Relationship between Subclinical Thyroid Dysfunction and the Risk of Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Metabolic and Endocrine Correlates of Subclinical Hypothyroidism in Young Adults With First-Episode and Drug-Naive Major Depressive Disorder

BACKGROUND

Major depressive disorder is often associated with subclinical hypothyroidism (SCH), but the clinical and biochemical characteristics in young, first-episode, drug-naive patients remain unclear. This study aims to examine the prevalence and clinical correlates of SCH in this population to enhance screening and management strategies.

METHOD

A cross-sectional study included 917 young Chinese patients (aged 18-35 years) diagnosed with first-episode, drug-naive Major depressive disorder. Comprehensive clinical assessments were conducted, involving demographic data, psychiatric evaluations using the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Positive and Negative Syndrome Scale, alongside biochemical measurements such as thyroid stimulating hormone, thyroid peroxidase antibodies, fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure. Binary logistic regression identified clinical correlates of SCH.

RESULTS

The prevalence of SCH among the study population was 58%. Logistic regression analysis identified significant predictors of SCH, including higher Hamilton Depression Rating Scale scores (odds ratio [OR] = 1.26), thyroid peroxidase antibodies (OR = 1.003), fasting blood glucose (OR = 2.28), total cholesterol (OR = 1.66), systolic blood pressure (OR = 1.11), and diastolic blood pressure (OR = 1.07). In contrast, lower high-density lipoprotein cholesterol levels (OR = 0.28) were inversely associated with SCH.

CONCLUSION

The high prevalence of SCH in young, first-episode, drug-naive Major depressive disorder patients emphasizes the need for comprehensive metabolic and endocrine evaluations. Regular monitoring of thyroid function, glucose levels, blood pressure, and lipid profiles is crucial for early detection and intervention, potentially improving clinical outcomes in this vulnerable group.

Establishing the TSH reference intervals for healthy adults aged over 70 years: the Australian ASPREE cohort study

OBJECTIVES

As thyroid disorders are common amongst the elderly, this study aims to evaluate the reference interval (RI) for thyroid stimulating hormone (TSH) in healthy adults aged 70 years and over.

METHODS

A proposed RI was determined from the Australian participants of the ASPirin in Reducing Events in the Elderly (ASPREE) randomised trial. Participants had no history of cardiovascular disease, thyroid cancer, dementia, or life-threatening illnesses. Participants prescribed with any thyroid-related medication at baseline were excluded. TSH levels were measured using a commercial chemiluminescence microparticle immunoassay. The RI was determined using the middle 95th percentile of the logarithmic transformed data of baseline TSH. Cox proportional hazard regression models were used to validate the RI by assessing disease incidence over time.

RESULTS

A total of 10,995 participants had baseline TSH measures. Median (IQR) age was 73.9 (71.8-77.3) years. We propose a RI of 0.34-3.75 mU/L. TSH levels did not differ by age or sex. At baseline, there was no association between symptoms associated with thyroid disease and levels of TSH. Over the follow-up period of up to 11 years, no association was seen between baseline TSH levels and relevant disease outcomes for participants within the RI.

CONCLUSIONS

From a group of initially healthy, community-dwelling adults aged >=70 years, we propose a RI of TSH to best represent euthyroidism. This concentration was not associated with an increased risk of thyroid related symptoms or outcomes, confirming its appropriateness for clinical use.

Association of Serum Thyroxine and Atrial Fibrillation in Patients on Levothyroxine

INTRODUCTION

Excess thyroid hormone is a well-documented risk factor for the development of atrial fibrillation (AF). The purpose of the study is to assess incidence of AF in patients taking levothyroxine for hypothyroidism and correlate it with biochemical thyroid function.

MATERIALS AND METHODS

This was a retrospective cohort study of patients aged 18 years and older who were treated with levothyroxine. Exclusion criteria were pre-existing diagnosis of AF and use of amiodarone in the prior year. Patients were followed 2012 through 2019 and stratified into 4 groups based on mean thyroid-stimulating hormone (TSH) value or mean fT4 value in 2012. Primary outcome was incidence of AF. Rates of AF between groups were assessed via Poisson regression with control of underlying confounders.

RESULTS

Of 21,035 patients, 1091 (5.2%) developed AF during follow-up. Thyroid-stimulating hormone at baseline was not significantly associated with incident AF. Higher fT4 levels at baseline were associated with increased AF risk in age- and sex-adjusted analyses (hazard ratio 1.22; 95% CI, 1.03-1.44) for the highest quartile versus the lowest quartile of fT4.

CONCLUSIONS

In hypothyroid patients treated with levothyroxine, higher circulating fT4 levels are associated with increased risk of incident AF. There is no association of serum TSH with risk of AF. In patients at risk for AF, consideration should be given to avoiding fT4 levels in the highest quartile.

Subclinical hypothyroidism and clinical outcomes after cardiac surgery: A systematic review and meta-analysis

Background

Subclinical hypothyroidism (SCH) is associated with major adverse cardiovascular events. Despite the recognized negative impact of SCH on cardiovascular health, research on cardiac postoperative outcomes with SCH has yielded conflicting results, and patients are not currently treated for SCH before cardiac surgery procedures.

Methods

We performed a study-level meta-analysis on the impact of SCH on patients undergoing nonurgent cardiac surgery, including coronary artery bypass grafting and valve and aortic surgery. The primary outcome was operative mortality. Secondary outcomes were hospital length of stay (LOS), intensive care unit (ICU) stay, postoperative atrial fibrillation (POAF), intra-aortic balloon pump (IABP) use, renal complications, and long-term all-cause mortality.

Results

Seven observational studies, with a total of 3445 patients, including 851 [24.7%] diagnosed with SCH and 2594 [75.3%] euthyroid patients) were identified. Compared to euthyroid patients, the patients with SCH had higher rates of operative mortality (odds ratio [OR], 2.57; 95% confidence interval [CI], 1.09-6.04; P = .03), prolonged hospital LOS (standardized mean difference, 0.32; 95% CI, 0.02-0.62; P = .04), a higher rate of renal complications (OR, 2.53; 95% CI, 1.74-3.69; P < .0001), but no significant differences in ICU stay, POAF, or IABP use. At mean follow-up of 49.3 months, the presence of SCH was associated with a higher rate of all-cause mortality (incidence rate ratio, 1.82; 95% CI, 1.18-2.83; P = .02).

Conclusions

Patients with SCH have higher operative mortality, prolonged hospital LOS, and increased renal complications after cardiac surgery. Achieving and maintaining a euthyroid state prior to and after cardiac surgery procedures might improve outcomes in these patients.

Thyroid dysfunction and mortality in cardiovascular hospitalized patients

Background

Thyroid dysfunction (TD) is associated with increased cardiovascular morbidity and mortality. Early detection may influence the clinical management.

Objective

To determine the prevalence, predictors, and prognostic value of TD among hospitalized cardiac patients.

Methods

A retrospective analysis of a 12-year database consisting of nonselectively adult patients admitted to a Cardiology Department and who were all screened for serum thyroid-stimulation-hormone (TSH) levels . Statistical analysis of demographic and clinical characteristics, mortality and length of hospital stay (LOS) was performed.

