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Ranjan R, Ken-Dror G, Sharma P. Pathophysiology, diagnosis and management of cerebral venous thrombosis: A comprehensive review. Medicine (Baltimore) 2023; 102:e36366. [PMID: 38050259 PMCID: PMC10695550 DOI: 10.1097/md.0000000000036366] [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] [Received: 10/11/2023] [Accepted: 11/08/2023] [Indexed: 12/06/2023] Open
Abstract
Cerebral venous thrombosis is a rare cause of stroke in young mostly female adults which is frequently overlooked due to its variable clinical and radiological presentation. This review summarizes current knowledge on it risk factors, management and outcome in adults and highlights areas for future research. Females are 3 times more commonly affected and are significantly younger than males. The presenting symptoms can range from headache to loss of consciousness. However, the often-nebulous nature of symptoms can make the diagnosis challenging. Magnetic resonance imaging with venography is often the diagnostic imaging of choice. While unfractionated or low molecular-weight heparin is the mainstay of treatment, endovascular intervention with thrombolysis or thrombectomy and decompressive craniectomy may be required depending on clinical status. Nevertheless, approximately 80% of patients have a good recovery but mortality rates of -5% to 10% are not uncommon. Diagnosing cerebral venous thrombosis can be challenging but with vigilance and expert care patients have the best chance of a good clinical outcome.
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Affiliation(s)
- Redoy Ranjan
- Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
| | - Gie Ken-Dror
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
- Department of Clinical Neurology, Imperial College London Healthcare NHS Trust, London, United Kingdom
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2
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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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3
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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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4
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Andersen SL, Nielsen KK, Kristensen SR. The interrelationship between pregnancy, venous thromboembolism, and thyroid disease: a hypothesis-generating review. Thyroid Res 2021; 14:12. [PMID: 34034778 PMCID: PMC8146627 DOI: 10.1186/s13044-021-00102-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022] Open
Abstract
Pregnancy induces physiological changes that affect the risk of thrombosis and thyroid disease. In this hypothesis-generating review, the physiological changes in the coagulation system and in thyroid function during a normal pregnancy are described, and the incidence of venous thromboembolism (VTE) and thyroid disease in and after a pregnancy are compared and discussed. Furthermore, evidence regarding the association between thyroid disease and VTE in non-pregnant individuals is scrutinized. In conclusion, a normal pregnancy entails hormonal changes, which influence the onset of VTE and thyroid disease. Current evidence suggests an association between thyroid disease and VTE in non-pregnant individuals. This review proposes the hypothesis that maternal thyroid disease associates with VTE in pregnant women and call for future research studies on this subject. If an association exists in pregnant women specifically, such findings may have clinical implications regarding strategies for thyroid function testing and potential thromboprophylaxis in selected individuals.
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Affiliation(s)
- Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, 9000, Aalborg, Denmark.
| | - Kasper Krogh Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, 9000, Aalborg, Denmark
| | - Søren Risom Kristensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, 9000, Aalborg, Denmark
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5
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Lindner K, Kußmann J, Fendrich V. Preoperative Potassium Iodide Treatment in Patients Undergoing Thyroidectomy for Graves' Disease-Perspective of a European High-Volume Center. World J Surg 2021; 44:3405-3409. [PMID: 32447416 DOI: 10.1007/s00268-020-05593-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Potassium iodide (KI) treatment affects the vascularity of the thyroid gland and therefore may improve intraoperative visualization of essential structures. However, clear evidence for its usage is lacking, and its implementation in patients suffering from Graves' disease is becoming rare. The objective of this retrospective study was to assess the impact of KI treatment on the intraoperative course and the outcome of patients undergoing thyroidectomy for Graves' diseases. METHODS The study included 442 patients: 125 patients (28.3%) who received a preoperative treatment with KI ("Group KI") and 317 patients (71.7%) without a KI therapy ("Group No-KI"). Indication for KI treatment was a thyroid bruit (82.5%), as well as hyperthyroidism refractive to medical treatment with antithyroid drugs (17.4%). RESULTS All patients underwent total thyroidectomy. Permanent vocal cord paresis and permanent hypoparathyroidism were similar in both groups. KI treatment was associated with a significantly longer operative time (142 vs. 128 min, p < 0.001) and a significant higher weight of the thyroid gland. KI treatment did not impact duration of hospital stay or occurrence of secondary hemorrhage. CONCLUSIONS The complication rate of this study population with clinically severe GD was very low-which may be caused by pre-treatment of patients. The complementary option of a potassium iodide treatment before surgery remains a possibility and should be implemented individually.
