Long-term Consequences of Previously Treated Hyperthyroidism

Hypertyreoosilla tarkoitetaan sairastuneen kilpirauhasen liiallista kilpirauhashormonien tuotantoa. Tavallisimpia syitä ovat Basedowin tauti, monikyhmystruuma ja yksittäinen toksinen adenooma. Hypertyreoosia voidaan hoitaa kolmella tavalla: tyreostaattisilla lääkkeillä, radioaktiivisella jodilla (RAI) tai kilpirauhasen osa- tai kokopoistolla. Kaikki nämä hoitomuodot ovat olleet käytössä jo vuosikymmeniä. Kilpirauhashormonit säätelevät elimistön aineenvaihduntaa, solujen kasvua ja energian tuotantoa. Aiempiin tutkimuksiin perustuen hypertyreoosiin sairastuneilla potilailla on lisääntynyt sydän- ja verenkiertoelimistön sairauksien riski vielä pitkään hoidon jälkeenkin. Osassa seurantatutkimuksia on tullut esiin myös lisääntynyt syöpäriski RAI-hoidetuilla potilailla. Toistaiseksi on ollut epäselvää, johtuuko lisääntynyt sairastuvuus hypertyreoosin ja sydänsairauksien tai hypertyreoosin ja syövän yhteisistä riskitekijöistä, vai itse sairastetusta hypertyreoosista tai sen hoitomuodoista. Tutkimuksen tarkoituksena oli selvittää hypertyreoosipotilaiden sairastuvuutta ja kuolleisuutta sydän- ja verenkiertoelimistön sairauksiin ja syöpään ennen ja jälkeen hypertyreoosin hoidon ja verrata näiden sairauksien riskiä kahden erilaisen hoitomuodon, RAI-hoidon ja kilpirauhasleikkauksen jälkeen. Tähän vertailevaan kohorttitutkimukseen otettiin mukaan kaikki Suomessa vuosina 1986-2007 hypertyreoosin vuoksi kilpirauhasleikatut potilaat (n=4334) ja kaikki samaan aikaan Tampereen yliopistollisen sairaalan alueella hypertyreoosin vuoksi RAI-hoidetut potilaat (n=1 819). Jokaiselle haettiin kolme ikä- ja sukupuolivakioitua verrokkia Väestörekisterikeskuksesta. Tiedot potilaiden ja verrokkien syöpäsairastuvuudesta ja kuolleisuudesta haettiin Syöpärekisteristä ja tiedot sydän- ja verenkiertoelimistön sairauksista johtuvista sairaalahoitojaksoista Terveyden ja Hyvinvoinnin laitoksen (THL) Hoito- ja poistoilmoitusrekisterin (HILMO) tietokannasta. Ensin analysoitiin potilaiden sydän- ja verisuonisairauksiin liittyvät sairaalahoitojaksot ja syövän ilmaantuvuus hypertyreoosin hoitoon saakka. Sen jälkeen analysoitiin sydän-ja verisuonisairauksista johtuvan uuden sairaalahoitojakson ja uuden syövän riski ja sekä kuolleisuus verrattuna ikä- ja sukupuolivakioituihin verrokkeihin. Lisäksi verrattiin hypertyreoosin vuoksi RAI-hoidon saaneiden sairastuvuutta ja kuolleisuutta hypertyreoosin vuoksi leikattuihin potilaisiin. Tulokset vakioitiin aiemmalla syöpäsairastuvuudella syövän suhteen ja aiemmalla sydän- ja verisuonisairauksien sairastuvuudella sydänsairauksien suhteen. Saatujen tulosten perusteella hypertyreoosi lisäsi riskiä joutua sairaalahoitoon sydän- ja verenkiertoelimistön sairauksien vuoksi ja riski oli koholla vielä kahden vuosikymmenen ajan RAI-hoidon tai kilpirauhasleikkauksen jälkeen ikä- ja sukupuolivakioituihin verrokkeihin verrattuna. Kilpirauhasleikkaus vähensi tehokkaammin sydänsairastuvuutta ja kuolleisuutta hypertyreoosipotilailla kuin RAI-hoito ja RAI-hoidetuilla potilailla oli yli kaksinkertainen kuolleisuus leikattuihin potilaisiin verrattuna. Hypotyreoosi RAI-hoidon jälkeen merkitsi parempaa ennustetta. Syövän ilmaantuvuudessa ja syöpäkuolleisuudessa ei ollut eroa potilaiden ja verrokkien välillä, mutta hengitystiesyöpien ja mahasyövän riski oli potilailla korkeampi kuin verrokeilla. Hoitomuodolla ei ollut vaikutusta syövän ilmaantuvuuteen tai syöpäkuolleisuuteen. Tämän tutkimuksen tuloksista voidaan päätellä, että hypertyreoosin sairastaneiden potilaiden lisääntynyt sydän- ja verisuonisairauksien ja maha- ja hengitystiesyöpien riski ei näyttäisi liittyvän hypertyreoosin hoitoon, vaan sairastettuun hypertyreoosiin sekä hypertyreoosin ja sydän- ja verisuonisairauksien ja hypertyreoosin ja tiettyjen syöpien yhteisiin riskitekijöihin. Saadut tulokset korostavat hypertyreoosin tehokkaan hoidon merkitystä tulevaisuudessa. Valitusta hypertyreoosin hoitomuodosta huolimatta, potilaita tulisi pitää sydän- ja verisuonisairauksien ja syövän suhteen korkean riskin potilaina hoidon jälkeenkin ja huolehtia pitkäaikaisseurannan toteutumisesta näiden sairauksien suhteen.Hyperthyroidism is defined as excess secretion of thyroid hormones by a diseased thyroid gland. The most common diseases causing hyperthyroidism are Graves´ disease, multinodular goiter and toxic adenoma. There are three different treatment modalities of hyperthyroidism –antithyroid drugs (ATD), radioactive iodine (RAI) and thyroidectomy. All these treatments have been used for several decades. Hyperthyroidism causes several disadvantageous changes in the metabolism, due to excess amount of circulating thyroid hormones. Based on the previous studies, hyperthyroid patients have an increased risk of cardiovascular diseases, even after achieving euthyroidism. Furthermore, there are studies suggesting an increased risk of cancer in patients treated for hyperthyroidism with RAI. It is unclear, whether the excess risk is due to hyperthyroidism, its treatment, or the shared risk factors of these diseases. The aim of this study was to assess cardiovascular and cancer morbidity and mortality in hyperthyroidism before and after the treatment, and to compare the long- term outcome of patients treated with RAI and those treated with thyroid surgery. This comparative cohort study included all the patients treated for hyperthyroidism in Finland during 1986-2007 with subtotal or total thyroidectomy (n=4334) and all the patients treated with RAI in Tampere University Hospital during the same period of time (n=1819). Three age- and gender-matched controls were obtained for each patient from the National Population Registry. Cancer diagnoses of the patients and the controls were obtained from the Cancer Registry, and hospitalizations for cardiovascular diseases from the hospitalization database of National Institute for Health and Welfare (HILMO). Firstly, hospitalizations due to CVDs and the incidence of cancer until the treatment of hyperthyroidism were analyzed. Secondly, the hazard ratios (HR) for any new hospitalization and mortality due to CVDs and for the incidence of cancer after the treatment were estimated among all the hyperthyroid patients compared to the age- and gender-matched controls, and also in the RAI-treated patients compared to the thyroidectomy-treated patients. The results were adjusted for prevalent CVDs and prevalent cancers at the time of treatment. The main results of this study were that hyperthyroidism increased the risk of CVD-related hospitalizations, and the risk was sustained up to two decades after treatment with RAI or surgery. Subtotal or total thyroidectomy was more effective in decreasing cardiovascular morbidity and mortality in hyperthyroid patients than treatment with RAI, and the patients treated with RAI had over twice as high CVD mortality rates compared to patients treated with thyroidectomy. Hypothyroidism after treatment with RAI, however, predicted better cardiovascular outcome. The overall risk of cancer in hyperthyroid patients was unchanged compared to age- and gender- matched reference subjects, but there was an increased risk of gastric and respiratory tract cancers. The effect of treatment modality on cancer incidence was neutral. As a conclusion, the increased risk of CVDs and cancer in hyperthyroid patients is associated to hyperthyroidism and shared risk factors, not the treatment modality. This underlines the importance of efficient treatment of hyperthyroidism in the future. Furthermore, disregarding the treatment modality, the patients treated for hyperthyroidism should be regarded as high-risk patients for CVDs and to some cancers and long-term follow-up should be arranged