Results

A total of 14369 patients were included in the study; mean age was 67 years, 38.3% females. 1465 patients (10.2%) had TD. The most frequent type of TD was mildly elevated TSH (5.4%) followed by mildly reduced TSH (2.1%), markedly elevated TSH (1.5%), and markedly reduced TSH (1.2%). Female gender, history of hypothyroidism, heart failure, atrial fibrillation, renal failure and amiodarone use were significantly associated with TD. During follow-up 2975 (20.7%) patients died. There was increased mortality in the mildly reduced TSH subgroup (hazard ratio [HR] =1.44), markedly elevated TSH subgroup (HR=1.40) and mildly elevated TSH subgroup (HR=1.27). LOS was longer for patients with TD; the longest stay was observed in the markedly elevated TSH subgroup (odds ratio=1.69).

Conclusion

The prevalence of TD in hospitalized cardiac patients is 10.2%. TD is associated with an increased mortality rate and LOS. Consequently, routine screening for thyroid function in this population is advisable, particularly for selected high-risk subgroups. Future studies are needed to determine whether optimizing thyroid function can improve survival in these patients.

Current Trends in Biohumoral Screening for the Risk of Sudden Cardiac Death: A Systematic Review

Background and Objectives: Sudden cardiac death (SCD) represents a challenge to health systems globally and is met with increased frequency in the population. Over time, multiple screening methods have been proposed, including the analysis of various plasma biomarkers. This article aims to analyze for illustrative purposes the specialized literature in terms of current biomarkers and testing trends, in the case of cardiovascular diseases and implicitly sudden cardiac death. Materials and Methods: In this regard, we searched the PubMed database from 2010 to the present time using the keywords "sudden cardiac death" and "biomarkers". The inclusion criteria were clinical trials that analyzed the effectiveness of screening methods in terms of biomarkers used in stratifying the risk of cardiac distress and/or sudden cardiac death. We excluded reviews, meta-analyses, and studies looking at the effectiveness of treatments. Results: An extended approach was found, through studies that brought to the forefront both classical markers analyzed by new, more performant methods, markers for other pathologies that also determined cardiovascular impact, non-specific molecules with effects on the cardiovascular system, and state-of-the-art markers, such as microRNA. Some molecules were analyzed simultaneously in certain groups of patients. Conclusion: The observed current trend revealed the tendency to define the clinical-biological particularities of the person to be screened.

Clinical correlates and thyroid hormones of metabolic syndrome in first-episode and drug-naïve major depressive disorder outpatients with and without hyperglycemia: a comprehensive cross-sectional study

Hyperglycemia and metabolic syndrome (MetS) are common in patients with major depressive disorder (MDD). This study aimed to explore the prevalence and clinical factors of MetS in first-episode and drug-naïve MDD (FEDND) patients with and without hyperglycemia. A total of 1,718 FEDND patients' symptoms were assessed using the Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and positive subscale of the Positive and Negative Syndrome Scale (PANSS). Blood glucose levels, metabolic index, and thyroid hormones were measured during fasting. The prevalence of MetS in FEDND patients with hyperglycemia was 35.67 times higher than in FEDND patients without hyperglycemia. FEDND patients with MetS were older, had later age of onset, and were predominantly married than those without MetS (p < 0.05). Among FEDND patients without hyperglycemia, suicide attempts, severe anxiety, HAMD, HAMA, PANSS subscale scores, thyroid stimulating hormone, antithyroglobulin, and total cholesterol levels were all higher in patients with MetS than those without MetS (all p < 0.05). In FEDND patients without hyperglycemia, the combination of age and TgAb distinguished those patients with and without MetS. Our results suggest a high prevalence of MetS in FEDND patients with hyperglycemia. Several clinical variables and thyroid function-related hormones impact MetS in patients with FEDND.

Four-dimensional speckle tracking echocardiography and fragmented QRS in detection of early left ventricular systolic dysfunction in patients with subclinical hyperthyroidism

BACKGROUND

Thyroid disorders are associated with many cardiovascular risk factors. The importance of thyroid hormones in the pathophysiology of heart failure is underlined by the European guidelines of the European Society of Cardiology. However, the role of subclinical hyperthyroidism (SCH) in subclinical left ventricular (LV) systolic dysfunction is not entirely clear.

METHODS

This cross-sectional study included 56 SCH patients and 40 healthy volunteers. The 56 SCH group was divided into two subgroups depending on the presence of fragmented QRS (fQRS). In both groups, left ventricular global area strain (LV-GAS), global radial strain (GRS), global longitudinal strain (GLS), and global circumferential strain (GCS) were obtained with four-dimensional (4D) echocardiography.

RESULTS

GAS, GRS, GLS, and GCS values were significantly different in SCH patients and in healthy volunteers. GLS and GAS values were lower in the fQRS+ than in the fQRS- group (-17.06 ± 1.00 vs. -19.08 ± 1.71, p < .001, and -26.61 ± 2.38 vs. -30.61 ± 2.57, p < .001, respectively). ProBNP was positively correlated with LV-GLS (r = 0.278, p = .006) and LV-GAS (r = 0.357, p < .001). Multiple linear regression analysis showed that fQRS was an independent predictor of LV-GAS.

CONCLUSIONS

4D strain echocardiography may be helpful for the prediction of early cardiac dysfunction in patients with SCH. The presence of fQRS may be an indicator of subclinical LV dysfunction in SCH.

Thyroid-stimulating hormone within the normal reference range has a U-shaped association with the severity of coronary artery disease in nondiabetic patients but is diluted in diabetic patients

Too high or too low thyroid-stimulating hormone (TSH) has been associated with the progress and prognosis of coronary artery disease (CAD). However, whether TSH within its normal reference range plays a role in the severity of CAD remains unclear. In this observational study, we explored the potential relationship of hypersensitive TSH (hs-TSH) with the severity of CAD in euthyroid patients with or without diabetes mellitus. A total of 7357 CAD patients with euthyroidism were enrolled in this study. Of those, 1997 had diabetes mellitus. The severity of CAD was evaluated through the presence of myocardial infarction (MI) and the severity of coronary lesions, which was calculated using the Gensini score (GS). Logistic regression models treating hs-TSH as a categorical variable and restricted cubic spline analyses treating it as a continuous variable were used to evaluate the associations of hs-TSH with the severity of CAD. The propensity score matching method was used to further validate the differences between diabetic and nondiabetic patients. CAD patients with diabetes mellitus had lower levels of hs-TSH (1.6 (0.97-2.53) vs 1.67 (1.00-2.64)) in serum compared with CAD patients without diabetes mellitus. Meanwhile, hs-TSH was independently related to the severity of CAD. In CAD patients with vs without diabetes mellitus, the U-shaped relationship between hs-TSH and MI was more prominent in patients without diabetes mellitus, and the significant U-shaped association between higher GS and hs-TSH remained only in nondiabetes. Therefore, hs-TSH within the normal reference range has a U-shaped association with the severity of CAD in nondiabetic patients, which is markedly diluted in diabetic patients.

High Thyrotropin Levels and Risk of Mortality in the Elderly With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis

OBJECTIVE

This study aims to determine whether elevated endogenous thyrotropin levels contribute to an increased risk of adverse outcomes, such as all-cause mortality in older adults with subclinical hypothyroidism.

METHODS

Eight electronic databases were searched for relevant articles from inception until March 23, 2022. Cohort studies assessing the association between thyrotropin levels and the risk of mortality among older adults aged ≥60 years with subclinical hypothyroidism were eligible. The outcomes of interest were either all-cause or cardiovascular-related mortality. Two independent researchers assessed the eligibility of the studies and collected data through a previously defined data extraction form. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence, and multivariate-adjusted hazard ratios (HRs) (95% Cl) were collected as the necessary risk estimate for synthesis. Random-effects models were applied for meta-analysis.