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Affiliation(s)
- Kirsten Lindner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Jochen Kußmann
- Department of Endocrine Surgery, Schoen Clinic, Dehnhaide 120, 22081, Hamburg, Germany
| | - Volker Fendrich
- Department of Endocrine Surgery, Schoen Clinic, Dehnhaide 120, 22081, Hamburg, Germany.
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6
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Biguzzi E, Castelli F, Lijfering WM, Cannegieter SC, Eikenboom J, Rosendaal FR, van Hylckama Vlieg A. Rise of levels of von Willebrand factor and factor VIII with age: Role of genetic and acquired risk factors. Thromb Res 2020; 197:172-178. [PMID: 33221577 DOI: 10.1016/j.thromres.2020.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/29/2020] [Accepted: 11/11/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Von Willebrand factor (VWF) levels are regulated by genetic and acquired factors. The acquired factors are mostly related to age and could be mediators of the age effect on VWF levels. OBJECTIVES To disentangle the role of genetic (sex, blood group) and acquired factors (comorbidities, body mass index, reduced kidney function, hormone use, and inflammation) in regulating von Willebrand factor antigen (VWF:Ag) and factor VIII activity (FVIII:C) levels in the normal population. METHODS Analysis were performed in a large population sample (2923 individuals) from the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA study), after exclusion of individuals with active cancer and women who were pregnant or within nine months postpartum. The increase of VWF:Ag and FVIII:C with age was evaluated by linear regression after the age of 40 years. Analyses were adjusted for acquired factors and stratified for sex and blood group. RESULTS VWF:Ag and FVIII:C increased with age: increase per decade of age for VWF:Ag 18 IU/dL (95%CI 15-20) and for FVIII:C 12 IU/dL (95%CI 10-14). After adjustment for acquired factors, the increase per decade was 13 IU/dL (95%CI 10-16) for VWF:Ag and 9 IU/dL (95%CI 6-11) for FVIII:C. The stratified analysis for blood group showed higher increase in the non-O group, but these differences were annulled after adjustment for acquired factors. CONCLUSIONS VWF:Ag and FVIII:C increase with age. Carriers of blood group non-O present a steeper increase of VWF:Ag and FVIII:C with age, that is mediated by acquired factors.
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Affiliation(s)
- Eugenia Biguzzi
- IRCCS Fondazione Ca' Granda Ospedale Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Via Pace 9, 20122 Milan, Italy
| | | | - Willem M Lijfering
- Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Suzanne C Cannegieter
- Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Jeroen Eikenboom
- Leiden University Medical Center, Department of Internal Medicine, Division of Thrombosis and Hemostasis, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Frits R Rosendaal
- Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Astrid van Hylckama Vlieg
- Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333ZA Leiden, the Netherlands.
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7
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Christensen DH, Veres K, Ording AG, Jørgensen JOL, Cannegieter SC, Thomsen RW, Sørensen HT. Risk of cancer in patients with thyroid disease and venous thromboembolism. Clin Epidemiol 2018; 10:907-915. [PMID: 30123003 PMCID: PMC6080866 DOI: 10.2147/clep.s158869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Risk of venous thromboembolism (VTE) is increased in patients with hypo/hyperthyroidism. It is unknown whether VTE may be a presenting symptom of occult cancer in these patients. Design Nationwide population-based cohort study based on Danish medical registry data. Methods We identified all patients diagnosed with VTE during 1978–2013 who had a previous or concurrent diagnosis of hypothyroidism (N=1481) or hyperthyroidism (N=1788). We followed them until a first-time cancer diagnosis, death, emigration, or study end, whichever came first. We calculated 1-year absolute cancer risk and standardized incidence ratios (SIRs) for cancer incidence in the study population compared with national cancer incidence in the general population. Results During the first year after a VTE diagnosis, the 1-year absolute cancer risk was 3.0% among patients with hypothyroidism and 3.9% among those with hyperthyroidism. During the first year of follow-up, SIRs for cancer in the study population compared with the general population were 1.96 (95% CI: 1.42–2.64) among patients with hypothyroidism and 2.67 (95% CI: 2.07–3.39) among those with hyperthyroidism. SIRs declined substantially after 1 year but remained increased during the remainder of the follow-up period (up to 36 years) (SIR for hypothyroidism=1.16 [95% CI: 0.97–1.39]; SIR for hyperthyroidism=1.26 [95% CI: 1.08–1.46]). Conclusion VTE may be a marker of underlying occult cancer in patients with hypothyroidism or hyperthyroidism.