Non-specific intraventricular conduction delay or atypical LBBB - How to predict acute coronary occlusion?

We describe two patient cases with acute coronary syndrome (ACS) and broad QRS in the acute phase electrocardiogram (ECG). The patients' ECG findings resembled left bundle branch block (LBBB), but with atypical features. Broad QRS not fulfilling the criteria for LBBB or right bundle branch block (RBBB) is diagnosed as non-specific intraventricular conduction delay (NSIVCD). The case report deals with the challenges of predicting acute coronary occlusion in patients with NSIVCD in their acute phase ECG. In one of the cases, the ECG changed from typical LBBB to NSIVCD or atypical LBBB with the development of systolic dysfunction and clinical heart failure.publishedVersionPeer reviewe

Obesity and the Risk of Cryptogenic Ischemic Stroke in Young Adults

Objectives: We examined the association between obesity and early-onset cryptogenic ischemic stroke (CIS) and whether fat distribution or sex altered this association. Materials and Methods: This prospective, multi-center, case-control study included 345 patients, aged 18-49 years, with first-ever, acute CIS. The control group included 345 age-and sex-matched stroke-free individuals. We measured height, weight, waist circumference, and hip circumference. Obesity metrics analyzed included body mass index (BMI), waist-to-hip ratio (WHR), waist-to-stature ratio (WSR), and a body shape index (ABSI). Models were adjusted for age, level of education, vascular risk factors, and migraine with aura. Results: After adjusting for demographics, vascular risk factors, and migraine with aura, the highest tertile of WHR was associated with CIS (OR for highest versus lowest WHR tertile 2.81, 95%CI 1.43-5.51; P=0.003). In sex-specific analyses, WHR tertiles were not associated with CIS. However, using WHO WHR cutoff values (>0.85 for women, >0.90 for men), abdominally obese women were at increased risk of CIS (OR 2.09, 95%CI 1.02-4.27; P=0.045). After adjusting for confounders, WC, BMI, WSR, or ABSI were not associated with CIS. Conclusions: Abdominal obesity measured with WHR was an independent risk factor for CIS in young adults after rigorous adjustment for concomitant risk factors.Peer reviewe

European Society of Cardiology: Cardiovascular Disease Statistics 2019

Aims The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. Methods and results In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5–23.1%] vs. 15.7% (IQR 14.5–21.1%)}, diabetes [7.7% (IQR 7.1–10.1%) vs. 5.6% (IQR 4.8–7.0%)], and among males smoking [43.8% (IQR 37.4–48.0%) vs. 26.0% (IQR 20.9–31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0–10.8) vs. 16.7% (IQR 13.9–19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655–8115)] compared with high-income [2235 (IQR 1896–3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. Conclusion A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest

