Low triiodothyronine: A new facet of inflammation in acute ischemic stroke

Does this paper really imply we could argue like this:

"Doctor, Please let me have my liothyronine so that when I have a stroke, it will be mild rather than moderate."

Of course, far, far better would be if getting liothyronine in an appropriate dose actually meant no stroke at all. What do you think? After all, thyroid and inflammation are already deeply intertwined.

Clin Chim Acta. 2016 Apr 22. pii: S0009-8981(16)30148-6. doi: 10.1016/j.cca.2016.04.023. [Epub ahead of print]

Low triiodothyronine: A new facet of inflammation in acute ischemic stroke.

Ma L1, Zhu D2, Jiang Y1, Liu Y1, Ma X1, Liu M1, Chen X3.

Author information

    1Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, PR China.

    2Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, PR China; Department of Neurology, Shenzhen Second People's Hospital, PR China.

    3Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, PR China. Electronic address: xiaohongchenzssy@aliyun.com.



Patients with acute ischemic stroke (AIS) frequently experience low free triiodothyronine (fT3) concentrations. Inflammation is recognized as a key contributor to the pathophysiology of stroke. Previous studies, however, did not simultaneously evaluate fT3 and inflammation biomarkers in AIS patients.


Markers of inflammation, including serum concentrations of C-reactive protein (CRP) and albumin, and fT3 were assessed retrospectively in 117 patients. Stroke severity was measured on the National Institutes of Health Stroke Scale (NIHSS). Regression analyses were performed to adjust for confounders.


Serum fT3 concentrations were significantly lower in moderate AIS patients than those in mild AIS patients (P<0.001). fT3 concentration also positively correlated with serum albumin concentration (r=0.358, P<0.001) and negatively correlated with log10CRP concentration (r=-0.341, P<0.001), NIHSS score (r=-0.384, P<0.001). Multiple regression analysis showed that CRP, albumin concentrations and NIHSS score were independently correlated with fT3 concentration. Binary logistic regression analysis showed that fT3 concentration was an independent factor correlated with NIHSS score, the area under the receiver operating characteristic curve was 0.712 (95% CI, 0.618-0.805).


Low fT3 concentrations may be involved in the pathogenic pathway linking inflammation to stroke severity in AIS patients.

Copyright © 2015. Published by Elsevier B.V.


Albumin; C-reactive protein; Inflammation; Stroke; fT3



    [PubMed - as supplied by publisher]


26 Replies

  • Helvella,

    I'll opt for Liothyronine and NO stroke but if I have a stroke then obviously it would be better if it was mild.

  • I have also read that people with good T3 levels also recover from heart attacks better.  Think it was in the book I read - full of research papers - called Thyroid and Heart Failure .....


    Lots more research papers on the topic too.  As many of us have been advocating for years - the importance of the FT3 testing - and still it does not happen as routine.  It should be able to link so many conditions if discovered and treated.  I have just read a paper on CKD - Chronic Kidney Disease and low thyroid.  When will all the medical disciplines get together and put their thinking caps on and actually talk to each other ?

    Thanks Rod for getting me going this morning :-)

  • I have a raised CRP and PV and am  hoping that my endo helps make sure that my GP continues to prescribe me T3. This will give me fuel to add to my arguement that it could be reducing my stroke risk - especially as I also have mildly diseased carotid arteries and hypertension despite having a very healthy diet and lifestyle. Thanks for this I will point it out to my GP when she phones on Tuesday to discuss my latest Thyroid bloods. 

    I've only been taking T3 with my T4 for five weeks and my GP practice is already saying that my TSH is over suppressed. Last year I had three episodes of functional left sided hemiparesis (stroke like episodes) as a response to other medical trauma, so I'm determined to stay on T3 now. 

    But the lab refuses to test my FT3 so I've no way of knowing if it's low or not! 

  • > ...  I've no way of knowing if it's low or not!

    No other way than paying it to Blue Horizon or Genova



  • Would my GP and endo take the results of these seriously? 

