Thyroid function abnormalities during amiodarone therapy for persistent atrial fibrillation

Background

Many patients receiving amiodarone therapy are male. The long-term risk for amiodarone-induced thyroid dysfunction in these patients has not been systematically and prospectively investigated. The purpose of this study was to determine the extent of amiodarone-induced thyroid dysfunction in a large male cohort.

Methods

This is a substudy of a prospective randomized controlled trial (SAFE-Trial) in which amiodarone, sotalol, and placebo for persistent atrial fibrillation were evaluated. For the purpose of this substudy, sotalol and placebo groups were combined into a control group. Serial thyroid function tests were performed over 1-4.5 years. Of the 665 patients enrolled in the SAFE-Trial, 612 patients were included in this sub-study.

Results

Subclinical hypothyroidism, thyroid-stimulating hormone (TSH) level 4.5-10 mU/L, was seen among 25.8% of the amiodarone-treated patients and only 6.6% of controls (P <.0001). Overt hypothyroidism, TSH level >10 mU/L, was seen among 5.0% of the amiodarone-treated patients, and only 0.3% of controls (P <.001). By 6 months, 93.8% of the patients who developed TSH elevations above 10 mU/L on amiodarone had been detected. There was a trend toward a greater proportion of hyperthyroidism, defined as a TSH <0.35 mU/L, in the amiodarone group compared with the control group (5.3% vs 2.4%, P = .07).

Conclusions

Hypothyroidism developed in 30.8% of older males treated with amiodarone and in only 6.9% of the controls. Hypothyroidism presented at an early stage of therapy. Hyperthyroidism occurred in 5.3% of amiodarone treated patients, and was a subclinical entity in all but 1 case.     

Lipid changes on hormone therapy and coronary heart disease events in the Heart and Estrogen/progestin Replacement Study (HERS)

Background

Despite the effect of lowering low-density lipoprotein cholesterol (LDL-C) levels and raising high-density lipoprotein cholesterol (HDL-C) levels, combination hormone therapy did not reduce the incidence of coronary heart disease (CHD) events in the Heart and Estrogen/progestin Replacement Study (HERS). To explore possible mechanisms, we examined the association between lipid changes and CHD outcomes among women assigned to hormone therapy.

Methods

HERS participants were postmenopausal women with previously diagnosed CHD who were randomly assigned to receive conjugated estrogens and medroxyprogesterone or identical placebo and then followed-up for an average of 4.1 years. Among women assigned to hormone therapy, associations between baseline-to-year-1 lipid level changes and CHD events were compared with the associations observed for baseline lipids using multivariate proportional hazards models.

Results

Among women assigned to hormone therapy, CHD events were independently predicted by baseline LDL-C levels (relative hazard [RH] 0.94 per 15.6 mg/dL decrease, 95% CI 0.88-1.01) and HDL-C levels (RH 0.89 per 5.4 mg/dL increase, 95% CI 0.81-0.99), but not by triglyceride levels (RH 1.01 per 13.2mg/dL increase, 95% CI 0.97-1.06). CHD events were marginally associated with first-year reductions in LDL-C levels (RH 0.95 per 15.6mg/dL decrease, 95% CI 0.86-1.04), and were not associated with increases in HDL-C levels ( RH 1.03 per 5.4 mg/dL increase, 95% CI 0.91-1.16) or triglyceride levels (RH 1.01 per 13.2 mg/dL increase, 95% CI 0.98-1.05).

Conclusion

Changes in lipid levels with hormone therapy are not predictive of CHD outcomes in women with heart disease in the HERS trial.     

Bayesian Meta-analysis of Hormone Therapy and Mortality in Younger Postmenopausal Women

Background

There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue.

Methods

A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables.

Results

The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1.

Conclusions

The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.     

Racial disparity in long-term mortality rate after hospitalization for myocardial infarction: the Atherosclerosis Risk in Communities study

Background

The underlying reasons why African American patients have a significantly higher mortality rate than European American patients after a myocardial infarction (MI) remain unclear. This study examined the racial disparity in mortality rates after MI and possible explanatory factors.