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Affiliation(s)
- Diana H Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Katalin Veres
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Anne G Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Jens Otto L Jørgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
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8
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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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9
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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: 40] [Impact Index Per Article: 6.7] [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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10
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Massolt ET, Meima ME, Swagemakers SMA, Leeuwenburgh S, van den Hout-van Vroonhoven MCGM, Brigante G, Kam BLR, van der Spek PJ, van IJcken WFJ, Visser TJ, Peeters RP, Visser WE. Thyroid State Regulates Gene Expression in Human Whole Blood. J Clin Endocrinol Metab 2018; 103:169-178. [PMID: 29069456 DOI: 10.1210/jc.2017-01144] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/16/2017] [Indexed: 02/03/2023]
Abstract
CONTEXT Despite the well-recognized clinical features resulting from insufficient or excessive thyroid hormone (TH) levels in humans, it is largely unknown which genes are regulated by TH in human tissues. OBJECTIVE To study the effect of TH on human gene expression profiles in whole blood, mainly consisting of T3 receptor (TR) α-expressing cells. METHODS We performed next-generation RNA sequencing on whole blood samples from eight athyroid patients (four females) on and after 4 weeks off levothyroxine replacement. Gene expression changes were analyzed through paired differential expression analysis and confirmed in a validation cohort. Weighted gene coexpression network analysis (WGCNA) was applied to identify thyroid state-related networks. RESULTS We detected 486 differentially expressed genes (fold-change >1.5; multiple testing corrected P value < 0.05), of which 76% were positively and 24% were negatively regulated. Gene ontology (GO) enrichment analysis revealed that three biological processes were significantly overrepresented, of which the process translational elongation showed the highest fold enrichment (7.3-fold, P = 1.8 × 10-6). WGCNA analysis independently identified various gene clusters that correlated with thyroid state. Further GO analysis suggested that thyroid state affects platelet function. CONCLUSIONS Changes in thyroid state regulate numerous genes in human whole blood, predominantly TRα-expressing leukocytes. In addition, TH may regulate gene transcripts in platelets.
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Affiliation(s)
- Elske T Massolt
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Marcel E Meima
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
| | | | - Selmar Leeuwenburgh
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
| | | | - Giulia Brigante
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Boen L R Kam
- Department of Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - Theo J Visser
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - W Edward Visser
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands
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11
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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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Tufano A, Modesti PA. The "very rare" unusual sites venous thromboses. Intern Emerg Med 2017. [PMID: 28643210 DOI: 10.1007/s11739-017-1701-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy.
| | - Pietro Amedeo Modesti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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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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14
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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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15
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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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16
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Elbers LP, Boon HA, Moes MI, van Zaane B, Brandjes DP, Fliers E, Büller HR, Cannegieter S, Gerdes VE. Plasma Levels of Free Thyroxine and Risk of Major Bleeding in Bariatric Surgery. Eur Thyroid J 2016; 5:139-44. [PMID: 27493889 PMCID: PMC4949359 DOI: 10.1159/000446431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/25/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In a recent study of patients using vitamin K antagonists, those with low free thyroxin (FT4) levels within the normal range had a 3- to 5-fold increased risk of major bleeding. We tested the hypothesis that low levels of preoperative FT4 within the reference range are associated with an increased risk of major bleeding during and after bariatric surgery. METHODS The charts of 2,872 consecutive patients undergoing bariatric surgery were retrospectively screened for bleeding episodes. Patients with major bleeding until 1 month after surgery were compared to randomly selected control patients without bleeding, in a ratio of 1:4. We evaluated the association between preoperative FT4 levels and the risk of major bleeding by logistic regression. RESULTS Seventy-two cases (2.5%) with major bleeding were identified and 288 controls were selected. The median plasma level of FT4 was 13 pmol/l (interquartile range: 12-14) in the cases as well as in the controls. No clear effect was observed of low levels of FT4 on the risk of major bleeding: odds ratio 1.48 (95% CI: 0.46-4.80) for patients with an FT4 level <11 pmol/l, 1.03 (0.49-2.18) for patients with an FT4 level <12 pmol/l, and 1.12 (0.65-1.94) for patients with an FT4 level <13 pmol/l as compared to patients with FT4 values greater than or equal to these cutoff levels. INTERPRETATION We did not observe an increased risk of major bleeding with low levels of FT4 in patients undergoing bariatric surgery.
