Vol 27, No 3 (2020)
Original articles — Clinical cardiology
Published online: 2018-08-31

open access

Page views 1992
Article views/downloads 998
Get Citation

Connect on Social Media

Connect on Social Media

Association between mild thyroid dysfunction and clinical outcome in acute coronary syndrome undergoing percutaneous coronary intervention

Qian Cao1, Yundi Jiao1, Tongtong Yu1, Zhaoqing Sun1
Pubmed: 30234907
Cardiol J 2020;27(3):262-271.


Background: Thyroid hormones profoundly influence the cardiovascular system, but the effects of mild thyroid dysfunction on the clinical outcome of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) are not well defined. This study aimed to determine the effect of mild thyroid dysfunction on 12-month prognosis in ACS patients undergoing PCI.

Methods: In this prospective cohort study with a 12-month follow-up, 1560 individuals were divided into four groups based on thyroid hormone levels upon admission: euthyroidism (used as a reference group), subclinical hypothyroidism, subclinical hyperthyroidism, and low triiodothyronine syndrome (low T3 syndrome). The outcomes measured were all-cause mortality, cardiac mortality, nonfatal rein­farction, and unplanned repeat revascularization.

Results: In this study, the prevalence of mild thyroid dysfunction was 10.8%. Multivariate analysis showed that low T3 syndrome, but not subclinical hypothyroidism or subclinical hyperthyroidism, was associated with a higher rate of all-cause (HR 2.553, 95% CI 1.093–5.964, p = 0.030) and cardiac mortality (HR 2.594, 95% CI 1.026–6.559, p = 0.034), compared with the euthyroidism group.

Conclusions: Mild thyroid dysfunction was frequent in patients with ACS undergoing PCI. Low T3 syndrome was the predominant feature and was associated with 12-month adverse outcomes in these patients.