Methods

A prospective analysis was conducted within the Atherosclerosis Risk in Communities (ARIC) study, a community-based study of 15,792 middle-aged adults. From 1987 to 1998, 642 patients (471 European American and 171 African American) hospitalized for MI without prior history of MI were identified. Of these 642 patients, 129 (82 European American and 47 African American) died during follow-up.

Results

Cox proportional hazard models were used to analyze the racial difference in mortality rate after MI. After adjusting for age and sex, the relative hazard (RH) comparing African American patients to European American patients was 1.80 (95% CI, 1.24-2.61). The RH decreased after adjusting for vascular risk factors (1.29; 95% CI, 0.83-2.00), socioeconomic position (1.31; 95% CI, 0.83-2.09), severity of MI (1.60; 95% CI, 1.05-2.45), and treatment (1.36; 95% CI, 0.92-2.00). In the final model, which included all factors aforementioned, the RH for race was 1.00 (95% CI, 0.56-1.77).

Conclusions

Our findings suggested that vascular risk factors, socioeconomic position, and treatment play major roles in the racial disparity in mortality rate after MI.     

Predictors of long-term mortality in patients with ventilator-associated pneumonia

Purpose

To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality.

Methods

We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients.

Results

The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120 × 4> 10³/μL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively.

Conclusions

VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.     

Subclinical thyroid dysfunction and cardiac function amongst minority ethnic groups in the UK: A cross sectional study

Background

Subclinical thyroid disease is associated with abnormal cardiovascular haemodynamics and increased risk of heart failure. The burden of raised/low thyroid stimulating hormone (TSH) levels amongst South Asian (SA) and African–Caribbean (AC) minority groups in the UK is not well defined. Given that these groups are particularly susceptible to CVD, we hypothesised that STD would reflect abnormal cardiac function and heightened cardiovascular risk in these ethnic groups.

Methods

We examined SA (n = 1111, 56% male, mean age 57.6 yrs) and AC (n = 763, 44% male, mean age 59.2 yrs) participants from a large heart failure screening study. Euthyroidism is defined as TSH (0.4 – 4.9 mlU/l), subclinical hypothyroidism is defined as a raised TSH with normal serum free thyroxine (FT4) concentrations (9–19 pmol/l). Subclinical hyperthyroidism is defined as a low TSH with both FT4 and free triiodothyronine (FT3) concentrations within range (2.6–5.7 pmol/l).

Results

Across ethnic groups, prevalence of subclinical hypothyroidism was 2.9% (95% CI 2.1–3.7), and of hyperthyroidism was 2.0% (1.4–2.7). Hyperthyroidism was more common amongst SA compared to AC (2.8% vs. 0.9%, P = 0.017), while rates of subclinical hypothyroidism were similar. On multivariate analysis of variations in subclinical thyroid function, ethnicity was not independently significant.

Conclusion

The prevalence of subclinical thyroid disorders amongst SA and AC minority groups in Britain reflects levels reported in other populations. The clinical cardiovascular significance of subclinical thyroid disease is unclear, and it does not appear to be ethnically specific.     

Prognostic importance of the oxidized product of catecholamines,adrenolutin, in patients with severe heart failure

Objectives

The purpose of this study was to assess whether adrenolutin, the inert product of the highly reactive molecules aminochromes, is increased in severe chronic heart failure and whether it is associated with a poor prognosis.

Background

Experimental evidence suggests that oxidative products of catecholamines, aminochromes, are more cardiotoxic than unoxidized catecholamines and may be increased in heart failure.

Methods

Adrenolutin was measured at baseline and at 1 and 3 months in 263 patients with chronic New York Heart Association class III or IV heart failure and a left ventricular ejection fraction of 22% ± 7%. Adrenolutin levels were compared with normal levels, and their relation to prognosis was evaluated.

Results

Baseline adrenolutin was increased (55 ± 90 pg/mL vs 8.4 ± 9.1 pg/mL for control, P < .02) and remained increased at 1 month (49 ± 65 pg/mL). During a mean follow-up of 309 ± 148 days (22-609 days), 57 patients died. Baseline adrenolutin levels correlated with mortality rates by univariate and multivariate analyses (relative risk 1.06, 95% CI 1.01-1.10 for each 17.9-pg/mL rise, P = .032). Left ventricular ejection fraction (P = .013) and New York Heart Association class (P = .009) were the only other variables associated with survival. Age, sex, plasma creatinine, plasma N-terminal atrial natriuretic peptide, and plasma norepinephrine levels were not retained in our model. Adrenolutin levels 1 month after random assignment were not significantly correlated with total mortality rate (P = .061) but were correlated with mortality rate from low output (relative risk 1.14, 95% CI 1.06-1.22, P = .002).