RESULTS

Overall, 13 studies involving 44 514 participants were included in this meta-analysis. There were no significant differences in the risk of all-cause mortality (pooled HR: 1.18 [95% Cl: 0.95, 1.45], I² = 94%) and cardiovascular-related mortality (pooled HR: 1.08 [95% Cl: 0.94, 1.23], I² = 0%) between euthyroid older adults and older adults with subclinical hypothyroidism. The results remained the same when only older adults with thyrotropin ≥10 mIU/L were assessed (pooled HR for all-cause mortality and cardiovascular-related mortality, respectively: 1.53 [95% Cl: 0.81, 2.88], I² = 22%, 1.35 [95% Cl: 0.63, 2.86], I² = 43%).

CONCLUSION

High thyrotropin levels are not associated with increased risk for all-cause mortality as well as cardiovascular-related mortality in older adults aged ≥60 years with subclinical hypothyroidism, suggesting an unnecessity in initialing treatment.

Thyroid hormones and platelet activation in COVID-19 patients

PURPOSE

To retrospectively describe the association between thyroid hormones (TH) and platelet activation, as represented by mean platelet volume (MPV), in a cohort of patients hospitalized for COVID-19 with no known thyroid disease, and to correlate these data with the severity of COVID-19 and the occurrence of death/ARDS (Acute Respiratory Distress Syndrome).

METHODS

103 patients with real-time polymerase chain reaction (RT-PCR) testing-confirmed COVID-19 and hospitalized were enrolled. Serum samples were collected from patients upon admission before starting any treatment. Chi-squared test was used to determine the association between euthyroid sick syndrome (ESS) and COVID-19 severity. Multivariate logistic regression was performed to evaluate the best independent predictors of COVID-19 deaths/ARDS.

RESULTS

39/103 (37.9%) of patients were found to have ESS, and this condition was an independent predictor for the severity of COVID-19 (p = 0.003). Lower TSH and lower FT3/FT4 ratio correlated with higher MPV (p = 0,001 and p = 0.010), with an opposite trend with respect to what has been documented in non-COVID patients. Increasing MPV and lower FT3 significantly increased the risk, in COVID-19 patients, of an adverse outcome of death/ARDS.

CONCLUSION

Increased platelet activation, as represented by increased MPV, has already been reported to correlate with COVID-19 severity, possibly as a consequence of cytokine release. We demonstrated, in a cohort of 103 patients with COVID-19, that MPV is inversely correlated to TH levels, in particular in the case of ESS, where downregulation of TH axis may occur in case of systemic cytokine inflammation and more severe outcomes (death/ARDS). That ESS itself may directly cause platelet activation, as demonstrated by higher MPV in these patients, is an interesting hypothesis which deserves further investigation.

Association of high BMI with subclinical hypothyroidism in young, first-episode and drug-naïve patients with major depressive disorder: a large-scale cross-sectional study

Thyroid dysfunction is known to be associated with obesity, but the reliability of this relationship is easily affected by drug treatment, age, and subclinical hypothyroidism (SCH) with no apparent symptoms. Our research aims to compare obese and overweight BMI ranges with SCH and without SCH in a large sample of young, first-episode and drug-naïve (FEDN) patients with major depressive disorder (MDD), which has received little systemic investigation. A total of 1289 FEDN MDD young outpatients were recruited for this study. Serum thyroid function and lipid level parameters were measured; HAMD and PANSS scales were used to assess patients' depression and positive symptoms. A self-administered questionnaire collected other clinical and demographic data. The prevalence of SCH in FEDN MDD young patients was 58.26%. Compared to patients without SCH, the patients with SCH had a more prolonged illness duration, higher BMI levels, increased prevalence of overweight and obesity, higher HAMD score and PANSS-positive symptom scores, higher levels of TG, TC, LDL-C, and lower levels of HDL-C. Further logistic regression indicated that overweight BMI, obese BMI, illness duration, HAMD score, HDL-C, and TC were significantly associated with SCH. Our results indicate that obesity and overweight may be associated with SCH in young, FEDN MDD patients. The importance of regular thyroid function assessment in young FEDN MDD patients with high BMI should be taken into account.

Short-term outcomes among patients with subclinical hypothyroidism undergoing primary percutaneous coronary intervention

Objectives

This study aimed to examine possible associations between previously undiagnosed subclinical hypothyroidism and short-term outcomes and mortality in a sample of Iraqi patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

Design

This is a prospective observational cohort study.

Setting

The study was conducted in a single tertiary referral centre in Baghdad, Iraq.

Participants

Thyroid-stimulating hormone and free T4 levels were measured in 257 patients hospitalised with ST-elevation myocardial infarction who underwent primary percutaneous coronary intervention between January 2020 and March 2022.

Main outcome measures

Adverse cardiovascular and renal events during hospitalisation and 30-day mortality were observed.

Results

Previously undiagnosed subclinical hypothyroidism was detected in 36/257 (14%) ST-elevation myocardial infarction patients and observed more commonly in females than males. Patients with subclinical hypothyroidism had significantly worse short-term outcomes, including higher rates of suboptimal TIMI Flow (< III) (p =0.014), left ventricular ejection fraction ≤ 40% (p=0.035), Killip class >I (p=0.042), cardiogenic shock (p =0.016), cardiac arrest in the hospital (p= 0.01), and acute kidney injury (p= 0.044). Additionally, 30-day mortality was significantly higher in patients with subclinical hypothyroidism (p= 0.029).

Conclusion

Subclinical hypothyroidism previously undiagnosed and untreated had a significant association with adverse short-term outcomes and higher short-term mortality within 30 days compared to euthyroid patients undergoing primary percutaneous coronary intervention. Routine thyroid function testing during these patients' hospitalisation may be warranted.

Funding

None declared.

Approach to adult patients with primary hypothyroidism in some special situations: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

Primary hypothyroidism is a common disorder in clinical practice. The management of most cases of hypothyroidism is usually straightforward, but the best approach in some special situations may raise questions among physicians. This position statement was prepared by experts from the Brazilian Society of Endocrinology and Metabolism to guide the management of three special situations, namely, hypothyroidism in the elderly, subclinical hypothyroidism in patients with heart disease, and difficult-to-control hypothyroidism. The authors prepared the present statement after conducting a search on the databases MEDLINE/PubMed, LILACS, and SciELO and selecting articles with the best evidence quality addressing the selected situations. The statement presents information about the current approach to patients in these special situations.

Interplay between cardiovascular and thyroid dysfunctions: A review of clinical implications and management strategies

Cardiovascular diseases (CVD) and thyroid dysfunction are two of the most prevailing disorders in the world that are closely interlinked. Actions of thyroid hormones are mediated via thyroid receptors present in the myocardium and the vascular tissue. Primary mechanism that links thyroid dysfunction with CVD is the modification of cardiovascular risk factors (dyslipidemia, blood pressure, coagulation parameters, etc.) resulting in endothelial and left ventricular systolic and diastolic dysfunction.

Both overt and subclinical hyperthyroidism and hypothyroidism may cause adverse alterations in cardiac function. Hyperthyroidism gives rise to palpitation, atrial fibrillation, systolic hypertension, and heart failure, whereas hypothyroidism increases diastolic hypertension, pericardial effusion, and the risk of ischemic heart disease via altering lipid and coagulation parameters. Early recognition and treatment of thyroid dysfunction may prevent adverse cardiovascular events in patients with or without pre-existing CVD.