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Affiliation(s)
- Laura P.B. Elbers
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
- Departments of, Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
- *Laura P.B. Elbers, MD, Medical Center Slotervaart, 9B v010, Louwesweg 6, NL–1066 EC Amsterdam (The Netherlands), E-Mail
| | - Hjalmar A. Boon
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
| | - Maaike I. Moes
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
| | - Bregje van Zaane
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
- Departments of, Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
| | - Dees P.M. Brandjes
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
- Departments of, Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
| | - Eric Fliers
- Departments of, Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
| | - Harry R. Büller
- Departments of, Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
| | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Victor E.A. Gerdes
- Department of Internal Medicine, Medical Center Slotervaart, University of Amsterdam, Leiden, The Netherlands
- Departments of, Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Leiden, The Netherlands
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Lerstad G, Enga KF, Jorde R, Brodin EE, Svartberg J, Brækkan SK, Hansen JB. Thyroid function, as assessed by TSH, and future risk of venous thromboembolism: the Tromsø study. Eur J Endocrinol 2015; 173:83-90. [PMID: 25899580 DOI: 10.1530/eje-15-0185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 04/20/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The relationship between thyroid function and the risk of venous thromboembolism (VTE) has not been addressed in population-based cohorts. We investigated the association between TSH levels and the risk of VTE in a general adult population. DESIGN Population-based cohort study. METHODS TSH was measured in 11 962 subjects aged 25-89 years who participated in Tromsø 4-6 starting in 1994-1995. Incident VTE events were recorded through 31st December 2010. Cox's regression models with TSH as a time-varying covariate were used to calculate hazard ratios (HRs) of VTE by TSH categories (low TSH: <0.05 mU/l; moderately reduced TSH: 0.05-0.19 mU/l; normal TSH: 0.20-4.00 mU/l; moderately elevated TSH: 4.01-5.00 mU/l; and high TSH: >5.00 mU/l) and within the normal range of TSH, modeling TSH as a continuous variable. RESULTS There were 289 VTEs during 8.2 years of median follow-up. Subjects with low (prevalence: 0.22%) and high (3.01%) TSH had slightly higher risk estimates for VTE than did subjects with normal TSH (multivariable HRs: 2.16, 95% CI 0.69-6.76 and 1.55, 95% CI 0.87-2.77 respectively), but the CIs were wide. Moreover, there was no association between TSH within the normal range and VTE (HR per 1 mU/l increase: 0.95, 95% CI 0.82-1.11). CONCLUSION Serum levels of TSH within the normal range were not associated with a risk of VTE, whereas low and high TSH levels were rare and associated with a moderately higher risk of VTE. The present findings suggest that only a minor proportion of the VTE risk in the population can be attributed to thyroid dysfunction.
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Affiliation(s)
- Gunhild Lerstad
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - Kristin F Enga
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - Rolf Jorde
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - Ellen E Brodin
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - Johan Svartberg
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - Sigrid K Brækkan
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway Department of Clinical MedicineK.G. Jebsen Thrombosis Research and Expertise Center (TREC)Hematological Research Group (HERG)Department of Clinical MedicineEndocrine Research GroupDepartment of Clinical Medicine, University of Tromsø, N-9037 Tromsø, NorwayDivision of Internal MedicineUniversity Hospital of North Norway, Tromsø, Norway
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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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Elucidating mechanisms of toxicity using phenotypic data from primary human cell systems--a chemical biology approach for thrombosis-related side effects. Int J Mol Sci 2015; 16:1008-29. [PMID: 25569083 PMCID: PMC4307287 DOI: 10.3390/ijms16011008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/23/2014] [Indexed: 12/31/2022] Open
Abstract
Here we describe a chemical biology approach for elucidating potential toxicity mechanisms for thrombosis-related side effects. This work takes advantage of a large chemical biology data set comprising the effects of known, well-characterized reference agents on the cell surface levels of tissue factor (TF) in a primary human endothelial cell-based model of vascular inflammation, the BioMAP® 3C system. In previous work with the Environmental Protection Agency (EPA) for the ToxCast™ program, aryl hydrocarbon receptor (AhR) agonists and estrogen receptor (ER) antagonists were found to share an usual activity, that of increasing TF levels in this system. Since human exposure to compounds in both chemical classes is associated with increased incidence of thrombosis-related side effects, we expanded this analysis with a large number of well-characterized reference compounds in order to better understand the underlying mechanisms. As a result, mechanisms for increasing (AhR, histamine H1 receptor, histone deacetylase or HDAC, hsp90, nuclear factor kappa B or NFκB, MEK, oncostatin M receptor, Jak kinase, and p38 MAPK) and decreasing (vacuolar ATPase or V-ATPase) and mTOR) TF expression levels were uncovered. These data identify the nutrient, lipid, bacterial, and hypoxia sensing functions of autophagy as potential key regulatory points controlling cell surface TF levels in endothelial cells and support the mechanistic hypothesis that these functions are associated with thrombosis-related side effects in vivo.