Conclusions

Plasma adrenolutin is increased in patients with heart failure and correlates with a poor prognosis independent of other important predictors of survival. This finding has potentially important pathophysiologic, prognostic, and therapeutic implications.     

Sodium intake and mortality in the NHANES II follow-up study

Purpose

US Dietary Guidelines recommend a daily sodium intake <2300 mg, but evidence linking sodium intake to mortality outcomes is scant and inconsistent. To assess the association of sodium intake with cardiovascular disease (CVD) and all-cause mortality and the potential impact of dietary sodium intake <2300 mg, we examined data from the Second National Health and Nutrition Examination Survey (NHANES II).

Methods

Observational cohort study linking sodium, estimated by single 24-hour dietary recall and adjusted for calorie intake, in a community sample (n = 7154) representing 78.9 million non-institutionalized US adults (ages 30-74). Hazard ratios (HR) for CVD and all-cause mortality were calculated from multivariable adjusted Cox models accounting for the sampling design.

Results

Over mean 13.7 (range: 0.5-16.8) years follow-up, there were 1343 deaths (541 CVD). Sodium (adjusted for calories) and sodium/calorie ratio as continuous variables had independent inverse associations with CVD mortality (P = .03 and P = .008, respectively). Adjusted HR of CVD mortality for sodium <2300 mg was 1.37 (95% confidence interval [CI]: 1.03-1.81, P = .033), and 1.28 (95% CI: 1.10-1.50, P = .003) for all-cause mortality. Alternate sodium thresholds from 1900-2700 mg gave similar results. Results were consistent in the majority of subgroups examined, but no such associations were observed for those <55 years old, non-whites, or the obese.

Conclusion

The inverse association of sodium to CVD mortality seen here raises questions regarding the likelihood of a survival advantage accompanying a lower sodium diet. These findings highlight the need for further study of the relation of dietary sodium to mortality outcomes.     

Etiologic discussion and clinical relevance of thyroid ultrasonography in subclinical hypothyroidism. A retrospective study in 1845 patients

Background

Acquired subclinical hypothyroidism in adulthood is mainly due to autoimmune thyroiditis. In the absence of a goiter or a palpable firm thyroid, measurement of thyroid antibodies can improve the diagnosis. Whether thyroid antibodies are detected or not, what might be the clinical relevance of ultrasonography in this setting?

Methods

We studied 1845 cases of subclinical hypothyroidism in adults recruited for symptoms indicative of hypothyroidism or thyroid pathology. All patients were screened for thyroid antibodies and underwent an ultrasonographic thyroid examination.

Localisation

Multicentric retrospective study.

Results

Chronic autoimmune thyroiditis was confirmed in 70% of patients. Thyroid antibodies were undetectable in 30% of patients. In all patients, thyroid ultrasound facilitated measurement of the thyroid volume and detection of non-palpable nodules and therefore allowed biopsy. In patients negative for thyroid antibodies, ultrasonography suggested autoimmune thyroiditis in 31% of cases. Ultrasonography did not contribute to diagnosis in a large number of patients without nodules and in case of normal echostructure. The strategy of thyroid hormone replacement therapy was not influenced by ultrasonographic data. Thyroid biopsies detected smears suspected to be cancerous in 10 patients (4%). Cancer was confirmed in nine patients after surgery. Ultrasonography displayed suspicious aspects in six patients.

Conclusion

In subclinical hypothyroidism, thyroid ultrasonography is not required for the diagnosis of autoimmune thyroiditis but is useful for patients with abnormal thyroid palpation and allows detection of non-palpable thyroid nodules. For patients that were negative for thyroid antibodies, thyroid ultrasonography can improve diagnosis for some patients, allowing detection of autoimmune thyroiditis.     