Article available in PDF format

View PDF Download PDF file


  1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 64(24): e139–e228.
  2. O'Gara P, Kushner F, Ascheim D, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2013; 61(4): e78–e140.
  3. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37(3): 267–315.
  4. Steg PhG, James SK, Atar D, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20): 2569–2619.
  5. Ibáñez B, Heusch G, Ovize M, et al. Evolving therapies for myocardial ischemia/reperfusion injury. J Am Coll Cardiol. 2015; 65(14): 1454–1471.
  6. Eapen ZJ, Tang WH, Felker GM, et al. Defining heart failure end points in ST-segment elevation myocardial infarction trials: integrating past experiences to chart a path forward. Circ Cardiovasc Qual Outcomes. 2012; 5(4): 594–600.
  7. Jabbar A, Pingitore A, Pearce SHS, et al. Thyroid hormones and cardiovascular disease. Nat Rev Cardiol. 2017; 14(1): 39–55.
  8. Friberg L, Werner S, Eggertsen G, et al. Rapid down-regulation of thyroid hormones in acute myocardial infarction: is it cardioprotective in patients with angina? Arch Intern Med. 2002; 162(12): 1388–1394.
  9. Smith SJ, Bos G, Gerbrandy J, et al. Lowering of serum 3,3',5-triiodothyronine thyroxine ratio in patients with myocardial infarction; relationship with extent of tissue injury. Eur J Clin Invest. 1978; 8(2): 99–102.
  10. Viswanathan G, Balasubramaniam K, Hardy R, et al. Blood thrombogenicity is independently associated with serum TSH levels in post-non-ST elevation acute coronary syndrome. J Clin Endocrinol Metab. 2014; 99(6): E1050–E1054.
  11. Coceani M, Iervasi G, Pingitore A, et al. Thyroid hormone and coronary artery disease: from clinical correlations to prognostic implications. Clin Cardiol. 2009; 32(7): 380–385.
  12. Bai Mf, Gao Cy, Yang Ck, et al. Effects of thyroid dysfunction on the severity of coronary artery lesions and its prognosis. J Cardiol. 2014; 64(6): 496–500.
  13. Lymvaios I, Mourouzis I, Cokkinos DV, et al. Thyroid hormone and recovery of cardiac function in patients with acute myocardial infarction: a strong association? Eur J Endocrinol. 2011; 165(1): 107–114.
  14. Jankauskienė E, Orda P, Barauskienė G, et al. Relationship between left ventricular mechanics and low free triiodothyronine levels after myocardial infarction: a prospective study. Intern Emerg Med. 2016; 11(3): 391–398.
  15. Kim DH, Choi DH, Kim HW, et al. Prediction of infarct severity from triiodothyronine levels in patients with ST-elevation myocardial infarction. Korean J Intern Med. 2014; 29(4): 454–465.
  16. Jonklaas J, Bianco AC, Bauer AJ, et al. American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014; 24(12): 1670–1751.
  17. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016; 26(10): 1343–1421.
  18. Biondi B, Bartalena L, Cooper DS, et al. The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism. Eur Thyroid J. 2015; 4(3): 149–163.
  19. LeFevre ML. U.S. Preventive Services Task Force. Screening for thyroid dysfunction: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015; 162(9): 641–650.
  20. Chopra IJ. Clinical review 86: Euthyroid sick syndrome: is it a misnomer? J Clin Endocrinol Metab. 1997; 82(2): 329–334.
  21. Iervasi G, Molinaro S, Landi P, et al. Association between increased mortality and mild thyroid dysfunction in cardiac patients. Arch Intern Med. 2007; 167(14): 1526–1532.
  22. Marraccini P, Bianchi M, Bottoni A, et al. Prevalence of thyroid dysfunction and effect of contrast medium on thyroid metabolism in cardiac patients undergoing coronary angiography. Acta Radiol. 2013; 54(1): 42–47.
  23. Özcan KS, Osmonov D, Toprak E, et al. Sick euthyroid syndrome is associated with poor prognosis in patients with ST segment elevation myocardial infarction undergoing primary percutaneous intervention. Cardiol J. 2014; 21(3): 238–244.
  24. Yu T, Tian C, Song J, et al. Derivation and Validation of Shock Index as a parameter for Predicting Long-term Prognosis in Patients with Acute Coronary Syndrome. Sci Rep. 2017; 7(1): 11929.
  25. Cutlip DE, Windecker S, Mehran R, et al. Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007; 115(17): 2344–2351.
  26. Iervasi G, Pingitore A, Landi P, et al. Low-T3 syndrome: a strong prognostic predictor of death in patients with heart disease. Circulation. 2003; 107(5): 708–713.
  27. Wang B, Liu S, Li L, et al. Non-thyroidal illness syndrome in patients with cardiovascular diseases: A systematic review and meta-analysis. Int J Cardiol. 2017; 226: 1–10.
  28. Pfister R, Strack N, Wielckens K, et al. The relationship and prognostic impact of low-T3 syndrome and NT-pro-BNP in cardiovascular patients. Int J Cardiol. 2010; 144(2): 187–190.
  29. Brozaitiene J, Mickuviene N, Podlipskyte A, et al. Relationship and prognostic importance of thyroid hormone and N-terminal pro-B-Type natriuretic peptide for patients after acute coronary syndromes: a longitudinal observational study. BMC Cardiovasc Disord. 2016; 16: 45.
  30. Pantos C, Mourouzis I, Cokkinos DV. New insights into the role of thyroid hormone in cardiac remodeling: time to reconsider? Heart Fail Rev. 2011; 16(1): 79–96.
  31. Pantos C, Mourouzis I, Cokkinos DV. Thyroid hormone and cardiac repair/regeneration: from Prometheus myth to reality? Can J Physiol Pharmacol. 2012; 90(8): 977–987.
  32. Pantos C, Mourouzis I. Translating thyroid hormone effects into clinical practice: the relevance of thyroid hormone receptor α1 in cardiac repair. Heart Fail Rev. 2015; 20(3): 273–282.
  33. De Vito P, Incerpi S, Pedersen JZ, et al. Thyroid hormones as modulators of immune activities at the cellular level. Thyroid. 2011; 21(8): 879–890.
  34. De Groot LJ. Dangerous dogmas in medicine: the nonthyroidal illness syndrome. J Clin Endocrinol Metab. 1999; 84(1): 151–164.
  35. Zhang M, Sara JDS, Matsuzawa Y, et al. Clinical outcomes of patients with hypothyroidism undergoing percutaneous coronary intervention. Eur Heart J. 2016; 37(26): 2055–2065.
  36. Jabbar A, Ingoe L, Pearce S, et al. Thyroxine in acute myocardial infarction (ThyrAMI) - levothyroxine in subclinical hypothyroidism post-acute myocardial infarction: study protocol for a randomised controlled trial. Trials. 2015; 16: 115.
  37. Stott DJ, Gussekloo J, Kearney PM, et al. Study protocol; Thyroid hormone Replacement for Untreated older adults with Subclinical hypothyroidism - a randomised placebo controlled Trial (TRUST). BMC Endocr Disord. 2017; 17(1): 6.
  38. Gartner W, Weissel M. Do iodine-containing contrast media induce clinically relevant changes in thyroid function parameters of euthyroid patients within the first week? Thyroid. 2004; 14(7): 521–524.
  39. van der Molen AJ, Thomsen HS, Morcos SK, et al. Contrast Media Safety Committee, European Society of Urogenital Radiology (ESUR). Effect of iodinated contrast media on thyroid function in adults. Eur Radiol. 2004; 14(5): 902–907.