Long-term Consequences of Previously Treated Hyperthyroidism

Hypertyreoosilla tarkoitetaan sairastuneen kilpirauhasen liiallista kilpirauhashormonien tuotantoa. Tavallisimpia syitä ovat Basedowin tauti, monikyhmystruuma ja yksittäinen toksinen adenooma. Hypertyreoosia voidaan hoitaa kolmella tavalla: tyreostaattisilla lääkkeillä, radioaktiivisella jodilla (RAI) tai kilpirauhasen osa- tai kokopoistolla. Kaikki nämä hoitomuodot ovat olleet käytössä jo vuosikymmeniä. Kilpirauhashormonit säätelevät elimistön aineenvaihduntaa, solujen kasvua ja energian tuotantoa. Aiempiin tutkimuksiin perustuen hypertyreoosiin sairastuneilla potilailla on lisääntynyt sydän- ja verenkiertoelimistön sairauksien riski vielä pitkään hoidon jälkeenkin. Osassa seurantatutkimuksia on tullut esiin myös lisääntynyt syöpäriski RAI-hoidetuilla potilailla. Toistaiseksi on ollut epäselvää, johtuuko lisääntynyt sairastuvuus hypertyreoosin ja sydänsairauksien tai hypertyreoosin ja syövän yhteisistä riskitekijöistä, vai itse sairastetusta hypertyreoosista tai sen hoitomuodoista. Tutkimuksen tarkoituksena oli selvittää hypertyreoosipotilaiden sairastuvuutta ja kuolleisuutta sydän- ja verenkiertoelimistön sairauksiin ja syöpään ennen ja jälkeen hypertyreoosin hoidon ja verrata näiden sairauksien riskiä kahden erilaisen hoitomuodon, RAI-hoidon ja kilpirauhasleikkauksen jälkeen. Tähän vertailevaan kohorttitutkimukseen otettiin mukaan kaikki Suomessa vuosina 1986-2007 hypertyreoosin vuoksi kilpirauhasleikatut potilaat (n=4334) ja kaikki samaan aikaan Tampereen yliopistollisen sairaalan alueella hypertyreoosin vuoksi RAI-hoidetut potilaat (n=1 819). Jokaiselle haettiin kolme ikä- ja sukupuolivakioitua verrokkia Väestörekisterikeskuksesta. Tiedot potilaiden ja verrokkien syöpäsairastuvuudesta ja kuolleisuudesta haettiin Syöpärekisteristä ja tiedot sydän- ja verenkiertoelimistön sairauksista johtuvista sairaalahoitojaksoista Terveyden ja Hyvinvoinnin laitoksen (THL) Hoito- ja poistoilmoitusrekisterin (HILMO) tietokannasta. Ensin analysoitiin potilaiden sydän- ja verisuonisairauksiin liittyvät sairaalahoitojaksot ja syövän ilmaantuvuus hypertyreoosin hoitoon saakka. Sen jälkeen analysoitiin sydän-ja verisuonisairauksista johtuvan uuden sairaalahoitojakson ja uuden syövän riski ja sekä kuolleisuus verrattuna ikä- ja sukupuolivakioituihin verrokkeihin. Lisäksi verrattiin hypertyreoosin vuoksi RAI-hoidon saaneiden sairastuvuutta ja kuolleisuutta hypertyreoosin vuoksi leikattuihin potilaisiin. Tulokset vakioitiin aiemmalla syöpäsairastuvuudella syövän suhteen ja aiemmalla sydän- ja verisuonisairauksien sairastuvuudella sydänsairauksien suhteen. Saatujen tulosten perusteella hypertyreoosi lisäsi riskiä joutua sairaalahoitoon sydän- ja verenkiertoelimistön sairauksien vuoksi ja riski oli koholla vielä kahden vuosikymmenen ajan RAI-hoidon tai kilpirauhasleikkauksen jälkeen ikä- ja sukupuolivakioituihin verrokkeihin verrattuna. Kilpirauhasleikkaus vähensi tehokkaammin sydänsairastuvuutta ja kuolleisuutta hypertyreoosipotilailla kuin RAI-hoito ja RAI-hoidetuilla potilailla oli yli kaksinkertainen kuolleisuus leikattuihin potilaisiin verrattuna. Hypotyreoosi RAI-hoidon jälkeen merkitsi parempaa ennustetta. Syövän ilmaantuvuudessa ja syöpäkuolleisuudessa ei ollut eroa potilaiden ja verrokkien välillä, mutta hengitystiesyöpien ja mahasyövän riski oli potilailla korkeampi kuin verrokeilla. Hoitomuodolla ei ollut vaikutusta syövän ilmaantuvuuteen tai syöpäkuolleisuuteen. Tämän tutkimuksen tuloksista voidaan päätellä, että hypertyreoosin sairastaneiden potilaiden lisääntynyt sydän- ja verisuonisairauksien ja maha- ja hengitystiesyöpien riski ei näyttäisi liittyvän hypertyreoosin hoitoon, vaan sairastettuun hypertyreoosiin sekä hypertyreoosin ja sydän- ja verisuonisairauksien ja hypertyreoosin ja tiettyjen syöpien yhteisiin riskitekijöihin. Saadut tulokset korostavat