  • Twitchytoes,

    We have seen both ends of the spectrum on this issue. Some medics accept them without any problem at all. Others reject them without any apparent consideration at all. (Something like, "all private testing is poor quality, only our local NHS lab is able to test properly".)

    We have seen some NHS medics who will repeat tests that were first done privately in order to reassure themselves.

    We have seen reports of medics who, it would appear, wouldn't know what a Free Triiodothyronine (FT3) test was if it came up and boxed them round their ears.

    We have seen some results where, for example, the Blue Horizon results for the tests that were also done by NHS were near enough identical. I'd argue very hard that if NHS had done, say TSH and FT4, and you had BH tests showing these at the same levels, why would the BH FT3 and B12 not also be just as reliable?

    Some of the BH tests are done by The Doctors Laboratory (TDL), which seems to have a major portion of the London private testing market for the likes of Harley Street and some private hospitals. The consultants who work both privately and NHS seem to have no problem accepting TDL's results for their fee-paying patients and NHS tests for their NHS patients.

  • Depending where you are in the country you will find that some of your BH tests are actually done by an NHS lab. NHS labs do private work.

    For example I know  one of my 2 samples was sent to a NHS lab in Surrey.  They do all the NHS blood tests for NHS Surrey hospitals. I live in a different county  but some people  in my area get sent to other counties including Surrey for treatment by the NHS. I should add I took the test in a third county - Buckinghamshire .

    Unfortunately you will only know this in certain cases e.g. when there are issues with a test and they leave comments on the test results.

    In other words NHS doctors who don't believe private tests results are completely pig ignorant and don't know how NHS services work. They are wasting NHS money by repeating the same tests at very likely another NHS lab. 

  • I have found test results I got taken privately at a clinic in Edinburgh - lovely creamy London Laboratory paper with test results on - have proved very useful to my NHS rheumatologist and the endo. It also forced my old GP's hand because my vitamin D, which he had refused to test on grounds I was "too healthy" came back at 28. As I was on DMARDs and an oral steroid at the time, it forced him to prescribe AdCal D3. It also made me feel much more confident about following my instincts. The other doctors have copied these - TPO antibodies were high confirming Hashimoto's and my FT3 was bottom end of range. This was in 2013 - the only FT3 result I have. 

  • I wonder if they looked at t3 levels in people who did not have  a stroke?  The pattern might well be 

                              good levels of t3 - low risk of stroke

                             Medium levels of t3 - stroke is mild

                              Low levels of t3 - stroke is more severe.

    Who knows?  Would be interesting to see.

  • They should be looking at EVERYONE's FT3 levels in my non-medical opinion. 

  • ...then we have to factor in the fact that the result is only as good as the person looking at them :-)

  • I have a CRP of 10 and an ESR in the 60's. I've been hearing since 1998 this should be followed up, but it never has happened. My last bloods 2 years ago,  were duly flagged by the lab, I remember saying to my GP my inflammation is the highest it's ever been, to silence. 

    I'm relieved I'm funding T3, my symptoms before diagnosis were very much on a par with heart failure.

    At least I don't smoke, but being very overweight I feel like I'm a walking candidate for a stroke.

    Has anyone looked at the link of inflammation and low cortisol causing strokes?

  • My CRP went up last year to 150 twice - put down to autoimmune flare up only. My ESR has always fluctuated from 17 and 80 - reflecting my aches and pains. I did have RA but it's subsided now after four drugs and I'm off everything. Yet still my CRP goes up and down - last time it was 12 about 2 months ago - slowly rising once I got off steroids which got it down to 2. 

    GPs are usually baffled but then they eventually give up and chalk it down to one of those things. I guess if I have a heart attack or stroke they will say "ah yes - we did wonder about her inflammation levels"!

     I'm overweight too but I lost four and a half stone and it made no odds to my CRP. But obesity and age are a factor with ESR. For women it's supposed to be a case of halving your age and adding five. Still 60 is high. I would ask to have your total protein checked and keep pestering the doctors - if you have  rashes or joint pain or IBS symptoms then ask to be referred to a rheumatologist or a gastroenterologist to exclude RA, Lupus, Crohn's, Psoriatic Arthritis, malignant or renal problems. It can't be right to have a high ESR/ PV or CRP with no obvious explanation such as infection. 

