Subclinical thyroid dysfunction is associated with adverse prognosis in heart failure patients with reduced ejection fraction

Nanoscale organization of cardiac calcium channels is dependent on thyroid hormone status

Thyroid hormone dysfunction is frequently observed in patients with chronic illnesses including heart failure, which increases the risk of adverse events. This study examined the effects of thyroid hormones (THs) on cardiac transverse-tubule (TT) integrity, Ca2+ sparks, and nanoscale organization of ion channels in excitation-contraction (EC) coupling, including L-type calcium channel (CaV1.2), ryanodine receptor type 2 (RyR2), and junctophilin-2 (Jph2). TH deficiency was established in adult female rats by propyl-thiouracil (PTU) ingestion for 8 wk; followed by randomization to continued PTU without or with oral triiodo-l-thyronine (T3; 10 µg/kg/day) for an additional 2 wk (PTU + T3). Confocal microscopy of isolated cardiomyocytes (CMs) showed significant misalignment of TTs and increased Ca2+ sparks in thyroid-deficient CMs. Density-based spatial clustering of applications with noise (DBSCAN) analysis of stochastic optical reconstruction microscopy (STORM) images showed decreased (P < 0.0001) RyR2 cluster number per cell area in PTU CMs compared with euthyroid (EU) control myocytes, and this was normalized by T3 treatment. CaV1.2 channels and Jph2 localized within a 210 nm radius of the RyR2 clusters were significantly reduced in PTU myocytes, and these values were increased with T3 treatment. A significant percentage of the RyR2 clusters in the PTU myocytes had neither CaV1.2 nor Jph2, suggesting fewer functional clusters in EC coupling. Nearest neighbor distances between RyR2 clusters were greater (P < 0.001) in PTU cells compared with EU- and T3-treated CMs that correspond to disarray of TTs at the sarcomere z-discs. These results support a regulatory role of T3 in the nanoscale organization of RyR2 clusters and colocalization of CaV1.2 and Jph2 in optimizing EC coupling.NEW & NOTEWORTHY Thyroid hormone (TH) dysfunction exacerbates preexisting heart conditions leading to an increased risk of premature morbidity/mortality. Triiodo-l-thyronine (T3) optimizes cardiac excitation-contraction (EC) coupling by maintaining myocardial T-tubule (TT) structures and organization of calcium ion channels. Single-molecule localization microscopy shows T3 effects on the clustering of ryanodine receptors (RyR2) with colocalization of L-type calcium channels (CaV1.2) and junctophilin-2 (Jph2) at TT-SR structures. Heart disease with subclinical hypothyroidism/low T3 syndrome may benefit from TH treatment.

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.

[Type 2 amiodarone-induced thyrotoxicosis: prevalence, time and predictors of development]

BACKGROUND

Amiodarone takes a leading position in arrhythmological practice in the prevention and relief of various cardiac arrhythmias. Type 2 amiodarone-induced thyrotoxicosis is a frequent side effect of the drug. It is the most complex type of thyroid dysfunction both in terms of the severity of clinical manifestations, and in terms of understanding the mechanisms of pathogenesis, possibility of differential diagnosis and providing effective treatment. Due to the increasing life expectancy of the population, corresponding increase in the frequency of cardiac arrhythmias, the problem does not lose its relevance. Identification of predictors, assessment and prediction of the individual risk of developing this thyroid pathology is a necessity in daily clinical practice for making a reasonable decision when prescribing the drug, determining the algorithm for further dynamic monitoring of the patient.

AIM

To evaluate the structure of amiodarone-induced thyroid dysfunction, prevalence, time and predictors of development type 2 amiodarone-induced thyrotoxicosis in a prospective cohort study. MATERIALS AND METHODS: The study involved 124 patients without thyroid dysfunction who received amiodarone therapy for the first time. Evaluation of the functional state of the thyroid gland was performed initially, after prescribing the drug for the first 3 months 1 time per month, in the future - every 3 months. The follow-up period averaged 12-24 months. The end of the observation occurred with the development of amiodaron-induced thyroid dysfunction or patient's refusal to further participate in the study. For the differential diagnosis of the type of amiodarone-induced thyrotoxicosis, the level of anti-TSH receptor antibodies and thyroid scintigraphy with technetium pertechnetate were determined. The type and frequency of thyroid dysfunction, time and predictors of development type 2 amiodarone-induced thyrotoxicosis were evaluated.