Elevated leukocyte count and adverse hospital events in patients with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events (GRACE)

Objective

To examine the association between elevated leukocyte count and hospital mortality and heart failure in patients enrolled in the multinational, observational Global Registry of Acute Coronary Events (GRACE).

Background

Elevated leukocyte count is associated with adverse hospital outcomes in patients presenting with acute myocardial infarction (AMI). The association of this prognostic factor with hospital mortality and heart failure in patients with other acute coronary syndromes (ACS) is unclear.

Methods

We examined the association between admission leukocyte count and hospital mortality and heart failure in 8269 patients presenting with an ACS. This association was examined separately in patients with ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina. Leukocyte count was divided into 4 mutually exclusive groups (Q): Q1 <6000, Q2 = 6000-9999, Q3 = 10,000-11,999, Q4 >12,000. Multiple logistic regression analysis was performed to examine the association between elevated leukocyte count and hospital events while accounting for the simultaneous effect of several potentially confounding variables.

Results

Increasing leukocyte count was significantly associated with hospital death (adjusted odds ratio [OR] 2.8, 95% CI 2.1-3.6 for Q4 compared to Q2 [normal range]) and heart failure (OR 2.7, 95% CI 2.2-3.4) for patients presenting with ACS. This association was seen in patients with ST-segment elevation AMI (OR for hospital death 3.2, 95% CI 2.1-4.7; OR for heart failure 2.4, 95% CI 1.8-3.3), non-ST-segment elevation AMI (OR for hospital death 1.9, 95% CI 1.2-3.0; OR for heart failure 1.7, 95% CI 1.1-2.5), or unstable angina (OR for hospital death 2.8, 95% CI 1.4-5.5; OR for heart failure 2.0, 95% CI 0.9-4.4).

Conclusion

In men and women of all ages with the spectrum of ACS, initial leukocyte count is an independent predictor of hospital death and the development of heart failure.     

A 14-year follow-up study of chest pain patients including stress hormones and mental stress at index event

Background

Knowledge of long-term outcome in chest pain patients is limited. We reinvestigated patients who 14 years earlier had visited the emergency department due to chest pain, and were discharged without hospitalization. Extensive examinations were made at that time on 484 patients including full medical history, exercise test, a battery of stress questions and stress hormone sampling.

Methods

From a previously conducted chest pain study patients still alive after 14 years were approached. Hospitalization or deaths with a diagnosis of ischemic heart disease or cerebrovascular disease were used as end point.

Results

During the follow-up period 24 patients had died with a diagnosis of ischemic heart or cerebrovascular disease, and 50 patients had been given such a diagnosis at hospital discharge. Age (OR 1.12, CI 1.06-1.19), previous history of angina pectoris (OR 9.69, CI 2.06-71.61), pathological ECG at emergency department visit (OR 3.27, CI 1.23-8.67), hypertension (OR 5.03, CI 1.90-13.76), smoking (OR 3.04, CI 1.26-7.63) and lipid lowering medication (OR 14.9, CI 1.60-152.77) were all associated with future ischemic heart or cerebrovascular events. Noradrenalin levels were higher in the event group than in the non-event group, mean (SD) 2.44 (1.02) nmol/L versus 1.90 (0.75) nmol/L. When noradrenalin was included in the regression model high maximal exercise capacity was protective of an event (OR 0.986, CI 0.975-0.997).

Conclusion

In chest pain patients previous history of angina pectoris, hypertension, smoking, pathological ECG at primary examination, and age were the main risk factors associated with future cardiovascular or cerebrovascular events.     

Socio demographic wise risk assessment of thyroid function abnormalities in far western region of Nepal: A hospital based descriptive study

Objective

To know the status of thyroid disorder in population of far western region of Nepal.

Methods

A total of 808 cases (133 men and 675 non pregnant women) were included and study was carried out using data retrieved from the register maintained in the Department of Biochemistry of the Nepalgunj Teaching Hospital between 1st January, 2011 and 28th February, 2012. The variables collected were age, sex, and thyroid function profile including free T3, free T4 and TSH.

