Primary therapy of Graves' disease and cardiovascular morbidity and mortality: a linked-record cohort study

[helvella]

The importance of "early and effective control of hyperthyroidism" is probably of no surprise. Just good that it is in black and white.

The difficulty I have is the "early definitive treatment with radioiodine". In the limited abstract, I cannot see anything which explains the apparent recommendation of radio-active iodine over all alternatives (surgery and non-radio-active ablation such as radio-frequency or high-intensity focused ultrasound ablation and anything else that has been tried).

Despite this, some here might find it interesting to consider that their data has been used in this sturdy. Most likely, judging by the author information, for those who are based in Wales.

Lancet Diabetes Endocrinol. 2019 Feb 28. pii: S2213-8587(19)30059-2. doi: 10.1016/S2213-8587(19)30059-2. [Epub ahead of print]

Primary therapy of Graves' disease and cardiovascular morbidity and mortality: a linked-record cohort study.

Okosieme OE1, Taylor PN2, Evans C3, Thayer D4, Chai A2, Khan I2, Draman MS2, Tennant B5, Geen J6, Sayers A7, French R2, Lazarus JH2, Premawardhana LD8, Dayan CM2.

Author information

1 Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK; Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK. Electronic address: [e-mail].

2 Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK.

3 Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK.

4 Secure Anonymised Information Linkage Databank, School of Medicine, Swansea University, Swansea, UK.

5 Clinical Biochemistry Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK.

6 Clinical Biochemistry Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK; Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.

7 Department of Social and Community Medicine, University of Bristol, Bristol, UK.

8 Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK; Section of Endocrinology, Department of Medicine, Ysbyty Ystrad Fawr Hospital, Aneurin Bevan University Health Board, Ystrad Mynach, UK.

Abstract

BACKGROUND:

Graves' disease is routinely treated with antithyroid drugs, radioiodine, or surgery, but whether the choice of initial therapy influences long-term outcomes is uncertain. We evaluated cardiovascular morbidity and mortality according to the method and effectiveness of primary therapy in Graves' disease.

METHODS:

In this retrospective cohort study, we identified patients with hyperthyroidism, diagnosed between Jan 1, 1998, and Dec 31, 2013, from a thyroid-stimulating hormone (TSH)-receptor antibody (TRAb) test register in south Wales, UK, and imported their clinical data into the All-Wales Secure Anonymised Information Linkage (SAIL) Databank (Swansea University, Swansea, UK). Patients with Graves' disease, defined by positive TRAb tests, were selected for the study, and their clinical data were linked with outcomes in SAIL. We had no exclusion criteria. Patients were matched by age and sex to a control population (1:4) in the SAIL database. Patients were grouped by treatment within 1 year of diagnosis into the antithyroid drug group, radioiodine with resolved hyperthyroidism group (radioiodine group A), or radioiodine with unresolved hyperthyroidism group (radioiodine group B). We used landmark Kaplan-Meier and Cox regression models to analyse the association of treatment with the primary outcome of all-cause mortality and the secondary outcome of major adverse cardiovascular events (myocardial infarction, heart failure, ischaemic stroke, or death) with the landmark set at 1 year after diagnosis. We analysed the association between outcomes and concentration of TSH using Cox regression and outcomes and free thyroxine (FT4) concentration using restricted cubic-spline regression models.

FINDINGS:

We extracted patient-level data on 4189 patients (3414 [81·5%] females and 775 [18·5%] males) with Graves' disease and 16 756 controls (13 656 [81·5%] females and 3100 [18·5%] males). In landmark analyses, 3587 patients were in the antithyroid drug group, 250 were in radioiodine group A, 182 were in radioiodine group B. Patients had increased all-cause mortality compared with controls (hazard ratio [HR] 1·22, 95% CI 1·05-1·42). Compared with patients in the antithyroid drug group, mortality was lower among those in radioiodine group A (HR 0·50, 95% CI 0·29-0·85), but not for those in radioiodine group B (HR 1·51, 95% CI 0·96-2·37). Persistently low TSH concentrations at 1 year after diagnosis were associated with increased mortality independent of treatment method (HR 1·55, 95% CI 1·08-2·24). Spline regressions showed a positive non-linear relationship between FT4 concentrations at 1 year and all-cause mortality.

INTERPRETATION:

Regardless of the method of treatment, early and effective control of hyperthyroidism among patients with Graves' disease is associated with improved survival compared with less effective control. Rapid and sustained control of hyperthyroidism should be prioritised in the management of Graves' disease and early definitive treatment with radioiodine should be offered to patients who are unlikely to achieve remission with antithyroid drugs alone.

FUNDING:

National Institute for Social Care and Health Research, Wales.

Copyright © 2019 Elsevier Ltd. All rights reserved.

PMID: 30827829

DOI: 10.1016/S2213-8587(19)30059-2

ncbi.nlm.nih.gov/pubmed/308...

[Pascha1]

when I was discovered dangerously hyperthyroid with Thyroid storm My heart beat I know for a fact had been 180bpm resting for quite a few years,,

My eyes were out on stalks, I couldn't even hold a cup of tea it would be empty in a minute as my shakes were so bad, I don't know before that though as hadn't checked it,, but know I suffered any illness ten times worse than my sister, and was pure white back then and never used to wear a coat even in a Scottish winter snow I never wanted a coat on so I guess I had it at school for some time till they discovered it in my late teens ,

so probably had hyper for about 6 or 7 years or even more who knows

Before they discovered I was hyper as was often at doctors asking why I felt quite tired and shaky well to the Dr I had severe anxiety and thats why I felt tired and the shakes was my neves and severe anxiety hmm hmmm and was put on lorazepam and valium but made me much worse.....,, SO these ignorant GPs dont even know what severe hyperthyroidism is as well as hypo its really quite disgusting what little they know !

They whipped me in pretty quick for sub total thyroidectomy, but I was told by many doctors I would probably die before I reached 40, and at the clinics after loads of different Drs said i would die very young ,, I saw many as what I had was rare and as a teaching hospital I had every Dr and his uncle at my bedside in hospital and when I attended the after clinic ! all looking on in amazement as never seen it before,, I think the whole of medi school was round my bed chatting all about it, it was quite exhausting , .. anyway I didnt die before I was 40 and am still alive at the age of 55 yrs and 56 this year.....and as yet dont know if i have any heart problems, I havent had AF with T3 yet so Im guessing its ok, but who knows with the GPS as they wouldnt have a clue ! i should ask them to check it really ... I wanted to get medical records as why they all said i would die early but they have destroyed my notes ..