Endocrinol Metab.  2020 Jun;35(2):308-318. 10.3803/EnM.2020.35.2.308.

Subclinical Hypothyroidism Affects the Long-Term Outcomes of Patients Who Undergo Coronary Artery Bypass Grafting Surgery but Not Heart Valve Surgery

Affiliations
  • 1Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
  • 2Department of Internal Medicine, Ilsan Cha Medical Center, Goyang, Korea
  • 3Departments of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
  • 4Departments of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

Abstract

Background
The aim of this study was to determine the associations between subclinical hypothyroidism (SCH) and long-term cardiovascular outcomes after coronary artery bypass grafting (CABG) or heart valve surgery (HVS).
Methods
We retrospectively reviewed and compared all-cause mortality, cardiovascular mortality, and cardiovascular events in 461 patients who underwent CABG and 104 patients who underwent HVS.
Results
During a mean±standard deviation follow-up duration of 7.6±3.8 years, there were 187 all-cause deaths, 97 cardiovascular deaths, 127 major adverse cardiovascular events (MACE), 11 myocardial infarctions, one unstable angina, 70 strokes, 30 hospitalizations due to heart failure, 101 atrial fibrillation, and 33 coronary revascularizations. The incidence of all-cause mortality after CABG was significantly higher in patients with SCH (n=36, 55.4%) than in euthyroid patients (n=120, 30.3%), with a hazard ratio of 1.70 (95% confidence interval, 1.10 to 2.63; P=0.018) after adjustment for age, sex, current smoking status, body mass index, underlying diseases, left ventricular dysfunction, and emergency operation. Interestingly, low total triiodothyronine (T3) levels in euthyroid patients who underwent CABG were significantly associated with increased risks of all-cause mortality, cardiovascular mortality, and MACE, but those associations were not observed in HVS patients. Both free thyroxine and thyroid-stimulating hormone levels in euthyroid patients were not related with any cardiovascular outcomes in either the CABG or HVS group.
Conclusion
SCH or low total T3 might be associated with a poor prognosis after CABG, but not after HVS, implying that preoperative thyroid hormonal status may be important in ischemic heart disease patients.

Keyword

Cardiovascular diseases; Heart valve diseases; Cause of death; Prognosis; Hypothyroidism; Thyrotropin; Triiodothyronine

Figure

  • Fig. 1 Kaplan-Meier curves of cardiovascular outcomes in patients with ischemic heart disease. (A) All-cause mortality in subclinical hypothyroidism (SCH) patients over euthyroid patients. (B) Cardiovascular (CV) mortality in SCH patients over euthyroid patients. (C) All-cause mortality according to the total triiodothyronine (T3) tertile in euthyroid patients. (D) Cardiovascular mortality according to the total T3 tertile in euthyroid patients. Cox regression analysis was performed. The hazard ratios (HRs) are for SCH patients with euthyroid patients as references. The HRs are for T3-G1 and T3-G2 patients with T3-G3 as reference. Total T3 tertiles: T3-G1, 0.3 to 83 ng/dL; T3-G2, 85 to 109 ng/dL; T3-G3, 110 to 163 ng/dL. CI, confidence interval.


Cited by  1 articles

Subclinical Hypothyroidism: Prevalence, Health Impact, and Treatment Landscape
Won Sang Yoo, Hyun Kyung Chung
Endocrinol Metab. 2021;36(3):500-513.    doi: 10.3803/EnM.2021.1066.