Results

The percentage of thyroid disorders was 33.66% in far western region of Nepal. The people were highly affected by overt hyperthyroidism (14.9%) followed by subclinical hyperthyroidism (9.9%). The subclinical hypothyroidism was 7.9% while 1% overt hypothyroidism only in a far western region of Nepal. Females were highly affected by overt hyperthyroidism (17.8%), followed by subclinical hyperthyroidism (11.9%). A total of 5.9% females were affected by subclinical hypothyroidism while only 1.2% by overt hypothyroidism. Males were affected only by subclinical hypothyroidism (18.0%) in this present study. High number of total thyroid dysfunction was observed in 21 to 40 years of age groups, followed by 41 to 60 years of age groups. Less than 40 years people were having 1.03, 0.99, 2.51 and 1.15 times risk of developing overt hyperthyroidism, subclinical hyperthyroidism, overt hypothyroidism and subclinical hyperthyroidism respectively compared to greater than 40. Female were having 0.29 times risk of developing subclinical hyperthyroidism compared to male. But overt hyperthyroidism, subclinical hyperthyroidism and overt hypothyroidism female were having more risk of developing compared to male.

Conclusions

The thyroid disorder, especially overt hyperthyroidism (14.9%) and subclinical hyperthyroidism (9.9%) was high. Further studies are required to characterize the reasons for this high prevalence.     

Descriptive epidemiology of thyroid cancer in France: Incidence, mortality and survival

Objectives

Describe time trends of incidence and mortality associated with thyroid cancer and provide 1 and 5-year survivals by histological group in French areas covered by cancer registries.

Material and methods

Data for 1975 to 2004 were provided by one thyroid-dedicated and 11 general registries. Incidence estimates were obtained by correction of incidence from areas with registries, then projections for 2008 were derived. Overall and relative survivals by sex and age (diagnosis period 1989-1997; cut-off date 1st January 2002) were obtained from the dedicated and nine other registries. Comparisons between areas or time periods used world-standardized rates.

Results

Between 1980 and 2005, incidence increased but mortality decreased in men and women. Annual cases increased five times and projections for 2008 were 8,000 cases and 400 deaths. The main increasing subtype was papillary carcinoma. One-year overall and relative survivals were 92 and 94%, respectively. Five-year overall and relative survivals were 87 and 93%, respectively. The highest survival (> 94%) concerned papillary carcinomas and the lowest (< 15%) anaplastic carcinomas. Survivals were generally higher in women than in men; precisely, higher in women for papillary and follicular carcinomas but higher in men for medullary and anaplastic carcinomas. Survivals increased with age, but for medullary carcinomas. Survivals from anaplastic carcinomas were very low whatever the age.

Conclusion

The increase of thyroid cancer frequency is dramatic but survivals are improving. Though the prognosis of the most increasing histological subtype is generally good, it remains very important to identify the causes of this steady increase to implement adequate preventive measures.     

Prevalence and Relative Risk of Other Autoimmune Diseases in Subjects with Autoimmune Thyroid Disease

Background

Common autoimmune disorders tend to coexist in the same subjects and to cluster in families.

Methods

We performed a cross-sectional multicenter study of 3286 Caucasian subjects (2791 with Graves' disease; 495 with Hashimoto's thyroiditis) attending UK hospital thyroid clinics to quantify the prevalence of coexisting autoimmune disorders. All subjects completed a structured questionnaire seeking a personal and parental history of common autoimmune disorders, as well as a history of hyperthyroidism or hypothyroidism among parents.

Results

The frequency of another autoimmune disorder was 9.67% in Graves' disease and 14.3% in Hashimoto's thyroiditis index cases (P = .005). Rheumatoid arthritis was the most common coexisting autoimmune disorder (found in 3.15% of Graves' disease and 4.24% of Hashimoto's thyroiditis cases). Relative risks of almost all other autoimmune diseases in Graves' disease or Hashimoto's thyroiditis were significantly increased (>10 for pernicious anemia, systemic lupus erythematosus, Addison's disease, celiac disease, and vitiligo). There was relative “clustering” of Graves' disease in the index case with parental hyperthyroidism and of Hashimoto's thyroiditis in the index case with parental hypothyroidism. Relative risks for most other coexisting autoimmune disorders were markedly increased among parents of index cases.