  • I can't believe how high your CRP went up to Twitchytoes!

    I had an hospital infection after major surgery that was prolonged and not treated. During this time I started to have bloods done regularly ( not thyroid though) my ESR was in the 30's then, CRP was negative, I had really a high white blood cell count for many years, so much so it almost prevented me from being discharged from hospital after a kidney stone.

    When all this kicked off in 1998 I was sent to a Rheumatologist who told me I didn't have arthritis, but fibromyalgia. 6 years later when I finally started to have X rays I was riddled with arthritis, so much so I was offered knee replacements. The symptoms of arthritis started in my late 20's when I had terrible problems with my neck, pain and getting my head stuck if I looked up, or too far to one side. All my cervical vertebrae are totally shot, I have arthritis in my fingers, wrists, shoulders, knees, spine and neck, so much for fibromyalgia. The orthopaedic hospital I was attending wanted to refer me to a Rheumatologist, this was 10 years after I was told I had fibromyalgia. He was a colleague of the first Rheumatologist, and wouldn't budge from the diagnosis of fibromyalgia. He didn't examine me or order tests. My hand and wrist consultant always said to me something systemic was going on as I was far too young in my 40's to have arthritis. I had surgery to remove lumps of bone from my fingers and on going steroid injections, ( that's another story) I was told the inflammation was coming from my bladder as I have interstitial cystitis. My own theory is this hospital infection set off a huge inflammatory response in my body that never switched off. I also now know that my cortisol is on the floor, how long has it been like this? I'm in the adrenal exhaustion phase taking 20 mg hydrocortisone a day. My cortisol could have been like this for decades as I've had a lot of trauma in my life.

    I don't think we'll ever get to the bottom of this, there were times that I thought I was going completely mad, until my GP finally said the infection has caused my health problems. Immediately after I was crippled, I couldn't get out of a chair or walk normally for years, I felt like I was walking through very thick porridge and the exhaustion has never left me. I was diagnosed with ME until I insisted on a thyroid blood test in 2011.

    Thank you for your helpful reply!

  • I really think you've been very badly served with a diagnosis of Fibro and ME Helcaster. I've been researching for five years and don't know of anyone who has this much arthritis at so young an age who doesn't suffer from some sort of inflammatory disease. Do you suffer from back pain or psoriasis or both I wonder? Spondyloarthtisis could account for raised inflammatory markers and the aggressive arthritis that you describe. 

    RA presents very specifically even if it's in seronegative form but Spondy doesn't always show up in inflammatory markers, is antibody negative (seronegative) and the two main types are thought now to be of a slightly different family to RA, Sjogrens and Lupus. Psoriatic Arthritis (PsA) doesn't always present in form of psoriasis and Ankylosing Spondylitis is much harder to diagnose in women. I think these spondy diseases are know known as auto- inflammatory diseases rather than autoimmune.  There is an inflammatory form of osteoarthritis (OA)- just known as Inflammatory Arthritis I believe. It can be treated quite aggressively with DMARDs with some success I believe.

    Please don't give up pushing for answers - Fibro and ME wouldn't account for aggressive OA of the kind you describe I am sure. Can you ask to be referred to a rheumatologist in a different hospital or ask for MRI to see if there is an inflammatory process going on in your joints and tendons. If there is then you could try and find a rheumatologist who specialises in spondyloarthritis perhaps? 

    Also Addison's Disease might be a contender if you have such low levels of cortisol. This is a serious and rare endocrine autoimmune disease and can also cross over with inflammatory arthritis and osteoporosis - my friend has this and has all sorts of crossover with my symptoms.  