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Debeij J, van Zaane B, Dekkers OM, Doggen CJM, Smit JWA, van Zanten AP, Brandjes DPM, Büller HR, Gerdes VEA, Rosendaal FR, Cannegieter SC. High levels of procoagulant factors mediate the association between free thyroxine and the risk of venous thrombosis: the MEGA study. J Thromb Haemost 2014; 12:839-46. [PMID: 24679097 DOI: 10.1111/jth.12573] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 03/13/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thyroid hormone affects the coagulation system, but its effect on clinical disease is not clear. We determined the associations of levels of free thyroxine (FT4), thyroid-stimulating hormone (TSH) and anti-thyroid peroxidase antibodies (antiTPO) with levels of coagulation factors and the risk of venous thrombosis. METHODS In a large population based case-control study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis study) on the etiology of venous thrombosis, we determined the levels of FT4, TSH, antiTPO, factor FII, FVII, FVIII, FIX, FX, von Willebrand factor (VWF), antithrombin, protein C, protein S and fibrinogen in 2177 cases and 2826 controls. RESULTS High levels of FT4 were associated with increased concentrations of procoagulant factors, and not with levels of anticoagulant factors. High levels of FT4 were also associated with the risk of venous thrombosis, up to an odds ratio (OR) of 2.2 (95% confidence interval [CI] 1.0-4.6) for levels above 24.4 pm relative to FT4 levels between 15.5 and 18.9 pm. In 11 cases and one control, clinical hyperthyroidism had been diagnosed within a year of the thrombotic event, leading to an OR of 17.0 (95% CI 2.2-133.0) for thrombosis. The ORs approached unity after adjustment for FVIII and VWF, which suggests that the effect was mediated by these factors. Low TSH levels were also, but less evidently, associated with thrombosis, whereas there was no association between antiTPO and venous thrombosis risk. CONCLUSIONS High levels of FT4 increase the concentrations of the procoagulant proteins FVIII, FIX, fibrinogen, and VWF, and by this mechanism increase the risk of venous thrombosis.
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Affiliation(s)
- J Debeij
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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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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Debeij J, Cannegieter SC, van Zaane B, van Zanten AP, Rosendaal FR, Gerdes VE, Reitsma PH, Dekkers OM. Major Haemorrhage during Vitamin K Antagonist Treatment: The Influence of Thyroid Hormone Levels. Eur Thyroid J 2014; 3:32-7. [PMID: 24847463 PMCID: PMC4005261 DOI: 10.1159/000357578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/28/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Annually, approximately 1-3% of patients treated with vitamin K antagonists (VKA) suffer from major haemorrhage. Since high levels of free thyroxine (fT4) are associated with increased thrombosis risk, the aim was to assess whether low levels of fT4 contribute to major haemorrhage in patients under VKA treatment. METHODS The FACTORS (Factors in Oral Anticoagulant Safety) study is a case-control study on patients receiving VKA treatment, including 110 cases with major haemorrhage. Controls were 220 matched participants treated with VKA without major haemorrhage. Odds ratios (OR) and 95% confidence intervals (95% CI) for the association of fT4 levels with major haemorrhage were calculated for different fT4 cutoffs by conditional logistic regression. RESULTS In patients with an fT4 level below 13 pmol/l, the risk of major haemorrhage was 5-fold increased (OR = 5.1; 95% CI: 0.9-28.6) compared with patients with an fT4 level above 13 pmol/l. At a cutoff of 14 pmol/l, the risk was 3-fold increased (OR = 2.9; 95% CI: 1.0-8.5). High levels of fT4 did not affect bleeding risk. No clear effect of thyroid-stimulating hormone and thyroid peroxidase antibodies was seen on the risk of major haemorrhage. CONCLUSIONS These results indicate that fT4 levels below 14 pmol/l play a role in the aetiology of major haemorrhage in VKA users.
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Affiliation(s)
- Jan Debeij
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
| | - Bregje van Zaane
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Anton P. van Zanten
- Department of Clinical Biochemistry, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- Department of Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
| | - Victor E.A. Gerdes
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Pieter H. Reitsma
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- Department of Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, Amsterdam, The Netherlands
- *Olaf M. Dekkers, Department of Clinical Epidemiology C7-P, Leiden University Medical Centre, PO Box 9600, NL-2300 RC Leiden (The Netherlands), E-Mail
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