RESULTS

The structure of amiodarone-induced thyroid dysfunction was represented by hypothyroidism in 19,3% (n=24), type 1 thyrotoxicosis in 1,6% (n=2), type 2 thyrotoxicosis in 23,4% (n=29). The median time of its development was 92,0 [69,0;116,0] weeks; the average period of common survival - 150,2±12,6 weeks (95% CI: 125,5-175,0), median - 144±21,7 weeks (95% CI: 101,4-186,6). The main predictors of type 2 amiodarone-induced thyrotoxicosis were: age (OR=0,931; 95% CI: 0,895-0,968; p<0.001), BMI (OR=0,859; 95% CI: 0,762-0,967; p=0,012), time from the start of amiodarone therapy (OR=1,023; 95% CI: 1,008-1,038; p=0,003). Age ≤60 years was associated with increased risk of the dysfunction by 2.4 times (OR=2,352; 95% CI: 1,053-5,253; p=0,037), BMI≤26,6 kg/m2 - 2,3 times (OR=2,301; 95% CI: 1,025-5,165; p=0,043). CONCLUSION: The results allow to personalized estimate the risk of type 2 amiodarone-induced thyrotoxicosis and determine the patient's management tactic.

Analysis of Subclinical Thyroid Dysfunction and Metabolic Abnormality in 28568 Healthy People

We analyzed the detection rates of metabolic syndrome (MetS) and subclinical thyroid dysfunction, including subclinical hyperthyroidism (SCHyper) and subclinical hypothyroidism (SCH), in healthy people, as well as their relationship. Clinical data were collected from 28,568 healthy individuals who underwent physical examinations. The detection rates of SCHyper, SCH, and MetS, as well as in different genders and ages, were analyzed. The detection rate of SCHyper and SCH in females was significantly higher than that in males (P < 0.001), but that of MetS in males was significantly higher than that in females (P < 0.001). In each age group, the detection rate of SCH in females was higher than that in males (P < 0.001). The detection rate of SCH was significantly different in different age groups (P < 0.001). The detection rates of hyperlipidemia (P < 0.001), obesity (P = 0.004), hypertension (P = 0.009), and hyperglycemia (P < 0.001) in the female SCH group were significantly higher than those in the normal group. The detection rates of hyperlipidemia (P = 0.006), obesity (P = 0.04), and hypertension (P = 0.04) in the male SCH group were higher than those in the normal group. The males with SCHyper were more prone to hyperlipidemia (P = 0.02) and obesity (P = 0.03). In addition, the female SCHyper group was not significantly different from the normal group (P > 0.05). Conclusively, the detection rate of SCHyper and SCH in females is higher than that in males, which increases with age. Attention should be paid to subclinical thyroid dysfunction in elderly people, especially females. Early individualized screening and early intervention should be carried out for people with abnormal metabolism.

Cardiovascular outcomes in subclinical thyroid disease: an update

PURPOSE OF REVIEW

Subclinical thyroid disease is defined by a thyroid stimulating hormone (TSH) level outside of the normal range with normal circulating thyroid hormone levels. Excess adverse cardiovascular outcomes have been observed in certain patient populations with subclinical hypothyroidism (SCH) and hyperthyroidism (SCHr). The role of thyroid hormone and antithyroid treatments for subclinical thyroid disease remains debated.

RECENT FINDINGS

Cardiovascular disease appears to be a major mediator of all-cause mortality in patients with SCH, in particular those aged at least 60 years of age. In contrast, pooled clinical trial results did not find that levothyroxine reduced the incidence of cardiovascular events or mortality in this patient population. The association between SCHr and atrial fibrillation is well established; however, a 5-year follow-up of older patients with mild (TSH 0.1-0.4 mIU/l) SCHr found no increased incidence of atrial fibrillation. Separately, SCHr was associated with derangements in endothelial progenitor cell function that may underlie vascular disease independent from effects on cardiac function.

SUMMARY

The impact of treatment of subclinical thyroid disease on cardiovascular outcomes remains uncertain. Additional prospective and trial data are needed to evaluate treatment effects on cardiovascular outcomes in younger populations.

Right Ventricular Function Indices at Rest and During Exercise in Hyperthyroid Patients: A Cross-sectional Study

Background

Since hyperthyroidism could be associated with right ventricular dysfunction, this study intended to investigate right ventricular (RV) function using strain echocardiography in hyperthyroid patients both at rest and in maximum-stress conditions.