hypertyreoosin tehokkaan hoidon merkitystä tulevaisuudessa. Valitusta hypertyreoosin hoitomuodosta huolimatta, potilaita tulisi pitää sydän- ja verisuonisairauksien ja syövän suhteen korkean riskin potilaina hoidon jälkeenkin ja huolehtia pitkäaikaisseurannan toteutumisesta näiden sairauksien suhteen.Hyperthyroidism is defined as excess secretion of thyroid hormones by a diseased thyroid gland. The most common diseases causing hyperthyroidism are Graves´ disease, multinodular goiter and toxic adenoma. There are three different treatment modalities of hyperthyroidism –antithyroid drugs (ATD), radioactive iodine (RAI) and thyroidectomy. All these treatments have been used for several decades. Hyperthyroidism causes several disadvantageous changes in the metabolism, due to excess amount of circulating thyroid hormones. Based on the previous studies, hyperthyroid patients have an increased risk of cardiovascular diseases, even after achieving euthyroidism. Furthermore, there are studies suggesting an increased risk of cancer in patients treated for hyperthyroidism with RAI. It is unclear, whether the excess risk is due to hyperthyroidism, its treatment, or the shared risk factors of these diseases. The aim of this study was to assess cardiovascular and cancer morbidity and mortality in hyperthyroidism before and after the treatment, and to compare the long- term outcome of patients treated with RAI and those treated with thyroid surgery. This comparative cohort study included all the patients treated for hyperthyroidism in Finland during 1986-2007 with subtotal or total thyroidectomy (n=4334) and all the patients treated with RAI in Tampere University Hospital during the same period of time (n=1819). Three age- and gender-matched controls were obtained for each patient from the National Population Registry. Cancer diagnoses of the patients and the controls were obtained from the Cancer Registry, and hospitalizations for cardiovascular diseases from the hospitalization database of National Institute for Health and Welfare (HILMO). Firstly, hospitalizations due to CVDs and the incidence of cancer until the treatment of hyperthyroidism were analyzed. Secondly, the hazard ratios (HR) for any new hospitalization and mortality due to CVDs and for the incidence of cancer after the treatment were estimated among all the hyperthyroid patients compared to the age- and gender-matched controls, and also in the RAI-treated patients compared to the thyroidectomy-treated patients. The results were adjusted for prevalent CVDs and prevalent cancers at the time of treatment. The main results of this study were that hyperthyroidism increased the risk of CVD-related hospitalizations, and the risk was sustained up to two decades after treatment with RAI or surgery. Subtotal or total thyroidectomy was more effective in decreasing cardiovascular morbidity and mortality in hyperthyroid patients than treatment with RAI, and the patients treated with RAI had over twice as high CVD mortality rates compared to patients treated with thyroidectomy. Hypothyroidism after treatment with RAI, however, predicted better cardiovascular outcome. The overall risk of cancer in hyperthyroid patients was unchanged compared to age- and gender- matched reference subjects, but there was an increased risk of gastric and respiratory tract cancers. The effect of treatment modality on cancer incidence was neutral. As a conclusion, the increased risk of CVDs and cancer in hyperthyroid patients is associated to hyperthyroidism and shared risk factors, not the treatment modality. This underlines the importance of efficient treatment of hyperthyroidism in the future. Furthermore, disregarding the treatment modality, the patients treated for hyperthyroidism should be regarded as high-risk patients for CVDs and to some cancers and long-term follow-up should be arranged