  • Hi Twitchytoes, the problem I have had is doctors covering their backs as the hospital infection has cause so many health problems. I had terrible psoriasis in my armpits, it was really aggressive for 8 years and the burning kept me awake at night. I also had large amounts of skinning from my genitals, even inside my vagina, I saw a professor in gynaecology and he had no idea what it was, but prescribed steroids. The inside of my mouth skins so much I choke on the skin at times, just keep getting told it's autoimmune. I thought I had RA because everything on my right side of my body got painful, and the arthritis is much worse on my right side. What seems to start on my right side is eventually copied on my left. I've had chronic diarrhoea since this time too. In the early days I could eat scrambled eggs and see it in the toilet within 30 minutes,  the same with salads, leaves in brown liquid.

    I saw 11 consultants at one time, years of weekly hospital appointments, endless x rays and MRI'S and none of them could come up with a diagnosis, they didn't even spot underactive thyroid. I kept showing my enlarged tongue and none of them knew what was causing it. I have so given up on doctors and do my best to manage my symptoms.

    My spine shows spondylitis, and I have bone spurs on every joint you can grow them on. 

    My last bloods so many things were flagged, even a protein I seem to remember was low, I'll have to look it up.

    My Gp put me on hydrocortisone based on two adrenal stress tests, but she is so out of her depth. I was fainting all the time and found a consultant who has a special interest in adrenals and pituitary,  I asked for a referral and my Gp forgot to do it. I showed her my armpit hair loss and pubic hair which would point to adrenal, but she had no idea. 

    Thanks again for your help. 

  • Oh my gosh I can't believe what you've been through! I really think you need to see someone who specialises in psoriatic arthritis and ask about mixed connective tissue disease too. 

    My advice to you is to join the Lupus UK and Vasculitis UK HU communities so that you can find others with similarly rare autoimmune problems to yours. 

    The atrophy you mention might be Behcets or Sjogrens - hairloss applies to a whole host of other types of autoimmunity - some extremely rare. 

    You could just get your GP by scruff of neck in a friendly but firm hold and request an appointment with an immunologist ASAP. Good rheumatologists and immunologists will concede that there's still an awful lot they don't know. But there's also a lot that can be done to help stall the disease process  with drugs like Hydroxichloraquine and Methotrexate and anti-tnf drugs. PsA qualifies for all of these. Even Psoriasis alone does. 

    Please don't give up and only plump for self management. I've come across a whole host of shadowlands dwellers as I call those of us with rare and unrecognised autoimmunity. Psoriatic Arthritis is a dreadful disease that causes absolute havoc in all the ways you describe. RA almost invariably presents bilaterally and in the small synovial joints of the hands. But PsA is a different beast although there are many with it who use the NRAS HU too. 

    I too experienced a really bad cover up job with a post op hospital born infection last summer so I know what you are up against. I have moved to a new area far away now and have made a formal complaint about that hospital but not heard back yet. Much better now though. 

    Twitchy x

  • I'm so sorry you have had an hospital infection too Twitchytoes.  Do you think this has contributed to your health problems? Mine was a urinary tract infection post op after a hysterectomy and pelvic floor repair. I expected to feel very battered and bruised but I was sweating so badly, had thigh and back pain, and pain on urination. I told the staff that I suspected cystitis, my urine was never sent to the lab. I was drinking jug fulls of water to try and stay comfortable, but I was going to the toilet every 10 minutes day and night. It wasn't until I had a haemorrhage 10 days post op and am emergency admission that the infection was found. Then whilst waiting for lab reports I was given the wrong antibiotic,  so all in all this infection was raging for a month. I felt very angry for years because if the nurse had taken a sample of urine I may not be in the position I am now. The bladder problems started shortly after, I was drinking pints of cranberry juice a day, not knowing this was the worst thing I could do. I had antibiotic after antibiotic, most of the time there wasn't any bacteria in my urine, but a lot of pus and occasionally protein. I had a cystoscopy but the urologist I saw wasn't familiar with interstitial cystitis and didn't know how to interpret the biopsy results of high mast cells and inflammation on the bladder wall. So I suffered in intense pain and going to the loo every 10 minutes day and night, not being able to go anywhere for 5 years. At the same time the exhaustion and mobility issues, joint and muscle pain was off the scale, I began having terrible migraines too, and a marriage on the rocks. If someone had offered an injection to put me out of my misery I would have said do it. I think this infection, along with the shock of hysterectomy finally saw off my adrenals. I read that ovaries talk to other glands, and hysterectomy can trigger arthritis and all sorts of nasty things. I finally found an urologist 60 miles away who is an expert in interstitial cystitis and he diagnosed me and started treatment. It can't be cured but drugs and a low acid diet can help the symptoms.