Certain cardiac conditions and medications can cause alterations in thyroid function that may predispose an individual to higher morbidity and mortality. In certain situations, thyroid dysfunction treatment may have cardiovascular benefits. This study deals with the interplay between cardiovascular and thyroid dysfunctions associated with clinical implications and management strategies.

Minor perturbations of thyroid homeostasis and major cardiovascular endpoints—Physiological mechanisms and clinical evidence

It is well established that thyroid dysfunction is linked to an increased risk of cardiovascular morbidity and mortality. The pleiotropic action of thyroid hormones strongly impacts the cardiovascular system and affects both the generation of the normal heart rhythm and arrhythmia. A meta-analysis of published evidence suggests a positive association of FT4 concentration with major adverse cardiovascular end points (MACE), but this association only partially extends to TSH. The risk for cardiovascular death is increased in both subclinical hypothyroidism and subclinical thyrotoxicosis. Several published studies found associations of TSH and FT4 concentrations, respectively, with major cardiovascular endpoints. Both reduced and elevated TSH concentrations predict the cardiovascular risk, and this association extends to TSH gradients within the reference range. Likewise, increased FT4 concentrations, but high-normal FT4 within its reference range as well, herald a poor outcome. These observations translate to a monotonic and sensitive effect of FT4 and a U-shaped relationship between TSH and cardiovascular risk. Up to now, the pathophysiological mechanism of this complex pattern of association is poorly understood. Integrating the available evidence suggests a dual etiology of elevated FT4 concentration, comprising both ensuing primary hypothyroidism and a raised set point of thyroid function, e. g. in the context of psychiatric disease, chronic stress and type 2 allostatic load. Addressing the association between thyroid homeostasis and cardiovascular diseases from a systems perspective could pave the way to new directions of research and a more personalized approach to the treatment of patients with cardiovascular risk.

Subclinical hypothyroidism in women's health: from pre- to post-menopause

OBJECTIVE

Subclinical hypothyroidism (SCH) is a quite frequent condition among women, affecting 3-12% of the general population. Its consequences on women's health in reproductive age, pregnancy and menopause have been extensively investigated but data about the effective impact of treatment with levothyroxine (LT4) remain conflicting.

METHODS

This is a narrative review and analysis of the most relevant data until June 2021.

RESULTS

SCH may affect reproduction. Evidence suggests that women with SCH undergoing assisted reproductive technique (ART) may benefit from LT4 therapy whereas there are no conclusive data regarding women attempting natural conception. SCH may be associated with several negative pregnancy outcomes, that is to say recurrent pregnancy loss (RPL), preterm delivery, preeclampsia and neurocognitive disturbances of offspring. However, the protective role of LT4 treatment has been established in selected cases, for instance in thyroid peroxidase antibody (TPOAb) -positive women with TSH greater than the pregnancy specific reference range and/or in TPOAb-negative women with TSH >10.0 mIU/L. In menopause, SCH can worsen the negative cardio-metabolic effects of hormonal loss and/or aging, by exacerbating dyslipidaemia and hypertension. Nevertheless, robust data about the benefits of LT4 therapy are still lacking and treatment should be encouraged with caution.

CONCLUSIONS

SCH represents a challenging condition during pre- and post- menopause. An aware knowledge of its possible principal consequences could help all clinicians who are involved in women's health to manage more properly it, preventing its sequelae.

Impact of persistent subclinical hypothyroidism on clinical outcomes in non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Data on the association of subclinical hypothyroidism (SCH) with the severity of coronary artery disease and major adverse cardiovascular and cerebral events (MACCE) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI) are limited and conflicting.

OBJECTIVE

We established the baseline rate of SCH and followed the trajectory of thyroid-stimulating hormone (TSH) values during and after hospitalisation for PCI for up to six months and determined whether persistent SCH was associated with the severity of coronary artery disease and MACCE in patients with NSTE-ACS after PCI.

DESIGN

Population-based prospective cohort study.

PATIENTS

We included patients with NSTE-ACS who underwent PCI with simple balloon angioplasty or stent implantation for coronary heart disease.

MEASUREMENTS

Thyroid function tests of patients before PCI and 1 day, 1 week, 1 and 6 months after PCI were performed. Cases showing transient SCH were excluded. Patients were divided into two groups based on the results of four TSH tests: 0.27-4.2 mIU/L (n = 1472, 89.7%) and >4.2 mIU/L (n = 170, 10.4%). The risk factors for the severity of coronary artery lesions were estimated using multinomial logistic regression analysis. Univariate and multivariate Cox regression analyses were used to study the relationship between TSH and MACCE.

RESULTS

Among 1642 patients, there were 1070 males (65.2%) and 572 females (34.8%), with an average age of 62.5 ± 9.6 years. SCH patients had a wider range of diseased vessels and a higher number of diseased vessels (p < .05). TSH level was an independent risk factor for moderate [odds ratio (OR) = 1.144, 95% confidence interval (95% CI): 1.057-1.237, p = .001] and severe (OR = 1.131, 95% CI: 1.043-1.226, p = .003) coronary artery lesions. After adjusting for covariates, the risk of MACCE [hazard ratio (HR): 4.067, p < .001], nonfatal myocardial infarction (HR: 14.724, p = .003), and unplanned PCI (HR: 5.028, p < .001) were higher in the SCH group than in the euthyroidism group. There were no significant differences in the incidence of heart failure (HR: 6.012, p = .175), nonfatal stroke (HR: 2.039, p = .302), unplanned coronary artery bypass grafting (CABG) (HR: 1.541, p = .57), or cardiac death (HR: 2.704, p = .375) between the two groups.

CONCLUSIONS

Preoperative TSH levels and changes in thyroid hormone levels several months post-PCI in NSTE-ACS patients are highly significant in practice. Persistent SCH is associated with severe coronary artery lesions and MACCE, and may be a predictor for evaluating the prognosis of PCI-treated NSTE-ACS patients.

Association of Mild Thyroid Dysfunction and Adverse Prognosis Among Chinese Patients With Acute ST Segment Elevation Myocardial Infarction

AIMS

Thyroid hormones widely affect the cardiovascular system, but the effects of mild thyroid dysfunction on the clinical prognosis of patients with acute ST segment elevation myocardial infarction (STEMI) remains unclear. Our aims were to analyze the relations between mild thyroid dysfunction at admission and clinical outcomes in Chinese patients with STEMI.

METHODS

A total of 1,176 STEMI patients with the available data of thyroid function and follow-up were analyzed, including 348 patients with mild thyroid dysfunction [subclinical hypothyroidism (n=81), hyperthyroidism (SHyper) (n=51), and low triiodothyronine syndrome (LT3S) (n=216)] and 828 patients with euthyroid function. During a median 4.4-year follow-up, in-hospital mortality, cardiac and all-cause mortalities were subsequently compared among the four groups.

RESULTS

Compared with the euthyroid group, STEMI patients in the SHyper and LT3S groups faced obviously increased risks of in-hospital death [odds ratio (OR): 5.007, 95% confidence interval (CI): 1.246-20.124, p = 0.023 and OR: 2.491, 95% CI: 1.054-5.887, p = 0.037, respectively) even after adjustment for various confounding factors. During a median 4.4-year follow-up, STEMI patients with LT3S at baseline had higher cardiovascular mortality [hazard ratio (HR): 1.880, 95% CI: 1.178-2.998, p = 0.008] and all-cause mortality HR: 1.647, 95% CI: 1.072-2.531, p = 0.023] than those with euthyroid at baseline, whereas no significantly increased mortality was found for STEMI patients with SCH and SHyper at baseline.

