Effect of thyroid dysfunction on N-terminal pro-B-type natriuretic peptide levels: A systematic review and meta-analysis

Development and validation of an integrated prognostic model for all-cause mortality in heart failure: a comprehensive analysis combining clinical, electrocardiographic, and echocardiographic parameters

BACKGROUND

Accurate risk prediction in heart failure remains challenging due to its complex pathophysiology. We aimed to develop and validate a comprehensive prognostic model integrating demographic, electrocardiographic, echocardiographic, and biochemical parameters.

METHODS

We conducted a retrospective cohort study of 445 heart failure patients. The cohort was randomly divided into training (n = 312) and validation (n = 133) sets. Feature selection was performed using LASSO regression followed by backward stepwise Cox regression. A nomogram was constructed based on independent predictors. Model performance was assessed through discrimination, calibration, and decision curve analyses. Random survival forest analysis was conducted to validate variable importance.

RESULTS

During a median follow-up of 4.14 years, 142 deaths (31.91%) occurred. Our model development followed a systematic approach: initial feature selection using LASSO regression identified 15 potential predictors, which were further refined to nine independent predictors through backward stepwise Cox regression. The final predictors included age, NYHA class, left ventricular systolic dysfunction, atrial septal defect, aortic valve annulus calcification, tricuspid regurgitation severity, QRS duration, T wave offset, and NT-proBNP. The integrated model demonstrated good discrimination for 2-, 3-, and 5-year mortality prediction in both training (AUCs: 0.726, 0.755, 0.809) and validation cohorts (AUCs: 0.686, 0.678, 0.706). Calibration plots and decision curve analyses confirmed the model's reliability and clinical utility across different time horizons. A nomogram was constructed for individualized risk prediction. Kaplan-Meier analyses of individual predictors revealed significant stratification of survival outcomes, while restricted cubic spline analyses demonstrated non-linear relationships between continuous variables and mortality risk. Random survival forest analysis identified the top five predictors (age, NT-proBNP, QRS duration, tricuspid regurgitation severity, NYHA), which were compared with our nine-variable model, confirming the superior performance of the integrated model across all time points.

CONCLUSIONS

Our integrated prognostic model showed robust performance in predicting all-cause mortality in heart failure patients. The model's ability to provide individualized risk estimates through a nomogram may facilitate clinical decision-making and patient stratification.

CLINICAL TRIAL NUMBER

Not applicable.

Cardiovascular Risk and Plasma N-terminal Pro-B-type Natriuretic Peptide in Adults With Resistance to Thyroid Hormone β

Purpose

People with resistance to thyroid hormone due to defective thyroid receptor β (RTHβ) exhibit adverse cardiovascular outcomes and premature mortality. Whether this reflects increased global cardiovascular disease (CVD) risk or hyperthyroxinemia-associated effects on cardiac rhythm and contractility is unknown. We determined CVD risk and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations as a marker of reduced cardiac function in 99 individuals (mean age 41 years, 37% males) with RTHβ.

Results

The mean (SD range) QRISK3 score for 82 participants was 2.0% (0.5-8.8%) vs 1.3% (0.3-5.0%) for age, sex, and ethnicity-matched healthy controls (P = .005). The QRISK3 heart age of RTHβ participants was 49.8 ± 14.5 years vs actual age 44.5 ± 12.4 years [difference 5.3 (95% confidence interval: 4.0, 6.5) years; P < .001]. The mean (SD range) plasma NT-proBNP in 79 RTHβ participants was 51 (18-142) pg/mL; 10.1% of values were above the age-specific 97.5th percentile of a large control sample. In multiple linear regression, age and female sex were significant independent predictors of NT-proBNP (P ≤ .001), but free T3, free T4, TSH, and QRISK3 10-year CVD risk were not.

Conclusion

Elevated NT-proBNP concentrations, seen even in young people with RTHβ, suggest that myocardial dysfunction contributes to early adverse cardiovascular outcomes in this disorder, with increased atherosclerotic disease risk likely manifesting later in life. Measurement of NT-proBNP and assessment of cardiovascular risk should be considered at first presentation and periodically during follow-up of RTHβ.