Methods

This cross-sectional study was conducted at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, from January 2019 to January 2020. All study participants completed a maximum treadmill exercise test, as well as a complete two-dimensional echocardiogram at rest and the peak of stress test. The data were analyzed using SPSS statistical software. The independent samples t test and Mann-Whitney U test were used for numerical, and the Chi square test was used for nominal variables. P<0.05 was considered statistically significant.

Results

The final analysis included 52 participants (26 subjects in each group). In a maximal stress situation, we found that among the RV function indices, RV global longitudinal strain (P=0.0001), systolic strain rate (P=0.0001), diastolic strain rate (P=0.0002), and tricuspid annular plane systolic excursion (P=0.019) were reduced significantly in the hyperthyroid patients compared to the control group. There was also a linear correlation between RV size and thyroid stimulating hormone (TSH) level (P=0.009, r=0.36). Moreover, we found a negative linear correlation between TSH level with maximum stress RV strain and diastolic strain rate (P<0.001).

Conclusion

The findings of the present study revealed a significant change in RV function indices among hyperthyroid patients. Therefore, it highlights the necessity of early diagnosis and treatment of hyperthyroidism, as well as RV function evaluation in these patients.

Subclinical hypothyroidism, outcomes and management guidelines: a narrative review and update of recent literature

Subclinical hypothyroidism (SCH) is diagnosed when serum thyroid stimulation hormone (thyrotropin; TSH) levels are above the reference range, accompanied by levels of free thyroxine within its reference range. The management of SCH remains a diagnostic and therapeutic challenge despite many years of research relating to its epidemiology, aetiology, effectiveness of treatment and safety. European Thyroid Association (ETA) guidelines for the management of SCH were published almost a decade ago. This narrative review summarizes the clinical literature relating to SCH and outcomes since the publication of these guidelines. Clinical evidence emerging during the previous decade generally supports the view that SCH is associated with adverse outcomes to an extent that is intermediate between euthyroidism and overt hypothyroidism although evidence that treatment with thyroid hormone replacement is beneficial is lacking. Accordingly, the rationale for the recommendations for intervention in the ETA guidelines based on the age of the patient, level of serum TSH, symptoms and comorbidities remains valid today.

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.

The impact of the management strategies for patients with subclinical hypothyroidism on long-term clinical outcomes: An umbrella review

AIM

This umbrella review summarises and compares synthesised evidence on the impact of subclinical hypothyroidism and its management on long-term clinical outcomes.

METHODS

We conducted comprehensive searches on MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, the PROSPERO register, Epistemonikos Database and PDQ Evidence from inception to February and July 2021 using keywords on subclinical hypothyroidism, treatment with levothyroxine, monitoring and primary outcomes (all-cause mortality, cardiovascular events, stroke, frailty fractures and quality of life). Only systematic reviews and meta-analyses on adult patient populations were considered. Study selection, data extraction and quality appraisal using AMSTAR-2 were done independently by two reviewers and discrepancies were resolved through discussion. Overlap across the selected reviews was also assessed, followed by a narrative synthesis of findings.

RESULTS

A total of 763 studies were identified from literature searches; 20 reviews met inclusion criteria. Methodological quality ratings were high (n = 8), moderate (n = 7), and low (n = 5), but no reviews were excluded on this basis. Though there was slight overlap across all reviews, some pairwise comparisons had high corrected covered area scores. Compared to euthyroidism, untreated subclinical hypothyroidism was associated with a higher risk of cardiovascular events or death if Thyroid Stimulating Hormone was above 10mIU/L at baseline. Treatment was associated with a lower risk of death from all causes for patients younger than 70 years and possibly better cognitive and quality of life scores than untreated individuals. Evidence on the risk of strokes and fractures was inconclusive.

CONCLUSION

In the long term, treatment of subclinical hypothyroidism may be beneficial for some patient groups. However, the findings of this review are negatively impacted by the relative sparseness and poor quality of available evidence. Additional large and adequately powered studies are needed to investigate this topic further.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42021235172).

Cardiac manifestations in hyperthyroidism

Thyroid hormones have a fundamental impact on cardiac function that is mediated by genomic and nongenomic effects, alterations that condition physiological repercussions that lead to changes in frequency, contractility, rhythm and cardiac output as well as an increase in the incidence and prevalence of different cardiovascular diseases. This document presents an updated review of the implications that hyperthyroidism has in different cardiac conditions, including its importance in the evaluation of perioperative cardiovascular risk.