    It was private hospital I was in, and the fact they wouldn't re admit me made me very angry. I remember the doctor who came out and called the ambulance was arguing with this hospital on the phone. As soon as I was able I wrote a letter of complaint and got my £3,000 back, if I had know the effect on my health I would have sued them for negligence.

    The GP's in this rural practice are 30 years out of date with their knowledge, I have had many run ins and have already written a complaint after my first appointment, where the Gp threatened to withdraw Levothyroxine because I was having appointments with Dr Skinner, who he called a quack. It's a complete waste of time. The vets here are more compassionate and knowledgeable.  When my anal fissures started I actually had athletes foot cream prescribed, when I told a pharmacist in a small town 20 miles away, the look of shock on her face was priceless. I live quite near to Dr Myhill, not sure if she's taking patients.

    Good luck with your complaint, I would be very surprised if you get anywhere acting on your own. You need a good solicitor familiar with medical blunder cases.

    Hugs. X

  • Your story does have overlaps with mine - but I'm not nearly as incapacitated as you are and fortunately the new hospital I'm under for gastro, gynae, neurologyabs rheumatology has a much better reputation than the last ones I've been under. 

    My problems last year were triggered by a drug called Duloxetine - prescribed by my GP at the neurologist's suggestion. I had a terrible time coming off it when it wasn't working and my mouth was very sore on it. Then, after terrible retching and migraines I got off it only to get pneumonia. Then my rheumatologist decided my RA needed treating once more - despite 3 DMARDs over four years for RA. 

    Once my chest was clear I started this drug, Azathioprine, at lowest dose. Within two weeks I was in hospital with pancreatitis - which the surgeon misdiagnosed and treated as a UTI sepsis. Then I was put back on Aza by my rheumy and went back in to hospital again with same acute abdominal pain. This time they took me off it properly but never acknowledged the pancreatitis - although it was the only thing it could have been as I was vomiting bile and unable to move in hosiital for another week!

    Then my GP and surgeon felt I should get my gallbladder out although it wasn't inflamed but I had a large gallstone of many years. This op was disastrous as there was only one theatre and I was operated on too late in day for him to change it from keyhole to full surgery. The size of stone and fact gallbladder had become attached to my liver and also the fact that I was on steroids for RA meant that an abcess formed at base of wound and I ended up back in hospital with blood poisoning! 

    During all four of these stays there was some serious malpractice - including being refused sedation for an endoscopy - surgeon was so foul about my request for sedation that even nurses advised me to report him - other surgeon shoving knife and scissors into abscess 3 inches inside with no anaesthetic - a nurse attaching IV antibiotics to curtain rail despite my having diarrhoea-and open wound oozing everywhere - me lying on floor of waiting room in too much pain while they tried to find a bed, having a vent shoved into a vein in my hand because all others were full of phlebitis - SHO ignoring my screams. Also 3 swabs were "lost" and my GP thought this likely to be because of what the results might contain! 

    I don't expect financial compensation but I'm a lay hospital inspector representing the public interest so really did need to complain for my own peace of mind but it's taken me a year to face describing these experiences to the hospital's complaints officer! She seems grateful though and I hope it helps others to have much better treatment than I received last year. 

    Like you the consequences of all this is now impacting on my health in many ways - from a haemorrhage inside my eye by optic nerve to hardened carotid arteries, hypertension, rectal bleeding and vaginal  prolapse - all from the physical and mental trauma of last year! X

  • I'm so sorry to read about all the trauma you've gone through Twitchytoes.