CONCLUSIONS

STEMI patients with SHyper at admission had increased risk of in-hospital mortality, and STEMI patients with LT3S at baseline had worse prognosis and higher incidences of in-hospital mortality and cardiovascular and all-cause deaths compared with euthyroid patients.

Specific impact of cardiovascular risk factors on coronary microcirculation in patients with subclinical hypothyroidism

Background

Although thyroid hormones have significant effect on cardiovascular system, the impact of subtle thyroid dysfunction such as subclinical hypothyroidism (SCH) remains to be determined. We investigated coronary flow reserve (CFR) in patients with subclinical hypothyroidism.

Methods

Thirty two subjects with SCH and eighteen control subjects with normal serum thyroid hormones and thyroid-stimulating hormone (TSH) levels were included in the study. TSH, free thyroxine, free triiodothyronine, glucose, insulin, HbA1c, cholesterol, triglyceride and plasma levels of C-reactive protein were measured. Coronary diastolic peak flow velocities in left anterior descending coronary artery were measured at baseline and after adenosine infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocity.

Results

CFR values were not significantly different between the two groups (SCH 2.76±0.35 vs controls 2.76±0.42). There was a significant correlation of CFR with waist to hip ratio, hypertension, smoking habits, markers of glucose status (glucose level, HbA1c, insulin level, HOMA IR), cholesterol, LDL-cholesterol and triglyceride levels in SCH group, whereas only cholesterol level showed significant correlation with CFR in controls. There was no correlation between CFR and thyroid hormones.

Conclusions

We concluded that there is a different impact of cardiovascular risk factors on CFR in SCH patients compared to healthy control and that these two groups behave differently in the same circumstances under the same risk factors. The basis for this difference could be that the altered thyroid axis "set point" changes the sensitivity of the microvasculature in patients with SCH to known risk factors.

Thyroid and heart, a clinically relevant relationship

BACKGROUND

Thyroid disorders, both overt and subclinical, are highly prevalent conditions in the general population. Although a clear relationship between overt thyroid dysfunctions and cardiovascular complications has long been established, data regarding subclinical thyroid dysfunction are by far more controversial.

PURPOSE

The present review will be aimed at providing a summary of most recent evidence coming from meta-analyses regarding the complex relationship between thyroid dysfunction and cardiovascular disease.

CONCLUSIONS

The review will summarize, in the first part, the physiopathological link between thyroid hormone imbalances and the cardiovascular system. In the second part the review will outline the evidence coming from meta-analyses regarding the cardiovascular risk related with both overt and subclinical thyroid dysfunctions. Particular attention will be put towards studies showing data stratified for patient's age, TSH levels and pre-existing cardiovascular disease. Finally, an overview regarding the effects of specific therapy for subclinical thyroid diseases in terms of amelioration of cardiovascular outcomes will be included.

Cardiovascular Outcomes in Thyroid Cancer Patients Treated With Thyroidectomy: A Meta-analysis

CONTEXT

Thyroid dysfunction is associated with an increased risk of cardiovascular disease (CVD) in the general population; however, it remains controversial whether differentiated thyroid cancer (DTC) treatment, including thyroidectomy and thyroid-stimulating hormone suppression, further increases the risk of CVD.

OBJECTIVE

This study aimed to evaluate the risk of CVD in patients with DTC.

METHODS

We performed a review of observational studies on associations between DTC and cardiovascular outcomes, indexed in MEDLINE, Embase, and Web of Science. We excluded studies that evaluated CVD as comorbidity before DTC diagnosis and those that used active surveillance without thyroidectomy as an intervention. Risk estimates were pooled using random- and fixed-effects models when 3 or more studies reported on the outcome of interest. Echocardiographic and hemodynamic parameters were examined.

RESULTS

Eighteen studies were included in the quantitative analysis (193 320 cases with DTC and 225 575 healthy controls). DTC was associated with an increased risk of atrial fibrillation (pooled risk ratio [RR] = 1.55 [95% CI: 1.30-1.84]), coronary artery disease (RR = 1.10 [1.00-1.21]), cerebrovascular accidents (RR = 1.15 [1.09-1.20]), and all-cause mortality (RR = 1.95 [1.03-3.69]). DTC was associated with higher diastolic blood pressure (standardized mean difference [SMD], 0.22 [0.01-0.42]), heart rate (0.37 [0.17-0.57]), left ventricular mass index (0.66 [0.45-0.88]), and interventricular septal thickness (0.91 [0.33-1.49]) and lower early to late ventricular filling velocities (-0.42 [-0.79 to -0.05]), but not with ejection fraction.

CONCLUSION

Patients with DTC are at an increased risk of atrial fibrillation, CVD, increased heart rate, and left ventricular mass development.

The impact of subclinical hypothyroidism on long-term outcomes in older patients undergoing percutaneous coronary intervention

BACKGROUND

Subclinical hypothyroidism (SCH) is reportedly associated with an increased risk of adverse events in patients undergoing percutaneous coronary intervention (PCI). The prognostic significance of SCH in the elderly was poorly defined. The purpose of this study was to evaluate the association between SCH and long-term outcomes in older patients undergoing PCI.

METHODS

Three thousand one hundred sixty-eight patients aged 65 years or older who underwent PCI from January 2012 to October 2014 were included. Patients were divided into SCH group (n = 320) and euthyroidism (ET) group (n = 2848) based on thyroid function test. Cox proportional hazard regression analyses were used to estimate the relative risks (RRs) of all-cause death and cardiac death for patients with SCH during a 4-year follow-up period.

RESULTS

There were 227 deaths during the follow-up period including 124 deaths caused by cardiac events. There was no significant difference in mortality rate between the SCH group and the ET group (p > 0.05). After adjustment for covariates, compared with patients with ET, the RRs of death from all-cause and cardiac in patients with SCH were 1.261 (95%CI: 0.802-1.982, p = 0.315) and 1.231 (95%CI: 0.650-2.334, p = 0.524), respectively. When SCH was stratified by age, gender, and degree of thyroid-stimulating hormone elevation, no significant associations were also found in any stratum.

CONCLUSION

Our investigation revealed that SCH was negatively associated with the outcome of PCI in older patients.

EVALUATION OF HORMONAL AND METABOLIC PARAMETERS, ALONG WITH CARDIOVASCULAR RISK FACTORS IN WOMEN WITH NON-ALCOHOLIC FATTY LIVER DISEASE COMBINED WITH SUBCLINICAL HYPOTHYROIDISM DEPENDING ON AGE

Patients with NAFLD (non-alcoholic fatty liver disease) and subclinical hypothyroidism are at risk of cardiovascular complications that cause cardiometabolic changes, thus enabling to broaden our understanding of the cardiovascular events risk in a comorbid patient. The aim: The study of hormonal and metabolic indicators and cardiovascular risk factors in women from NAFLD combined with SH (subclinical hypothyroidism) depending on the age. Materials and methods: 128 patients with NAFLD were studied, which were divided into 2 groups: І group – patients with NAFLD and level of thyroid-stimulating hormone (TSH) – 4 to 10 mIU/mL (n=45), ІІ group - patients with NAFLD and level of TSH >10 mIU/mL (n=49). The control group consisted of 34 NAFLD patients without SH. Depending on the level of TSH and age, degree of cardiovascular risk, indicators of carbohydrate and lipid metabolism, as well as the indicators that reflect ED were evaluated. Results: Comparison of metabolic parameters in two groups showed a significant difference (p<0.01 between indicators depending on the TSH level, where patients were below 50 years of age: HbA1c, LDL cholesterol, HDL cholesterol, gamma-glutamyltranspeptidase (GGTP). The levels of CDEC (circulating desquamated endothelial cells), VEGF (vascular endothelial growth factor), CRP (C-reactive protein) and TNF-α (tumor necrosis factor-α) were dependent not only on TSH, but also on age. Significant differences (p=0.001) were obtained in patients aged ≤ 50 years: CDEC; VEGF, CRP; TNF-α. Conclusions: Patients from NAFLD combined with SH have hormonal-metabolic disorders, and their degree depends on the TSH level. Early cardiometabolic changes in women are formed already at the age under 50 years, which indicates the formation of early atherosclerotic vascular changes

The Association of Overt and Subclinical Hyperthyroidism with the Risk of Cardiovascular Events and Cardiovascular Mortality: Meta-Analysis and Systematic Review of Cohort Studies

BACKGROUND

Whether hyperthyroidism is an independent risk factor for cardiovascular events remains controversial. We aimed to evaluate the association of overt and subclinical hyperthyroidism with the risk of ischemic heart disease (IHD), stroke, heart failure, and cardiovascular mortality.

