes
- V Gerdes, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Bregje van Zaane
- B van Zaane, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Joost Meijers
- J Meijers, Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Erik Endert
- E Endert, Laboratory of Endocrinology and Radiochemistry, Department of Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Greta Lyons
- G Lyons, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - V Krishna Chatterjee
- V Chatterjee, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Peter H Bisschop
- P Bisschop, Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Eric Fliers
- E Fliers, Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Engelmann B, Bischof J, Dirk AL, Friedrich N, Hammer E, Thiele T, Führer D, Homuth G, Brabant G, Völker U. Effect of Experimental Thyrotoxicosis onto Blood Coagulation: A Proteomics Study. Eur Thyroid J 2015; 4:119-24. [PMID: 26601083 PMCID: PMC4640288 DOI: 10.1159/000381769] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hyperthyroidism is known to induce a hypercoagulable state. It stimulates plasma levels of procoagulative factors and reduces fibrinolytic activity. So far most of the data have been derived from patients with endogenous hyperthyroidism with a wide variability in the underlying pathogenesis and severity of the disease. OBJECTIVES In this study we experimentally induced thyrotoxicosis in healthy volunteers to explore the effects of thyroxine excess on the plasma proteome. Using a shotgun proteomics approach, the abundance of plasma proteins was monitored before, during and after thyrotoxicosis. METHODS Sixteen healthy male subjects were sampled at baseline, 4 and 8 weeks under 250 µg/day thyroxine p.o., as well as 4 and 8 weeks after stopping the application. Plasma proteins were analyzed after depletion of 6 high-abundance proteins (MARS6) by LC-ESI-MS/MS mass spectrometry. Mass spectrometric raw data were processed using a label-free, intensity-based workflow. Subsequently, the linear dependence between protein abundances and fT4 levels were calculated using a Pearson correlation. RESULTS All subjects developed biochemical thyrotoxicosis, and this effect was reversed within the first 4 weeks of follow-up. None of the volunteers noticed any subjective symptoms. Levels of 10 proteins involved in the coagulation cascade specifically correlated with fT4, supporting an influence of thyroid hormone levels on blood coagulation even at nonpathological levels. CONCLUSIONS The results suggest that experimental thyrotoxicosis exerts selective and specific thyroxine-induced effects on coagulation markers. Our study design allows assessment of thyroid hormone effects on plasma protein levels without secondary effects of other diseases or therapies.
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Affiliation(s)
- Beatrice Engelmann
- Interfaculty Institute for Genetics and Functional Genomics, Greifswald, Germany
| | - Julia Bischof
- Interfaculty Institute for Genetics and Functional Genomics, Greifswald, Germany
| | - Anne-Luise Dirk
- Experimental and Clinical Endocrinology, Med Clinic I, University of Lübeck, Lübeck, Germany
| | - Nele Friedrich
- Institute for Clinical Chemistry and Laboratory Medicine, Greifswald, Germany
| | - Elke Hammer
- Interfaculty Institute for Genetics and Functional Genomics, Greifswald, Germany
- *Elke Hammer, Interfaculty Institute for Genetics and Functional Genomics, University Medicine Greifswald, Friedrich-Ludwig-Jahn-Strasse 15A, DE-17487 Greifswald (Germany), E-Mail
| | - Thomas Thiele
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Dagmar Führer
- Clinic for Endocrinology and Metabolic Disorders, University Clinics Essen, Essen, Germany
| | - Georg Homuth
- Interfaculty Institute for Genetics and Functional Genomics, Greifswald, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, Med Clinic I, University of Lübeck, Lübeck, Germany
| | - Uwe Völker
- Interfaculty Institute for Genetics and Functional Genomics, Greifswald, Germany
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27
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Horacek J, Maly J, Svilias I, Smolej L, Cepkova J, Vizda J, Sadilek P, Fatorova I, Zak P. Prothrombotic changes due to an increase in thyroid hormone levels. Eur J Endocrinol 2015; 172:537-42. [PMID: 25637077 DOI: 10.1530/eje-14-0801] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE With increasing free thyroxine levels, a gradually rising risk of venous thromboembolism has been described in case-control studies. However, reports on the influence of thyroid hormones on haemostasis, while suggesting a hypercoagulable state in thyrotoxicosis, have often been inconclusive. This study evaluates multiple markers of haemostasis and fibrinolysis in a paired design, making it more sensitive to changes in thyroid hormone levels. DESIGN We analysed multiple variables in patients who shifted from severe hypothyroidism to mild hyperthyroidism during thyroid cancer treatment. Those with possible residual disease were excluded. METHODS Ninety patients following total thyroidectomy were tested on two occasions: i) before radioiodine remnant ablation and ii) 6 weeks later, on levothyroxine (lT4) suppression treatment, and the results were compared using the Wilcoxon's test for paired data. RESULTS During lT4 treatment, significant increases (all P<0.001) in fibrinogen (from median 3.4 to 3.8 g/l), von Willebrand factor (from 85 to 127%), factor VIII (from 111 to 148%) and plasminogen activator inhibitor 1 (from 6.5 to 13.9 μg/l) were observed. In addition, the activation times of platelet adhesion and aggregation stimulated with collagen and epinephrine (EPI)/ADP, i.e. closure times in platelet function analyser (PFA-100), were significantly shortened (P<0.001): for EPI from median 148 to 117 s and for ADP from 95 to 80 s. Changes in other tests were less prominent or insignificant. CONCLUSIONS An increase in thyroid hormone levels shifts the haemostatic balance towards a hypercoagulable, hypofibrinolytic state. This may contribute to the increased cardiovascular morbidity and mortality observed even in mild thyrotoxicosis.