24-hour ambulatory blood pressure and cryptogenic ischemic stroke in young adults

AbstractBackground In young patients, up to 40% of ischemic strokes remain cryptogenic despite modern-day diagnostic work-up. There are limited data on blood pressure (BP) behavior in these patients. Thus, we aimed to compare ambulatory blood pressure (ABP) profiles between young patients with a recent cryptogenic ischemic stroke (CIS) and stroke-free controls.Patients and Methods In this substudy of the international multicenter case–control study SECRETO (NCT01934725), 24-hour ambulatory blood pressure monitoring (ABPM) was performed in consecutive 18–49-year-old CIS patients and stroke-free controls. The inclusion criteria were met by 132 patients (median age, 41.9 years; 56.1% males) and 106 controls (41.9 years; 56.6% males). We assessed not only 24-hour, daytime, and nighttime ABP but also hypertension phenotypes and nocturnal dipping status.Results 24-hour and daytime ABP were higher among controls. After adjusting for relevant confounders, a non-dipping pattern of diastolic blood pressure (DBP) was associated with CIS in the entire sample (odds ratio, 3.85; 95% confidence interval, 1.20–12.42), in participants without antihypertensives (4.86; 1.07–22.02), and in participants without a patent foramen ovale (PFO) (7.37; 1.47–36.81). After excluding patients in the first tertile of the delay between the stroke and ABPM, a non-dipping pattern of DBP was not associated with CIS, but a non-dipping pattern of both systolic BP and DBP was (4.85; 1.37–17.10). In participants with a PFO and in those without hypertension by any definition, no associations between non-dipping patterns of BP and CIS emerged.Conclusions Non-dipping patterns of BP were associated with CIS in the absence of a PFO but not in the absence of hypertension. This may reflect differing pathophysiology underlying CIS in patients with versus without a PFO. Due to limitations of the study, results regarding absolute ABP levels should be interpreted with caution.Key MessagesNocturnal non-dipping patterns of blood pressure were associated with cryptogenic ischemic stroke except in participants with a patent foramen ovale and in those without hypertension by any definition, which may indicate differing pathophysiology underlying cryptogenic ischemic stroke in patients with and without a patent foramen ovale.It might be reasonable to include ambulatory blood pressure monitoring in the diagnostic work-up for young patients with ischemic stroke to detect not only the absolute ambulatory blood pressure levels but also their blood pressure behavior