Conclusion

This is one of the largest studies to date to quantify the risk of diagnosis of coexisting autoimmune diseases in more than 3000 index cases with well-characterized Graves' disease or Hashimoto's thyroiditis. These risks highlight the importance of screening for other autoimmune diagnoses if subjects with autoimmune thyroid disease present with new or nonspecific symptoms.     

Impact of anemia on mortality, cognition, and function in community-dwelling elderly

Purpose

To explore the impact of varying hemoglobin levels on mortality, function, and cognition in a representative population of older persons.

Methods

Participants in this prospective cohort study included 1 744 men and women, aged 71 years or older, from a random household sample living in Durham and surrounding counties in North Carolina. Hemoglobin levels were obtained from participants at baseline in 1992. Functional status was measured at the 4-year follow-up interview using Katz and instrumental activities of daily living. Cognition was measured using the Short Portable Mental Status Questionnaire (SPMSQ). Death was determined by search of the National Death Index, and all deaths through 2000 are included.

Results

Using World Health Organization (WHO) criteria, the prevalence of anemia was 24%. There was a strong racial difference with an odds ratio, adjusted for age, education, estimated glomerular filtration rate and comorbidity of 3.0 (95% CI, 2.3-3.9) in African Americans compared with Caucasians. The risk ratio for 8-year mortality was 1.7 (95% CI, 1.5-2.0) for anemic subjects (P = .0001) and did not differ by sex or race. Anemia was strongly associated with poorer physical function (P = .0001) and cognitive function (P = .0001), and predicted decreases in both over a 4-year period.

Conclusions

In an elderly community-based population, anemia is more prevalent in African Americans and is independently associated with increased mortality over 8 years for both races and sexs. Anemia also is a risk factor for functional and cognitive decrease.     

Low triiodothyronine and exercise capacity in heart failure

Background

Cardiopulmonary exercise test (CPT) has a prominent value in assessing clinical severity in chronic heart failure (HF) patients. Reduced free triiodothyronine (fT3) plasma level is associated with a more severe disease and prognosis. The aim of this study was to evaluate the relationship between low fT3 plasma level and reduced exercise capacity in chronic HF, and to determine the influence of a low T3 status in subsets of patients with different functional impairment.

Methods and results

240 HF patients (79% males; age 62 ± 12 years, mean ± standard deviation; left ventricular ejection fraction, EF, 30 ± 9%) underwent a CPT, clinical and neurohormonal characterization (assay for plasma brain natriuretic peptide, BNP, norepinephrine, aldosterone, renin activity, fT3, free T4, thyroid-stimulating hormone). At multivariate analysis in the whole population, age, gender and BNP level were independently associated with peak VO2, whereas in patients with severe functional impairment (peak VO2 < 14 ml/min/kg) fT3 resulted independently related to peak VO2, together with gender and BNP. When patients with peak VO2 < 14 ml/min/kg were divided according to fT3 levels, patients with low T3 syndrome showed reduced exercise capacity and worse ventilatory efficiency.

Conclusions

BNP and fT3 are independently associated with exercise capacity in severely compromised HF patients.     

Thyroid and gastric autoimmune diseases

Objectives

Autoimmune thyroid disease (AITD) is frequently accompanied by other organ-specific diseases. We investigated the frequency of the association AITD-Biermer's disease (BD) in patients with AITD by investigating the prevalence of intrinsic factor antibodies (IF-Ab).

Design and Methods

Sera from 113 patients with AITD (hypo- or hyperthyroidism) were screened for the presence of type I IF-Ab with a competitive automated immunoassay based. Matched sera from 113 patients with dysthyroidism (not AITD) were tested.

Results

Four IF-Ab positive patients suffered from AITD. BD was known for two of them and strongly suspected in the two others. All patients with no AITD tested IF-Ab negative. B12 levels were often low whatever the etiology.

Conclusion

The prevalence of IF-AbI is higher (3.5%) in patients with AITD. Prospective studies should investigate whether correcting thyroid dysfunction improves vitamin B12 levels, and establish whether routine screening for gastric autoimmunity is clinically useful or purely academic.     

Incidence and mortality of heart failure: A community-based study

Background

Data on the incidence and mortality of heart failure (HF) in community-based populations of developed countries are limited. We estimated the trends of the incidence and, the mortality of HF.