METHODS

Studies regarding the association between hyperthyroidism and cardiovascular events were searched on PubMed and Embase databases. The cardiovascular disease (CVD) risk was classified as high and low, based on pre-existing diseases, including history of coronary, cerebral, or peripheral artery disease; heart failure; atrial fibrillation; diabetes mellitus; or chronic kidney disease.

RESULTS

Thirty-seven cohort studies were included in this meta-analysis. The pooled hazard ratio for subjects with overt hyperthyroidism compared with the control group was 1.11 (95% confidence interval [CI], 1.03 to 1.19) for IHD, 1.35 (95% CI, 1.03 to 1.75) for stroke, and 1.20 (95% CI, 1.00 to 1.46) for cardiovascular mortality. For subjects with subclinical hyperthyroidism, the pooled hazard ratio was 1.24 (95% CI, 1.07 to 1.45) for IHD, when compared with the control group. Subgroup analysis by CVD risk showed that the risk of stroke in overt hyperthyroidism was increased in the low CVD risk group; however, these association was not observed in the high CVD risk group. Similarly, the risk of IHD in subjects with subclinical hyperthyroidism was significantly increased in the low CVD risk group.

CONCLUSION

Overt hyperthyroidism is associated with increased risk of IHD, stroke, and cardiovascular mortality, and subclinical hyperthyroidism is associated with increased risk of IHD. These associations were particularly observed in the low risk CVD group without underlying CVD.

Unknown Subclinical Hypothyroidism and In-Hospital Outcomes and Short- and Long-Term All-Cause Mortality among ST Segment Elevation Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

Subclinical hypothyroidism (SCH) is defined as an elevated serum thyroid-stimulating hormone (TSH) level with a normal serum-free thyroxine (FT4) level. SCH has been associated with an increased risk of adverse cardiovascular outcomes. We investigated possible associations of unknown SCH with in-hospital outcomes and short- and long-term all-cause mortality in a large cohort of patients with ST segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). This retrospective, single-center observational study evaluated the TSH and FT4 levels of 1593 STEMI patients with no known history of hypothyroidism or thyroid replacement treatment who were admitted to the coronary care unit and underwent PCI between 1/2008 and 8/2017. SCH was defined as TSH levels ≥ 5 mU/mL in the presence of normal FT4 levels. Unknown SCH was detected in 68/1593 (4.2%) STEMI patients. These patients had significantly worse in-hospital outcomes compared to patients without SCH, including higher rates of acute kidney injury (p = 0.003) and left ventricular ejection fraction ≤ 40% (p = 0.03). Moreover, 30-day mortality (p = 0.02) and long-term (mean 4.2 ± 2.3 years) mortality (p = 0.007) were also significantly higher in patients with SCH. The thyroid function of STEMI patients should be routinely tested before they undergo a planned PCI procedure.

Subclinical Thyroid Dysfunction and the Risk of Cardiovascular Disease

The prevalence of subclinical hypothyroidism (SH) is 3-10%. The prevalence of subclinical hyperthyroidism (SHr) is 0.7-9.7%. Thyroid hormones affect cardiac electrophysiology, contractility, and vasculature. SH is associated with an increased risk of coronary heart disease (CHD), especially in subjects under 65. SHr seems to be associated with a slightly increased risk of CHD and an increase in CHD-related mortality. Both SH and SHr carry an increased risk of developing heart failure (HF), especially in those under 65. Both SH and SHr are associated with worse prognoses in patients with existing HF. SH is probably not associated with atrial fibrillation (AF). SHr, low normal thyroid-stimulating hormone (TSH) and high normal free thyroxine (FT4) are all associated with the increased risk of AF. An association between endothelial dysfunction and SH seems to exist. Data regarding the influence of SHr on the peripheral vascular system are conflicting. SH is a risk factor for stroke in subjects under 65. SHr does not increase the risk of stroke. Both SH and SHr have an unfavourable effect on cardiovascular disease (CVD) and all-cause mortality. There is a U-shaped curve of mortality in relation to TSH concentrations. A major factor that modifies the relation between subclinical thyroid disease (SCTD) and mortality is age. SH increases blood pressure (BP). SHr has no significant effect on BP. Lipids are increased in patients with SH. In SHr, high-density lipoprotein cholesterol and lipoprotein( a) are increased. SCTD should be treated when TSH is over 10 mU/l or under 0.1 mU/l. Treatment indications are less clear when TSH is between normal limits and 0.1 or 10 mU/L. The current state of knowledge supports the understanding of SCTD's role as a risk factor for CVD development. Age is a significant confounding factor, probably due to age-associated changes in the TSH reference levels.

Outcomes of Cardiac Resynchronization Therapy in Patients with Hypothyroidism and Heart Failure

Background

Hypothyroidism is known to be associated with adverse clinical outcomes in heart failure. The association between hypothyroidism and cardiac resynchronization therapy outcomes in patients with severe heart failure is not clear.

Methods

The study included 1316 patients who received cardiac resynchronization therapy between 2002 and 2015. Baseline demographics and cardiac resynchronization therapy outcomes, including left ventricular ejection fraction, New York Heart Association class, appropriate implantable cardioverter-defibrillator therapy, and all-cause mortality, were collected from the electronic health record.

Results

Of the study cohort, 350 patients (26.6%) were classified as the hypothyroidism group. The median duration of follow-up was 3.6 years (interquartile range, 1.7–6.2 years). Hypothyroidism was not associated with a higher risk of all-cause mortality in patients receiving CRT for heart failure. The risk of appropriate implantable cardioverter-defibrillator therapy significantly increased in association with increased baseline thyroid-stimulating hormone level in the entire cohort (hazard ratio, 1.23 per 5mIU/L increase; 95% CI, 1.01–1.5; P = 0.04) as well as in the hypothyroid group (hazard ratio, 1.44 per 5mIU/L increase; 95% CI, 1.13–1.84; P = 0.004).

Conclusions

CRT improves cardiac function in hypothyroid patients. The ventricular arrhythmic events requiring ICD therapies are associated with baseline TSH level, which might be considered as an important biomarker to stratify the risk of sudden death for patients with heart failure and hypothyroidism.

Individualized Therapy for Hypothyroidism: Is T4 Enough for Everyone?

CONTEXT

It is well recognized that some hypothyroid patients on levothyroxine (LT4) remain symptomatic, but why patients are susceptible to this condition, why symptoms persist, and what is the role of combination therapy with LT4 and liothyronine (LT3), are questions that remain unclear. Here we explore evidence of abnormal thyroid hormone (TH) metabolism in LT4-treated patients, and offer a rationale for why some patients perceive LT4 therapy as a failure.