The Impact of Subclinical Hyperthyroidism on Cardiovascular Prognosis in Patients Undergoing Percutaneous Coronary Intervention

CONTEXT

Limited studies have focused on the impact of subclinical hyperthyroidism (SHyper) on poor prognosis in patients with known coronary artery disease (CAD).

OBJECTIVE

We implemented the present study to explore the association between SHyper and adverse cardiovascular events in CAD patients who underwent drug-eluting stent implantation.

METHODS

We consecutively recruited 8283 CAD patients undergoing percutaneous coronary intervention (PCI). All subjects were divided into 2 groups according to their thyroid function: group 1 (euthyroidism group, n = 7942) and group 2 (SHyper group, n = 341). After 1:4 propensity score (PS) matching, 1603 patients (332 SHyper group and 1271 euthyroidism group) were selected. The primary endpoint was major adverse cardiovascular events (MACEs), a composite of cardiac mortality, nonfatal myocardial infarction (MI), and target vessel revascularization (TVR).

RESULTS

Kaplan-Meier (K-M) survival analyses suggested that there was no significant difference in the primary endpoint and secondary endpoints (MACE: 11.4% vs 8.8%, log-rank P = .124; cardiac death: 1.2% vs 0.9%, log-rank P = .540; nonfatal MI: 5.7% vs 4%, log-rank P = .177; and TVR: 6% vs 4.7%, log-rank P = .303) in the PS-matched population. Cox regression analysis indicated that SHyper was not an independent risk factor for MACEs (HR 1.33, 95% CI 0.92-1.92, P = .127).

CONCLUSION

SHyper is not independently associated with adverse cardiovascular events in CAD patients undergoing PCI. More studies should be implemented in the future to assess the long-term predictive value of SHyper with thyrotropin levels <0.1 mIU/L for CAD patients undergoing PCI.

Thyroid disorders and cardiovascular manifestations: an update

Cardiovascular disease (CVD) remains the leading cause of death worldwide, representing a major health, social, and economic issue. Thyroid disorders are very common and affect >10% of the adult population in total. The aim of this review is to describe the physiologic role of thyroid hormones on cardiovascular system, to present cardiovascular manifestations in patients with thyroid disorders, emphasizing in molecular mechanisms and biochemical pathways, and to summarize current knowledge of treatment options. Thyroid hormone receptors are located both in myocardium and vessels, and changes in their concentrations affect cardiovascular function. Hyperthyroidism or hypothyroidism, both clinical and subclinical, without the indicated therapeutical management, may contribute to the progression of CVD. According to recent studies, even middle changes in thyroid hormones levels increase cardiovascular mortality from 20% to 80%. In more details, thyroid disorders seem to have serious effects on the cardiovascular system via plenty mechanisms, including dyslipidemia, hypertension, systolic and diastolic myocardial dysfunction, as well endothelial dysfunction. On top of clinical thyroid disorders management, current therapeutics focus on younger patients with subclinical hypothyroidism and elderly patients with subclinical hyperthyroidism.

Subclinical hypothyroidism in older individuals

Subclinical hypothyroidism, which is defined as a thyroid-stimulating hormone concentration higher than the reference range (generally 4·5 mIU/L or higher) with normal free thyroxine concentrations, is frequently found in older individuals. International guidelines differ in recommendations for management of subclinical hypothyroidism in older individuals. We assessed published data during the past decade on the clinical significance and treatment of subclinical hypothyroidism in individuals aged 65 years and older. Meta-analyses, randomised clinical trials, and cohort studies are discussed in this narrative Review. Studies showed no significantly increased incidence in adverse cardiovascular, musculoskeletal, or cognitive outcomes in individuals aged 65 years or older when serum thyroid-stimulating hormone concentration was 4·5-7·0 mIU/L versus a euthyroid group. Moreover, in older individuals with subclinical hypothyroidism, symptoms of hypothyroidism and cardiac and bone parameters did not improve after levothyroxine treatment. These data suggest that treatment with levothyroxine should be considered for individuals aged 65 years or older with subclinical hypothyroidism when thyroid-stimulating hormone concentration is persistently 7 mIU/L or higher and to not initiate treatment with thyroid-stimulating hormone concentrations of less than 7 mIU/L. Levothyroxine doses should be personalised according to age, comorbidities, and life expectancy.