Reference

1. Kim YA, Park YJ. Prevalence and risk factors of subclinical thyroid disease. Endocrinol Metab (Seoul). 2014; 29:20–9.
Article
2. Park YJ, Lee YJ, Choi SI, Chun EJ, Jang HC, Chang HJ. Impact of subclinical hypothyroidism on the coronary artery disease in apparently healthy subjects. Eur J Endocrinol. 2011; 165:115–21.
Article
3. Ceresini G, Ceda GP, Lauretani F, Maggio M, Usberti E, Marina M, et al. Thyroid status and 6-year mortality in elderly people living in a mildly iodine-deficient area: the aging in the Chianti Area Study. J Am Geriatr Soc. 2013; 61:868–74.
Article
4. Gussekloo J, van Exel E, de Craen AJ, Meinders AE, Frolich M, Westendorp RG. Thyroid status, disability and cognitive function, and survival in old age. JAMA. 2004; 292:2591–9.
Article
5. Pereg D, Tirosh A, Elis A, Neuman Y, Mosseri M, Segev D, et al. Mortality and coronary heart disease in euthyroid patients. Am J Med. 2012; 125:826.
Article
6. Tseng FY, Lin WY, Lin CC, Lee LT, Li TC, Sung PK, et al. Subclinical hypothyroidism is associated with increased risk for all-cause and cardiovascular mortality in adults. J Am Coll Cardiol. 2012; 60:730–7.
Article
7. Ittermann T, Haring R, Sauer S, Wallaschofski H, Dorr M, Nauck M, et al. Decreased serum TSH levels are not associated with mortality in the adult northeast German population. Eur J Endocrinol. 2010; 162:579–85.
Article
8. Parle JV, Maisonneuve P, Sheppard MC, Boyle P, Franklyn JA. Prediction of all-cause and cardiovascular mortality in elderly people from one low serum thyrotropin result: a 10-year cohort study. Lancet. 2001; 358:861–5.
Article
9. Westerink J, van der Graaf Y, Faber DR, Spiering W, Visseren FL. SMART study group. Relation between thyroid-stimulating hormone and the occurrence of cardiovascular events and mortality in patients with manifest vascular diseases. Eur J Prev Cardiol. 2012; 19:864–73.
Article
10. Hyland KA, Arnold AM, Lee JS, Cappola AR. Persistent subclinical hypothyroidism and cardiovascular risk in the elderly: the cardiovascular health study. J Clin Endocrinol Metab. 2013; 98:533–40.
Article
11. Selmer C, Olesen JB, Hansen ML, von Kappelgaard LM, Madsen JC, Hansen PR, et al. Subclinical and overt thyroid dysfunction and risk of all-cause mortality and cardiovascular events: a large population study. J Clin Endocrinol Metab. 2014; 99:2372–82.
Article
12. Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010; 304:1365–74.
Article
13. Ochs N, Auer R, Bauer DC, Nanchen D, Gussekloo J, Cornuz J, et al. Meta-analysis: subclinical thyroid dysfunction and the risk for coronary heart disease and mortality. Ann Intern Med. 2008; 148:832–45.
Article
14. Moon S, Kong SH, Choi HS, Hwangbo Y, Lee MK, Moon JH, et al. Relation of subclinical hypothyroidism is associated with cardiovascular events and all-cause mortality in adults with high cardiovascular risk. Am J Cardiol. 2018; 122:571–7.
Article
15. Moon S, Kim MJ, Yu JM, Yoo HJ, Park YJ. Subclinical hypothyroidism and the risk of cardiovascular disease and all-cause mortality: a meta-analysis of prospective cohort studies. Thyroid. 2018; 28:1101–10.
Article
16. Park YJ, Yoon JW, Kim KI, Lee YJ, Kim KW, Choi SH, et al. Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg. 2009; 87:1846–52.
Article
17. Kong SH, Yoon JW, Kim SY, Oh TJ, Park KH, Choh JH, et al. Subclinical hypothyroidism and coronary revascularization after coronary artery bypass grafting. Am J Cardiol. 2018; 122:1862–70.
Article
18. Martinez-Comendador J, Marcos-Vidal JM, Gualis J, Martin CE, Martin E, Otero J, et al. Subclinical hypothyroidism might increase the risk of postoperative atrial fibrillation after aortic valve replacement. Thorac Cardiovasc Surg. 2016; 64:427–33.
Article
19. O’Connor GT, Plume SK, Olmstead EM, Coffin LH, Morton JR, Maloney CT, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. The Northern New England Cardiovascular Disease Study Group. JAMA. 1991; 266:803–9.
20. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972; 18:499–502.
Article
21. Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic surgery. N Engl J Med. 1997; 336:1429–34.
Article
22. Biondi B. Mechanisms in endocrinology: heart failure and thyroid dysfunction. Eur J Endocrinol. 2012; 167:609–18.
Article
23. Galli E, Pingitore A, Iervasi G. The role of thyroid hormone in the pathophysiology of heart failure: clinical evidence. Heart Fail Rev. 2010; 15:155–69.
Article
24. Kim TH, Choi HS, Bae JC, Moon JH, Kim HK, Choi SH, et al. Subclinical hypothyroidism in addition to common risk scores for prediction of cardiovascular disease: a 10-year community-based cohort study. Eur J Endocrinol. 2014; 171:649–57.
Article
25. Tian L, Ni J, Guo T, Liu J, Dang Y, Guo Q, et al. TSH stimulates the proliferation of vascular smooth muscle cells. Endocrine. 2014; 46:651–8.
Article
26. Marfella R, Ferraraccio F, Rizzo MR, Portoghese M, Barbieri M, Basilio C, et al. Innate immune activity in plaque of patients with untreated and L-thyroxine-treated subclinical hypothyroidism. J Clin Endocrinol Metab. 2011; 96:1015–20.
27. Hassan A, Altamirano-Ufion A, Zulfiqar B, Boddu P. Sub-clinical hypothyroidism and its association with increased cardiovascular mortality: call for action. Cardiol Res. 2017; 8:31–5.
Article
28. Daswani R, Jayaprakash B, Shetty R, Rau NR. Association of thyroid function with severity of coronary artery disease in euthyroid patients. J Clin Diagn Res. 2015; 9:OC10–3.
Article
29. Zhang Y, Chang Y, Ryu S, Cho J, Lee WY, Rhee EJ, et al. Thyroid hormones and mortality risk in euthyroid individuals: the Kangbuk Samsung health study. J Clin Endocrinol Metab. 2014; 99:2467–76.
Article
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