Methods

Prospective population-based study in a white, low-middle class Mediterranean community of 267,231 inhabitants in Spain. Participants were all the patients (= > 14 years), newly diagnosed with HF (4793), according to the Framingham criteria, from January 1, 2000 through December 31, 2007. Main outcome were incidence and mortality following an HF diagnosis.

Results

Incidence of HF increased among both men and women, and among persons with systolic and non-systolic HF. Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 (RR 1.32, CI 95% 1.27-13.7, P < .01). Although, risk-adjusted mortality declined from 2000 to 2007, the prognosis for patients with newly diagnosed HF remains poor. In 2007, risk-adjusted 30-day, 1-year, and 4-years mortality was 12.1%, 28.8%, and 61.4%, respectively. Incidence and mortality of systolic HF were higher than those of non-systolic HF (P < 0.05).

Conclusions

During the last 8 years, in a white, middle class population of the south of Europe, the increased incidence and the decreased mortality of heart failure have resulted in an increased prevalence of heart failure. Incidence and mortality of systolic heart failure were higher than those of non-systolic heart failure.     

In-hospital outcomes of a regional ST-segment elevation myocardial infarction acute transfer and repatriation program

Background

Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) presents challenges in a large geographic area for achieving treatment time targets and creates demands on the PCI centre resources.

Objective

We compare the in-hospital mortality rate of patients presenting with STEMI and referred for PCI from 11 transfer hospitals with those presenting to the cardiac centre in a regional STEMI program with a selective repatriation strategy.

Methods

Between June 1, 2003, and June 30, 2007, clinical and procedural data of all STEMI patients who were referred to the catheterization laboratory were prospectively collected. Patients who sustained prolonged cardiac arrest were excluded.

Results

A total of 1154 patients from regional hospitals and 325 patients initially presenting to the PCI centre were referred for acute intervention. There was no significant in-hospital mortality difference between the 2 groups (3.7% vs 4.0%, respectively; P = 0.87). Multiple logistic regression analysis showed that advanced age, female gender, multivessel coronary disease, history of hypertension, low ejection fraction, increased left ventricular end-diastolic pressure, and thrombolytic pretreatment, but not transfer status, were independent predictors for mortality. Among the 1154 transfer patients, 937 patients (81.2%) returned immediately post procedure and had a lower mortality rate than the remaining 217 patients (18.2%) who required admission to the PCI centre following cardiac catheterization (1.9% vs 11.5%, P < 0.001).

Conclusion

A regional system of STEMI care based on rapid patient transfer to a PCI centre and repatriation was feasible and safe.     

Coronary ischemic events after first atrial fibrillation: risk and survival

Purpose

We aimed to determine the long-term, gender-specific incidence and mortality risk of coronary ischemic events after first atrial fibrillation (AF).

Methods

In this longitudinal cohort study, adult residents of Olmsted County, Minnesota, with an electrocardiogram-confirmed AF first documented in 1980 to 2000 and without prior coronary heart disease, were followed to 2004. The primary outcome was first coronary events (angina with angiographic confirmation, unstable angina, nonfatal myocardial infarction, or coronary death). Sex-specific incidence of coronary ischemic events and survival after development of such events were assessed using Cox proportional hazards modeling. Kaplan-Meier estimates of risks for coronary ischemic events were compared with those predicted by the Framingham equation.

Results

Of the 2768 subjects (mean age 71 years, 48% were men), 463 (17%) had a first coronary event during a follow-up of 6.0 ± 5.2 years. The unadjusted incidence was 31 per 1000 person-years, and there was no difference between men and women. The incidence was higher in men (hazard ratio 1.32, P = .004) after adjusting for age. The 10-year event estimates were 22% and 19% in men and women, respectively, by our Kaplan-Meier analyses, and 21% and 11%, respectively, by Framingham risk equation. The mortality risk after coronary events was higher in women (hazard ratio 2.99 vs 2.33; P = .044), even after multiple adjustment.

Conclusions

First AF marks a high risk for new coronary ischemic events in both men and women. AF conferred additional risk for coronary events beyond conventional risk prediction in women only. The excess mortality risk associated with the development of coronary events was significantly greater in women.