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Affiliation(s)
- Jiri Horacek
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Jaroslav Maly
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Ioannis Svilias
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Lukas Smolej
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Jitka Cepkova
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Jaroslav Vizda
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Petr Sadilek
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Ilona Fatorova
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Pavel Zak
- 4 Department of Internal Medicine - HaematologyDepartment of Nuclear MedicineCharles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
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28
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Yang MH, Yang FY, Lee DD. Thyroid Disease as a Risk Factor for Cerebrovascular Disease. J Stroke Cerebrovasc Dis 2015; 24:912-20. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 11/25/2014] [Accepted: 11/28/2014] [Indexed: 12/19/2022] Open
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Abstract
Objective: To investigate the effect of autoimmune thyroiditis (AIT) on risk of stroke and to assess whether any increased risk (1) varied by AIT duration, and (2) was independent of classic cardiovascular risk factors. Methods: This was a large historical cohort study using data from The Health Improvement Network Database. Rates of first stroke during follow-up in thyroxine-treated patients with AIT (n = 34,907) were compared with those in matched individuals without AIT (n = 149,632) using random-effects Poisson regression models. Results: There was strong evidence for a slightly increased risk of stroke in patients with AIT (adjusted rate ratio = 1.10, 95% confidence interval: 1.01–1.20). The observed increase was partly independent of cardiovascular risk factors. Higher effect sizes were identified in the first year after AIT diagnosis (rate ratio = 1.33, 95% confidence interval: 1.14–1.56) but not in the long-term, consistent with a residual effect of hypothyroidism. Conclusion: Our results support the hypothesis of a slightly increased risk of stroke in patients with AIT. The higher effect size found soon after AIT diagnosis suggests an increased cardiovascular risk due to thyroid-hormone deficiency rather than a cumulative effect of autoimmune pathology. Better screening and early treatment of patients with asymptomatic hypothyroid AIT could help reduce excess risk of stroke in the first year after diagnosis.
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Affiliation(s)
- André Karch
- From the Department of Epidemiology (A.K.), Helmholtz Centre for Infection Research, Braunschweig, Germany; Faculty of Epidemiology & Population Health (A.K., S.L.T.), London School of Hygiene and Tropical Medicine, UK; and Department of Neurology (A.K.), University Medical Center Göttingen, Germany
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30
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Thyroid function, activated protein C resistance and the risk of venous thrombosis in users of hormonal contraceptives. Thromb Res 2014; 133:640-4. [DOI: 10.1016/j.thromres.2013.12.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/27/2013] [Accepted: 12/30/2013] [Indexed: 11/24/2022]
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31
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Grine S, Charfi N, Kamoun M, Mnif F, Naceur BB, Rekik N, Mnif M, Abid M. Hyperthyroidism: A rare cause of pulmonary embolism: Report of two cases. Indian J Endocrinol Metab 2013; 17:1104-1107. [PMID: 24381893 PMCID: PMC3872694 DOI: 10.4103/2230-8210.122640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Several disorders of coagulation and fibrinolysis have been widely reported in patients with hyperthyroidism. Most reports have focused on only the venous thromboembolism risk, and few of them have studied specifically the association between hyperthyroidism and pulmonary embolism (PE). We report two cases of Graves' disease complicated by PE. The first patient is a 32 year-old man, and the second patient is a 23-year-old female. PE was suspected on the basis of pulmonary hypertension in patient one, and clinical presentation in the other patient. The first patient had also right heart failure. PE was confirmed in both patients by a lung perfusion-ventilation scan test. Thrombophilia screen revealed normal findings in the first patient and an elevation in coagulation factor VIII in the second one. Both patients received heparin, followed by oral anticoagulant therapy. In addition, they were treated with radioactive iodine resulting in partial recovery from hyperthyroidismforpatient oneand clinical euthyroidism for patient two. The former died of acute heart failure secondary to a chest infection, while the later was lost to follow-up. In conclusion, hyperthyroidism is associated with increased risk of venous thromboembolism, including PE. Potential mechanisms involved in this association include endothelial dysfunction, decreased fibrinolytic activity, and increased coagulation factors levels. Thyroid evaluation is recommended in patients with unprovoked venous thromboembolic events. Conversely, the diagnosis of venous thromboembolism should be considered in patients with hyperthyroidism, particularly if additional prothrombotic risk factors are present.
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Affiliation(s)
- Sonia Grine
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Nadia Charfi
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mahdi Kamoun
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Fatma Mnif
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Basma Ben Naceur
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Nabila Rekik
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mouna Mnif
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
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Stuijver DJF, Piantanida E, van Zaane B, Galli L, Romualdi E, Tanda ML, Meijers JCM, Büller HR, Gerdes VEA, Squizzato A. Acquired von Willebrand syndrome in patients with overt hypothyroidism: a prospective cohort study. Haemophilia 2013; 20:326-32. [DOI: 10.1111/hae.12275] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- D. J. F. Stuijver
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - E. Piantanida
- Endocrinology Unit; Department of Clinical and Experimental Medicine; University of Insubria; Varese Italy
| | - B. van Zaane
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - L. Galli
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
| | - E. Romualdi
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
| | - M. L. Tanda
- Endocrinology Unit; Department of Clinical and Experimental Medicine; University of Insubria; Varese Italy
| | - J. C. M. Meijers
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
- Department of Experimental Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - H. R. Büller
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - V. E. A. Gerdes
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - A. Squizzato
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
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