Long-Term, Single-Centre Observation of Patients with Cardiac Implantable Electronic Devices

Background and Objectives: Electrotherapy is a valuable treatment method for patients with heart rhythm disturbances. There are very few observations of long-term patients treated with these techniques. There is a particular lack of this type of study conducted in Eastern European countries. The aim of this single-centre analysis was to evaluate the long-term survival (from 2010 to 2018) of patients treated with electrotherapy devices, taking into account clinical factors facilitating the prognosis of these patients. Materials and Methods: The patients (N = 2071) subsequently included in the study were subjected to the implementation or replacement of cardiac pacemakers. The medical records of all the patients were analysed. Data concerning death, made available by the State Systems Department of the Ministry of Administration and Digitization, were used. Results: The patients with VVI pacemakers had the worst prognosis after the replacement of the devices. Male patients had a worse prognosis, regardless of the kind of device implanted. Advanced atrioventricular conduction disturbances, chronic kidney disease, and hypothyroidism with reduced left ventricular ejection fraction were among the most significant coexisting diseases. Conclusions: The long-term prognosis of patients under different forms of electrotherapy remains poor. Despite the more straightforward technique, a single-chamber device (VVI/AAI) or generator replacement leads to the worst prognosis. The complexity of the clinical picture that stems from coexisting diseases and advanced age is of the utmost importance.

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.

Incidence of Post-Heart Transplant Chronic Thyroiditis and Its Association With Pretransplant Amiodarone Use

BACKGROUND

Chronic thyroiditis (CT) is a common cause of thyroid dysfunction and could therefore adversely affect outcomes in patients undergoing heart transplant (HT). The incidence of post-HT CT and whether amiodarone, a commonly used anti-arrhythmic drug in patients with heart failure during pre-HT period, is associated with the development of post-HT CT are unknown.

METHODS

A retrospective review of HT recipients from February 2, 2010 to October 16, 2018 was performed. Patients who lacked relevant pre-/post-HT records, underwent thyroidectomy, had pre-HT thyroid dysfunction or thyroiditis within 15 days post-HT, and those on amiodarone during the post-HT period were excluded, yielding a final cohort of 75 patients.

RESULTS

Patients had a mean age of 63.3 ± 1.4 years and were predominantly male (90.7%) and white (80%). The incidence of post-HT CT was 32% with the majority (83.3%) manifesting as hypothyroidism. Median time to diagnosis of CT after transplant was 10.2 months (interquartile range, 4-27.4). Additionally, the CT group had higher pre-HT use of amiodarone (non-CT vs CT: 21.6% vs 50%, P = .01), higher prevalence of atrial fibrillation (non-CT vs CT: 23.5% vs 45.8%; P = .05), and more stage IV/V chronic kidney disease (non-CT vs CT: 2% vs 16.7%, P = .02). On multivariate analysis, pre-HT amiodarone use was associated with the development of post-HT CT after adjustment for age, sex, and chronic kidney disease (odds ratio, 3.65; 95% CI, 1.17-11.44; P = .03).

CONCLUSION

The incidence of post-HT CT is high and is strongly associated with pre-HT amiodarone use underpinning the importance of closely following the post-HT thyroid profile in these patients.

A practical contemporary approach to decision-making on subclinical hypothyroidism

Subclinical hypothyroidism (Shypo) is an increasingly frequent condition in common medical practice. Its diagnosis continues to pose a challenge since a series of non-thyroidal and temporary conditions can elevate serum TSH levels. In addition, the consequences of Shypo are still up for debate. Although detrimental cardiovascular effects have been consistently demonstrated in the young, they are less evident in older adults (65-79 years), and even more so in the oldest old (≥80 years). In the absence of evidence of any benefits of treating Shypo in patients' clinical manifestations and unfavorable outcomes, the most effective decision-making approach should include a thorough investigation of the patient's condition integrating all relevant clinical data, such as TSH levels, age, quality of life, comorbidities, cardiovascular risk, safety, and personal preferences. The decision-making process needs to take into account the risk of levothyroxine overtreatment and the resulting adverse consequences, such as reduction of bone mineral density, heart failure, and atrial fibrillation. Hence, current evidence suggests that individuals with TSH > 10 mU/L, who test positive for TPO Ab or are symptomatic may benefit from levothyroxine treatment. However, a more cautious and conservative approach is required in older (≥65 years of age), and oldest-old (≥80 years) patients, particularly those with frailty, in which the risk of treatment can outweigh potential benefits. The latter may benefit from a wait-and-see approach.