EVIDENCE ACQUISITION

This review is based on a collection of primary and review literature gathered from a PubMed search of "hypothyroidism," "levothyroxine," "liothyronine," and "desiccated thyroid extract," among other keywords. PubMed searches were supplemented by Google Scholar and the authors' prior knowledge of the subject.

EVIDENCE SYNTHESIS

In most LT4-treated patients, normalization of serum thyrotropin levels results in decreased serum T3/T4 ratio, with relatively lower serum T3 levels; in at least 15% of the cases, serum T3 levels are below normal. These changes can lead to a reduction in TH action, which would explain the slower rate of metabolism and elevated serum cholesterol levels. A small percentage of patients might also experience persistent symptoms of hypothyroidism, with impaired cognition and tiredness. We propose that such patients carry a key clinical factor, for example, specific genetic and/or immunologic makeup, that is well compensated while the thyroid function is normal but might become apparent when compounded with relatively lower serum T3 levels.

CONCLUSIONS

After excluding other explanations, physicians should openly discuss and consider therapy with LT4 and LT3 with those hypothyroid patients who have persistent symptoms or metabolic abnormalities despite normalization of serum thyrotropin level. New clinical trials focused on symptomatic patients, genetic makeup, and comorbidities, with the statistical power to identify differences between monotherapy and combination therapy, are needed.

Congestive Heart Failure and Thyroid Dysfunction: The Role of the Low T3 Syndrome and Therapeutic Aspects

Background:

Both the morbidity and mortality rates from congestive heart failure (CHF) remain elevated despite the medical and non-medical management of the disease, thus suggesting the existence of residual risk factors such as thyroid dysfunction. Particularly, the 15-30% of patients with CHF, especially those with severe ventricular dysfunction, display the so-called low T3 syndrome (LT3S), which seems to negatively affect the cardiovascular prognosis.

Objective:

Only a few clinical trials have been carried out to verify both the safety and the efficacy of thyroid replacement in the LT3S, aiming to ameliorate the prognosis of CHF, and most of the results were controversial.

Methods:

Since the aim of the present review was to briefly overview both the indication and contraindication of triiodothyronine replacement in CHF and LT3S, the authors searched PubMed using the medical subject headings (MeSH) related to the following terms: “congestive heart failure” and “low T3 syndrome” or “euthyroid sick syndrome” or “non-thyroidal sick syndrome”. The research study only focused on the narrative and systematic reviews, randomized clinical trials and meta-analysis studies which were conducted before June 2019.

Results:

Studies conducted in both animal models and humans provided controversial information about the effectiveness and safety of the T3 replacement for improving ventricular dysfunction, particularly in the long-term.

Conclusion:

Further clinical trials are needed to better explore the role of LT3S in patients with CHF and its consequent therapeutic strategy in this clinical setting.

Prevalence and clinical correlates of subclinical hypothyroidism in first-episode drug-naive patients with major depressive disorder in a large sample of Chinese

BACKGROUND

The coexistence of subclinical hypothyroidism (SCH) and depression has been intensively examined in the patients receiving thyroxine or antidepressant treatment. This study aimed to investigate the prevalence and clinical correlates of severe SCH in Chinese first-episode drug naïve patients with major depressive disorder (MDD).

METHODS

Using a cross-sectional design, we recruited a total of 1706 MDD patients. Depressive symptoms were evaluated using the 17-item Hamilton Depression Rating Scale (HAMD). Severity of anxiety and psychiatric symptoms were evaluated by the Hamilton Anxiety Rating Scale (HAMA) and the Positive and Negative Syndrome Scale (PANSS), respectively. Serum thyroid function parameters were measured by a chemiluminescence immunoassay. Based on the serum thyroid stimulating hormone (TSH) level, SCH was further divided into mild (TSH < 10 mIU/L) and severe SCH (TSH ≥ 10 mIU/L).

RESULTS

More patients with severe SCH had severe anxiety, psychotic symptoms, suicide attempts (all p < 0.001), compared with those without severe SCH. Logistic regression showed that suicide attempts and psychiatric symptoms were associated with severe SCH (both p < 0.001). Multiple linear regression showed that age (p < 0.05), BMI (p < 0.001), HAMD score (p < 0.001), HAMA score (p < 0.001), PANSS positive subscore (p = 0.001) and CGI score (p = 0.001) were associated with TSH levels.

CONCLUSION

Our findings suggest that suicide attempts and psychiatric symptoms may be associated with severe SCH. Moreover, severe anxiety, depressive and psychotic symptoms, as well as older age and higher BMI are possibly related to elevated TSH levels.

Thyroid hormone therapy for subclinical hypothyroidism

Subclinical Hypothyroidism (SCH) is defined as a raised level of serum TSH level in the presence of normal circulating free thyroid hormones. SCH is a highly prevalent condition displaying some peculiarities, both in terms of the diagnostic and therapeutic approach, when specific population and/or concomitant diseases are taken into account. The debate upon whether LT4 therapy should be initiated or not in patients with SCH is a long lasting one and still it remains controversial. Current evidence supports the concept that the clinical consequences of SCH may be profoundly different in relation to several patient-specific characteristics. Aim of the present review is to provide updated indications for SCH treatment in specific clinical settings. These will include the management of SCH in obese and diabetic patients, in pregnant women, and in specific age groups. Treatment modalities, including LT4 doses and recommended follow-up strategy will also be discussed. In the era of "precision medicine" the decision to-treat-not-to-treat SCH should be individualized taking into account risks and beneficial outcomes of LT4 therapy. With this in mind, we reviewed the most relevant studies in the recent literature in order to provide evidence for or against LT4 replacement therapy for SCH in specific clinical settings.

The impact of thyroid hormone dysfunction on ischemic heart disease

Thyroid hormones have a central role in cardiovascular homeostasis. In myocardium, these hormones stimulate both diastolic myocardial relaxation and systolic myocardial contraction, have a pro-angiogenic effect and an important role in extracellular matrix maintenance. Thyroid hormones modulate cardiac mitochondrial function. Dysfunction of thyroid axis impairs myocardial bioenergetic status. Both overt and subclinical hypothyroidism are associated with a higher incidence of coronary events and an increased risk of heart failure progression. Endothelial function is also impaired in hypothyroid state, with decreased nitric oxide-mediated vascular relaxation. In heart disease, particularly in ischemic heart disease, abnormalities in thyroid hormone levels are common and are an important factor to be considered. In fact, low thyroid hormone levels should be interpreted as a cardiovascular risk factor. Regarding ischemic heart disease, during the late post-myocardial infarction period, thyroid hormones modulate left ventricular structure, function and geometry. Dysfunction of thyroid axis might even be more prevalent in the referred condition since there is an upregulation of type 3 deiodinase in myocardium, producing a state of local cardiac hypothyroidism. In this focused review, we summarize the central pathophysiological and clinical links between altered thyroid function and ischemic heart disease. Finally, we highlight the potential benefits of thyroid hormone supplementation as a therapeutic target in ischemic heart disease.

Hypothyroidism and related diseases: a methodological quality assessment of meta-analysis

OBJECTIVES

There is an increasing prevalence of hypothyroidism and there is a growing body of meta-analyses (MAs) on the association between hypothyroidism and other diseases. However, the methodological quality of the MAs significantly varies. Thus, this study aimed to evaluate and summarise data on the methodological quality of MAs on the associations between hypothyroidism and other diseases using the Assessment of Multiple Systematic Reviews (AMSTAR) scale, providing suggestions for clinical decision-making processes.