    Hopefully you've found a hospital that can help you now. You have such a long list of health problems. I find I'm quite assertive with doctors now and not afraid to ask for second opinions, I hope you can do the same, if there's a treatment or procedure you don't want to have it's your right to refuse.

    It's outrageous how you've been treated, but from my experiences in hospitals, all very believable. 

    I really get how difficult it can be to revisit these experiences in hospital in order to make a complaint, and the impact on your health and stress levels. Try and stay strong! 

    I am now totally phobic of anything medical, I can't even go to collect my repeat prescriptions it's so bad.

    I really hope you get some acknowledgement of your complaint, and get on top of some of these medical issues. You are your own expert, and all you can do is research and see how best you can manage everything. I know you're doing this, only you know what it's like to live with your health problems and the best course of action.

    Thinking of you. X

  • I do so understand your phobia about all things medical now. I saw private endo today. We decided on compromise based on how well I'm doing on T3/T4 combo but also designed to stay out of trouble with my GP practice. He's lowering my Levo to 100/75mcg alternate days and same 10mcg T3. As my TSH was only 0.04 and they wouldn't take my FT3, he's guessing that is best dosage for me. He thinks this will make them happy to prescribe but what he may have failed to grasp is that the probable reason they are questioning my results isn't really for my wellbeing, although this is the pretext of course! I believe it is actually because the practice pharmacist is having hissy fits about how expensive t3 is! 

  • Twitchytoes, I'm so glad you're seeing someone, even if it does mean paying!

    I refuse blood tests at my GP's as I'm self medicating, after Levothyroxine did nothing for me in 2 years. My GP knows this and they seem OK with it. I agree it's all about money now. Even my Doublebase I've been using since 2003 which helps my psoriasis had been dumbed down without any consultation, all because there's a similar cheaper product! I'm already funding thyroid meds, HC, E45 products, urine dip sticks etc , it makes me so angry.

    What has medicine come to when the patient's health is secondary to politics and cost? Dr Skinner always used to say doctors are paid out of the public purse and they are public servants!

  • Heck - the endo is such a delightful gent and he said he can't understand why doctors don't have curiosity/ enquiry skills anymore. He said his 8 years of medical training moons ago - inspired a deep curiosity in him. He can't understand how so many doctors blame their patients for symptoms when it's all their failing . Mind you He was no fan of Dr Skinner's from what I've read in old media coverage. But maybe time has changed his perspective somewhat. Please continue to push for possible Psoriatic Arthritis - it might help you make progress if you were diagnosed and treated for this rather than being forced to self manage and self fund your meds. I'm in Scotland so prescriptions are free but you should not have to pay of you have thyroid disease. X

  • The old school doctors could diagnose by using their skills. Too much emphasis on test results and computers now. I've lost count of how many doctors I've seen who never examine, let alone listen to symptoms. This is what is keeping people ill. An endo I saw said it wasn't my thyroid, which was ridiculous, my temps were down in the 35's and exhaustion and body pain, dry skin, memory problems, enlarged tongue are not thyroid symptoms. When he sent me my blood results, thyroid antibodies were in the 600's and he said I was hypo, I never saw him again!

    Dr Skinner didn't do much for me, although he was entertaining. I know he helped a lot of patients but he tossed my adrenal stress test results back to me and said they all look the same. I chose not to go again I was so upset. But he did do a physical examination and said I had been hypo for at least 20 years. No Gp I have ever been a patient of has ever done an examination because it's clear they don't know what to look for.

    Yes I'm getting free prescriptions since being diagnosed with Hashimotos.

    I need to get some self confidence back in order to face doctors again. I have written to my Gp though and enclosed info, she knows about my phobia. My blood pressure goes sky high when I'm in there, so much so the gauge says error! Also my temperature shoots up and I sweat a lot. She was always offering me antibiotics for infection but I always say it's anxiety! X

  • I've remembered that the responses/ comments on a post always turn up as e-notifications on the poster's inbox so I feel we should chat more by PM as I've a few bits and pieces of info may be relevant to you (or not!) so will be PM shortly. Twitchy x

  • Interesting article.  Just what is the relationship between T3 and inflammation?

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