Noncanonical Thyroid Hormone Receptor α Action Mediates Arterial Vasodilation

CONTEXT

Hypothyroidism impairs cardiovascular health and contributes to endothelial dysfunction with reduced vasodilation. How 3,5,3'-triiodothyronine (T3) and its receptors are involved in the regulation of vasomotion is not yet fully understood. In general, thyroid hormone receptors (TRs) either influence gene expression (canonical action) or rapidly activate intracellular signaling pathways (noncanonical action).

OBJECTIVE

Here we aimed to characterize the T3 action underlying the mechanism of arterial vasodilation and blood pressure (BP) regulation.

METHODS

Mesenteric arteries were isolated from male rats, wild-type (WT) mice, TRα knockout (TRα 0) mice, and from knockin mice with a mutation in the DNA-binding domain (TRα GS). In this mutant, DNA binding and thus canonical action is abrogated while noncanonical signaling is preserved. In a wire myograph system, the isolated vessels were preconstricted with norepinephrine. The response to T3 was measured, and the resulting vasodilation (Δ force [mN]) was normalized to maximum contraction with norepinephrine and expressed as percentage vasodilation after maximal preconstriction with norepinephrine (%NE). Isolated vessels were treated with T3 (1 × 10-15 to 1 × 10-5 mol/L) alone and in combination with the endothelial nitric oxide-synthase (eNOS) inhibitor L-NG-nitroarginine methyl ester (L-NAME) or the phosphatidylinositol 3-kinase (PI3K) inhibitor wortmannin. The endothelium was removed to determine the contribution of T3 to endothelium-dependent vasodilation. The physiological relevance of T3-induced vasodilation was determined by in vivo arterial BP measurements in male and female mice.

RESULTS

T3 treatment induced vasodilation of mesenteric arteries from WT mice within 2 minutes (by 21.5 ± 1.7%NE). This effect was absent in arteries from TRα 0 mice (by 5.3 ± 0.6%NE, P < .001 vs WT) but preserved in TRα GS arteries (by 17.2 ± 1.1%NE, not significant vs WT). Inhibition of either eNOS or PI3K reduced T3-mediated vasodilation from 52.7 ± 4.5%NE to 28.5 ± 4.1%NE and 22.7 ± 2.9%NE, respectively. Removal of the endothelium abolished the T3-mediated vasodilation in rat mesenteric arteries (by 36.7 ± 5.4%NE vs 3.5 ± 6.2%NE). In vivo, T3 injection led to a rapid decrease of arterial BP in WT (by 13.9 ± 1.9 mm Hg) and TRα GS mice (by 12.4 ± 1.9 mm Hg), but not in TRα 0 mice (by 4.1 ± 1.9 mm Hg).

CONCLUSION

These results demonstrate that T3 acting through noncanonical TRα action affects cardiovascular physiology by inducing endothelium-dependent vasodilation within minutes via PI3K and eNOS activation.

Subclinical Hypothyroidism in Geriatric Population and Its Association With Heart Failure

Heart failure (HF) is one of the most common causes of hospitalization in the geriatric age group, above 65 years. It is associated with high morbidity, mortality, and bad prognosis. Subclinical hypothyroidism (SCH) is a common condition present in this age group that significantly affects the cardiovascular system. Thus, this review attempts to elaborate on the association between subclinical hypothyroidism and heart failure in terms of their prevalence, pathogenesis, prognosis, and possible management in a geriatric age group. Among the various published literature on this topic on PubMed, PubMed Central, and Google Scholar, 36 relevant studies were selected to correlate this association. We found that both SCH and HF can be present concurrently in this age group. Especially in the geriatric population with thyroid-stimulating hormone (TSH) higher than ten mIu/L, there is an increased incidence of heart failure and a worse prognosis with preexisting heart failure. However, randomized controlled trials will be needed to explore further whether treatment is warranted or not in this age group.

Evaluation of Thyroid Function in Patients Hospitalized for Acute Heart Failure

BACKGROUND

Thyroid hormones (TH) are crucial for cardiovascular homeostasis. Recent evidence suggests that acute cardiovascular conditions, particularly acute heart failure (AHF), significantly impair the thyroid axis. Our aim was to evaluate the association of thyroid function with cardiovascular parameters and short- and long-term clinical outcomes in AHF patients.

METHODS

We performed a single-centre retrospective cohort study including patients hospitalized for AHF between January 2012 and December 2017. We used linear, logistic, and Cox proportional hazard regression models to analyse the association of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) with inpatient cardiovascular parameters, in-hospital mortality, short-term adverse clinical outcomes, and long-term mortality. Two models were used: (1) unadjusted, and (2) adjusted for age and sex.