DESIGN

To assess the methodological quality of MAs using the AMSTAR scale.

DATA SOURCES

A systematic literature search was performed in PubMed, EMBASE, the Cochrane Library, web of science and Chinese Biomedicine Literature Database.

ELIGIBILITY CRITERIA

We included MAs that had assessed the association between hypothyroidism and other diseases in humans and that had full texts regardless of the publication status. No restriction applied on language or date.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the titles and abstracts of all searched literature to acquire potentially eligible publications. The full texts of possible eligible publications were downloaded and assessed. Inconsistent comments were resolved through discussions with a third reviewer.

RESULTS

52 studies were included. The average AMSTAR score of the included articles was 8.6 (range: 5-10), and those of English and Chinese MAs were 8.8 and 7.0, respectively. A total of 52 MAs were evaluated, and 19 (36.5%) and 33 (63.5%) of these MAs were of moderate and high quality, respectively. None of the MAs were of low quality. Only two MAs had an a priori design. Items 3, 5 and 9 had the highest compliance (50/52, 96.2%), and aside from item 1, items 7 and 8 had the lowest compliance (33/52,63.5%). According to the results of these MAs, hypothyroidism was significantly associated with cardiovascular diseases, metabolic diseases, neuropsychiatric disorders, breast cancer and pregnancy outcome.

CONCLUSIONS

The methodological quality of the included MAs on the association between hypothyroidism and other diseases was moderate to high. MAs with high qualities confirmed that hypothyroidism was significantly associated with cardiovascular diseases, metabolic syndrome, preterm birth and neonatal outcomes. Consideration of scientific quality when formulating conclusions should be made explicit and more attention should be paid to improving the methodological quality of MAs, and increasing their applicability for clinical decision-making.

Thyroid Function and Dysfunction in Relation to 16 Cardiovascular Diseases

BACKGROUND

Subclinical thyroid dysfunction, defined as thyroid-stimulating hormone levels outside the reference range with normal free thyroxine levels in asymptomatic patients, is associated with alterations in cardiac hemodynamics. We used Mendelian randomization to assess the role of thyroid dysfunction for cardiovascular disease (CVD).

METHODS

Single-nucleotide polymorphisms associated with thyroid function were identified from a genome-wide association meta-analysis in up to 72 167 individuals. Data for genetic associations with CVD were obtained from meta-analyses of genome-wide association studies of atrial fibrillation (n=537 409 individuals), coronary artery disease (n=184 305 individuals), and ischemic stroke (n=438 847) as well as from the UK Biobank (n=367 703 individuals).

RESULTS

Genetically predicted thyroid-stimulating hormone levels and hyperthyroidism were statistically significantly associated with atrial fibrillation but no other CVDs at the Bonferroni-corrected level of significance ( P<7.8×10-4). The odds ratios of atrial fibrillation were 1.15 (95% CI, 1.11-1.19; P=2.4×10-14) per genetically predicted 1 SD decrease in thyroid-stimulating hormone levels and 1.05 (95% CI, 1.03-1.08; P=5.4×10-5) for genetic predisposition to hyperthyroidism. Genetically predicted free thyroxin levels were not statistically significantly associated with any CVD.

CONCLUSIONS

This Mendelian randomization study supports evidence for a causal association of decreased thyroid-stimulating hormone levels in the direction of a mild form of hyperthyroidism with an increased risk of atrial fibrillation but no other CVDs.

Overt and Subclinical Hypothyroidism in the Elderly: When to Treat?

Hypothyroidism is characterized by increased thyrotropin (TSH) levels and reduced free thyroid hormone fractions while, subclinical hypothyroidism (sHT) by elevated serum TSH in the face of normal thyroid hormones. The high frequency of hypothyroidism among the general population in Western Countries made levothyroxine (LT4) one of the 10 most prescribed drugs. However, circulating TSH has been demonstrated to increase with aging, regardless the existence of an actual thyroid disease. Thus, when confronting an increase in circulating TSH levels in the elderly, especially in the oldest old, it is important to carry an appropriate diagnostic path, comprehensive of clinical picture as well as laboratory and imaging techniques. In the current review, we summarize the recommendations for a correct diagnostic workup and therapeutic approach to older people with elevated TSH value, with special attention to the presence of frailty, comorbidities, and poly-therapy. The treatment of choice for hypothyroid patients is hormone replacement with LT₄ but, it is important to consider multiple factors before commencing the therapy, from the age dependent TSH increase to the presence of an actual thyroid disease and comorbidities. When treatment is necessary, a tailored therapy should be chosen, considering poly-pharmacy and frailty. A careful follow-up and treatment re-assessment should be always considered to avoid the risk of over-treatment. It is important to stress the need of educating the patient for a correct administration of LT₄, particularly when poly-therapy is in place, and the importance of a tailored therapeutic approach and follow-up, to avoid overtreatment.

Hypothyroidism in the Elderly: Who Should Be Treated and How?

Hypothyroidism is among the most frequent chronic diseases in the elderly, and levothyroxine (l-T4) is worldwide within the 10 drugs more prescribed in the general population. Hypothyroidism is defined by increased serum thyroid-stimulating hormone (TSH) values and reduced circulating free thyroid hormones, whereas subclinical hypothyroidism (sHT) is characterized by free hormone fractions within the normal ranges and has been divided into two classes, depending on circulating TSH levels (above or below 10 mIU/L). Given that during aging, a natural trend toward higher values of circulating TSH has been reported, it is necessary to verify carefully the diagnosis of sHT to tailor an appropriate follow-up and ad hoc therapy, avoiding unnecessary or excessive treatment. In the current review, we evaluate the state of the art on hypothyroidism in the elderly with special focus on the effect of sHT on cognition and the cardiovascular system function. We also summarize the recommendations for a correct diagnostic workup and therapeutic approach to older people with an elevated TSH value, with special attention to the presence of frailty, comorbidities, and poly therapy. In conclusion, personalized therapy is crucial in good clinical practice, and in the management of older patients with sHT, multiple factors must be considered, including age-dependent TSH cutoffs, thyroid autoimmunity, the burden of comorbidities, and the possible presence of frailty. l-T4 is the drug of choice for the treatment of hypothyroid older people, but the risk of overtreatment, potential adverse drug reactions, and patient compliance should always be considered and thyroid status periodically reassessed.

Diagnosis and Management of Hypothyroidism: Addressing the Knowledge-Action Gaps

Hypothyroidism presents a large epidemiological burden in India. As a result of subtle and nonspecific clinical symptoms and signs, the condition often goes undiagnosed and is not adequately treated when it is detected. There is heterogeneity in the diagnostic and treatment approaches to hypothyroidism. As a result of the physiological changes in thyroid hormones with age and illness, it is important to tailor the diagnosis and management of this condition in specific populations including pregnant women, infants, children, geriatric patients, and those with comorbid conditions. Enhanced understanding and education of physicians and patients can help to improve the outcomes of treatment in hypothyroidism which should be focused on patient-centered care. Policies and reforms should be crafted and implemented at the national level to curb public health challenges of hypothyroidism. This publication summarizes the recommendations of a national advisory board meeting to identify and bridge the gaps in understanding of the diagnosis and treatment of hypothyroidism in India. As a complement to clinical judgment, these recommendations will foster the diagnosis and management of hypothyroidism in the community and clinics for the benefit of the patients.

FUNDING

Merck Ltd, India.