Association of Thyroid Dysfunction in Individuals ≥ 65 Years of Age With Subclinical Cardiac Abnormalities

CONTEXT

The relationship between thyroid dysfunction and measures of myocardial disease in older individuals remains to be defined.

OBJECTIVE

To evaluate the impact of thyroid dysfunction on structure and function of the left heart chambers and blood markers of cardiac disease.

METHODS

Cross-sectional analysis of the Cardiovascular Health Study, a community-based cohort of older individuals recruited from 4 urban areas in the United States. Of 3163 participants studied, 2477 were euthyroid, 465 had subclinical hypothyroidism (SCH), 47 overt hypothyroidism (OH), 45 endogenous (endo) subclinical hyperthyroidism (endo-SCT), and 129 had exogenous (exo) SCT due to thyroid hormone supplementation. Participants underwent clinical evaluation, blood sampling and biomarker measurement, 2-dimensional and speckle tracking echocardiography for assessment of left heart myocardial deformation, circulating biomarkers of diastolic overload (NT-proBNP), fibrosis (sST2, gal-3), and cardiomyocyte injury (hs-cTnT).

RESULTS

SCH was associated with higher NT-proBNP (beta = 0.17, P = .004), whereas OH was associated with higher hs-cTnT (beta = 0.29, P = .005). There were also suggestive associations of SCH with higher sST2, as well as endo-SCT with higher gal-3 and lower (worse) left atrial reservoir strain. Left ventricular longitudinal strain and end diastolic strain rate did not differ significantly from euthyroid participants in SCH, OH, or exo-SCT.

CONCLUSION

In this free-living elderly cohort, subclinical and overt hypothyroidism were associated with abnormalities of blood biomarkers consistent with diastolic overload and myocardial necrosis respectively, whereas subclinical hyperthyroidism tended to be associated with myocardial fibrosis and decreased left atrial strain. Our findings could represent stage B heart failure and illuminate distinct aspects of the pathobiology of heart disease related to thyroid gland dysfunction with potential clinical implications.

Causal association of TSH with ischemic heart diseases and heart failure: A 2-sample Mendelian randomization study

Thyroid dysfunction is associated with the risk of cardiovascular disease; however, whether plasma thyroid-stimulating hormone (TSH) levels in subjects with euthyroidism affect the risk of cardiovascular disease remains unclear. This study aimed to investigate the causal association between plasma TSH levels and cardiovascular diseases, particularly ischemic heart disease and heart failure (HF). Summary statistics from the Integrative Epidemiology Unit Open genome-wide association studies Project and FinnGen consortium were used to investigate the causal relationship between plasma TSH levels and the risk of cardiovascular diseases. Two-sample Mendelian randomization analysis using inverse-variance weighting as the primary method was performed. The MR Pleiotropy RESidual Sum and Outlier and leave-one-out methods were used to ensure the robustness of our findings. Genetically determined plasma TSH levels were associated with major coronary heart disease events (OR 1.0557, 95% CI 1.0141-1.0991), all-cause HF (OR 0.9587, 95% CI 0.9231-0.9956), and HF + non-ischemic cardiomyopathy (OR 0.9318, 95% CI 0.8786-0.9882). After the Bonferroni correction, the causation described above disappeared. In the secondary analysis, genetically determined higher TSH levels were associated with a higher risk for unstable angina pectoris (OR 1.0913, 95% CI 1.0350-1.1507), but were associated with a lower risk for HF + overweight (OR 0.9265, 95% CI 0.8821-0.9731). These results were further validated using sensitivity analysis. Our findings show that increased plasma TSH levels in patients with euthyroidism may increase the risk of unstable angina pectoris but reduce the risk of HF in overweight patients. This evidence indicates that plasma TSH levels may need to be carefully controlled in specific patients.

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.