RESULTS

Of the 235 patients included, 59% were female, and the mean age was 77.5 (SD 10.4) years. In the adjusted model, diastolic blood pressure was positively associated with TSH [β = 2.68 (0.27 to 5.09); p = 0.030]; left ventricle ejection fraction (LVEF) was negatively associated with FT4 [β = -24.85 (-47.87 to -1.82); p = 0.035]; and a nonsignificant trend for a positive association was found between 30-day all-cause mortality and FT4 [OR = 3.40 (0.90 to 12.83); p = 0.071]. Among euthyroid participants, higher FT4 levels were significantly associated with a higher odds of 30-day all-cause death [OR = 4.40 (1.06 to 18.16); p = 0.041]. Neither TSH nor FT4 levels were relevant predictors of long-term mortality in the adjusted model.

CONCLUSIONS

Thyroid function in AHF patients is associated with blood pressure and LVEF during hospitalization. FT4 might be useful as a biomarker of short-term adverse outcomes in these patients.

The influence of microwave electromagnetic radiation on rat heart morphogenesis during thyroidectomy

It is known that electromagnetic radiation affects the functional systems of living beings, in particular, the endocrine and cardiovascular systems and directly the heart cells and their functioning. In this case, the influence of electromagnetic radiation significantly affects the properties of the cardiovascular system and changes physiological processes in it. Moreover, sensitivity to signals is higher for biosystems with a higher level of organization. The method of simulating hypothyroidism for rats makes it possible to develop an experimental model for analyzing morphogenetic changes in the rat heart. Under conditions of hypothyroidism modeling, destructive changes in muscle fibers are observed in the myocardium after thyroidectomy, but after microwave irradiation with an exposure of 45 minutes, a regenerative-compensatory reconstruction of the structural components of the myocardium of the heart wall occurs. After thyroidectomy and microwave irradiation with an exposure of 120 minutes, an increase in degenerative and destructive processes in the heart myocardium was observed. For the first time, a comparative ultramicroscopic study using electron microscopy was carried out. It showed that after electromagnetic irradiation with an exposure of 45 minutes, the general structure of the mitochondrial apparatus does not change. Irradiation with an exposure of 120 minutes causes the destruction of subsarcolemal and paranuclear organelles, edema and degradation of intermyofibrillar mitochondria. After exposure to electromagnetic radiation with the exposure of 45 minutes in a hypothyroid state, a compensatory restructuring of the energy apparatus of the contractile cardiomyocytes of the left ventricle occurs due to the formation of mitochondria and an increase in their contact interaction. After exposure to radiation for 120 minutes, the development of destructive-degenerative processes in the mitochondrial apparatus of left ventricular cardiomyocytes, deepening of damage to intermitochondrial contacts was observed. The most significant increase in the relative volume of the endothelium in the areas of the rat heart myocardium was observed for the case of microwave irradiation only (without experimental hypothyroidism) with exposure duration of 45 minutes. Immunohistochemical study both for the case of microwave irradiation only and for the case of microwave irradiation under conditions of experimental hypothyroidism allows us to conclude that morphogenetic transformations are highly active in the myocardium of the heart when the duration of exposure is 45 minutes. This study will make it possible to develop recommendations for persons with thyroid diseases on the duration of daily exposure of staying in electromagnetic field emitted by devices with characteristics similar to the case under study.

Efficacy and safety of thyroxine therapy on patients with heart failure and subclinical hypothyroidism: A protocol for systematic review and meta-analysis

BACKGROUND

Subclinical hypothyroidism (SCH) can increase the risk of heart failure (HF) clinically. However, thyroxine therapy for patients with HF and SCH has the risk of developing tachyarrhythmias. At present, there is no sufficient evidence-based medical evidence for levothyroxine in the therapy of this situation, and the treatment issue is still controversial. Therefore, our meta-analysis aims to assess the effectiveness and safety of thyroxine therapy for patients with HF and SCH.

METHODS

We searched the related randomized controlled trials that have been published in the following 7 electronic databases: PubMed, Cochrane Library, EMBASE, Chongqing VIP, China National Knowledge Infrastructure, Chinese biomedical literature database, and Wan Fang database. The treatment group was treated with routine HF therapy plus thyroxine, while the control group was treated with HF routine therapy. Main outcome measures effective rate and New York Heart Association classification; Secondary outcome measures included: left ventricular ejection fraction, quality of life score, brain natriuretic peptide / N-terminal pro brain natriuretic peptide, 6-minute walk test, and adverse events. After screening studies and extracting data, we will use Cochrane collaborative tools to evaluate the risk of bias to assess the methodological quality of the included randomized controlled trials. We will use STATA 14.0 software for data synthesis and statistical analysis. Both subgroup analysis and sensitivity analysis will be used to detect potential sources of heterogeneity. In addition, we will use sensitivity analysis to test the stability of the outcomes. If possible, we will perform a funnel chart and Eggers test evaluate publication bias. The quality of the evidence will be evaluated through the grades of recommendations assessment, development, and evaluation system.

RESULTS

Our findings will be published in peer-reviewed journals.

CONCLUSION

This research will provide evidence about the efficacy and safety of thyroxine in the treatment of patients with HF and SCH. Objective to provide evidence-based medicine basis for thyroxine treatment of patients with SCH and HF.

REGISTRATION NUMBER

INPLASY2020100062.

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.

The current debate over treatment of subclinical hypothyroidism to prevent cardiovascular complications

BACKGROUND

Subclinical hypothyroidism (SCH) is an asymptomatic condition associated with increased thyroid-stimulating hormone (TSH) >4 mIU/L with normal thyroxine (T4) and triidothyronine (T3) levels. It is more common in older subjects and especially in women with an overall incidence of 10%.

OBJECTIVE

Because the normal TSH levels increase with age up to 7.5 mIU/L in older people, several studies have reported either no benefits whereas others have reported the benefits of treatment. These studies have caused a great debate over the treatment of SCH, especially in older subjects. Therefore, the objective of this study was to review the current evidence over this debate by reviewing the recent literature on the subject to discern whether treatment of SCH is necessary and under what circumstances.

METHODS

To get a better perspective on the current debate over treatment of SCH, a focused Medline search of the English language literature was conducted from 2012 to 2019 using the terms, hypothyroidism, subclinical, dyslipidaemia, cardiovascular disease, heart failure and 38 papers with pertinent information were selected.

RESULTS

The analysis of results from these papers indicated that the normal levels of TSH are increasing with the advancement of age from 4 mIU/L up to 7.5 mIU/L for patients ≥75 years of age. Also, several of reviewed studies have shown no benefits of treatment whereas, others have shown definite benefits of treatment with levothyroxine supplementation on the clinical and metabolic effects of SBH with reductions in CVD, HF and mortality. The treatment is more effective in younger persons and less so in older persons.

CONCLUSIONS

Based on the overall evidence, treatment of SCH is indicated in younger persons with a TSH level >4.0 mIU/L. In older subjects, treatment should be individualised and based on the presence of symptoms, the level of TSH, and initiated at TSH levels ≥10 mIU/L and at low doses to avoid adverse cardiovascular effects from overtreatment.

Subclinical hypothyroidism and cardiovascular risk factors

INTRODUCTION

Thyroid hormones have multiple effects on lipid metabolism as well as on the cardiovascular system function. These negative cardiovascular effects have long been recognized in overt hypothyroidism but can be reversed by treatment with levothyroxine.

EVIDENCES ACQUISITION

We performed on PubMed a literature search for the articles published until March 2019 by using the search terms "subclinical hypothyroidism," "cardiovascular disease," "cholesterol," "LDL," "HDL," "triglycerides," "coronary heart disease," "heart failure," "atherosclerosis," "all-cause mortality," "levothyroxine."

EVIDENCES SYNTHESIS

Subclinical hypothyroidism, defined as an elevated thyrotropin (TSH) with a normal free thyroxine (FT4), is frequent in the general population and increase with age. Subclinical hypothyroidism has been linked to cardiovascular risk factors, dyslipidemia and increased atherosclerosis. Although some studies have demonstrated that lipids are elevated in subclinical hypothyroidism, other studies did not confirm these data. Clinical trials have also demonstrated there is no clear evidence that levothyroxine therapy in subjects with milder form (TSH<10 mU/L) of subclinical hypothyroidism could improve lipid status and the other cardiovascular risk factors. Nevertheless, TSH level seems the best predictor of cardiovascular disease, in particular when its levels are above 10 mU/L.

CONCLUSIONS

Prospective studies are necessary to clarify the cardiovascular risk in patients with mild subclinical hypothyroidism and to assess the importance of treating elderly people in order to improve or counteract the correlated risks. However, until clinical recommendations will be updated, the decision to treat or not treat patients with subclinical hypothyroidism will still base on clinical judgment, clinical practice guidelines, and expert opinion.

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.