Duration of Exposure to Thyrotoxicosis Increases Mortality of Compromised AIT Patients: the Role of Early Thyroidectomy

Author:

Cappellani Daniele1ORCID,Papini Piermarco2,Di Certo Agostino Maria1,Morganti Riccardo3,Urbani Claudio1,Manetti Luca1,Tanda Maria Laura4,Cosentino Giada1,Marconcini Giulia1,Materazzi Gabriele2,Martino Enio1,Bartalena Luigi4,Bogazzi Fausto1ORCID

Affiliation:

1. Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy

2. Unit of Endocrine Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy

3. Section of Statistics, University Hospital of Pisa, Pisa, Italy

4. Department of Medicine and Surgery, University of Insubria, Varese, Italy

Abstract

Abstract Context Patients with amiodarone-induced thyrotoxicosis (AIT) and severely reduced left ventricular ejection fraction (LVEF) have a high mortality rate that may be reduced by total thyroidectomy. Whether in this subset of patients thyroidectomy should be performed early during thyrotoxicosis or later after restoration of euthyroidism has not yet been settled. Objectives Mortality rates, including peritreatment mortality and 5-year cardiovascular mortality, and predictors of death, evaluated by Cox regression analysis. Methods Retrospective cohort study of 64 consecutive patients with AIT selected for total thyroidectomy from 1997 to 2019. Four groups of patients were identified according to serum thyroid hormone concentrations and LVEF: Group 1 (thyrotoxic, LVEF <40%), Group 2 (thyrotoxic, LVEF ≥40%), Group 3 (euthyroid, LVEF < 40%), Group 4 (euthyroid, LVEF ≥40%). Results Among patients with low LVEF (Groups 1 and 3), mortality was higher in patients undergoing thyroidectomy after restoration of euthyroidism (Group 3) than in those submitted to surgery when still thyrotoxic (Group 1): peritreatment mortality rates were 40% versus 0%, respectively (P = .048), whereas 5-year cardiovascular mortality rates were 53.3% versus 12.3%, respectively (P = .081). Exposure to thyrotoxicosis was longer in Group 3 than in Group 1 (112 days, interquartile range [IQR] 82.5-140, vs 76 days, IQR 24.8-88.5, P = .021). Survival did not differ in patients with LVEF ≥40% submitted to thyroidectomy irrespective of being thyrotoxic (Group 2) or euthyroid (Group 4): in this setting, peritreatment mortality rates were 6.3% versus 4% (P = .741) and 5-year cardiovascular mortality rates were 12.5% and 20% (P = .685), respectively. Age (hazard ratio [HR] 1.104, P = .029) and duration of exposure to thyrotoxicosis (HR 1.004, P = .039), but not presurgical serum thyroid hormone concentrations (P = .577 for free thyroxine, P = .217 for free triiodothyronine), were independent predictors of death. Conclusions A prolonged exposure to thyrotoxicosis resulted in increased mortality in patients with reduced LVEF, which may be reduced by early thyroidectomy.

Publisher

The Endocrine Society

Subject

Biochemistry (medical),Clinical Biochemistry,Endocrinology,Biochemistry,Endocrinology, Diabetes and Metabolism

Reference43 articles.

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4. 2018 European Thyroid Association (ETA) guidelines for the management of amiodarone-associated thyroid dysfunction;Bartalena;Eur Thyroid J.,2018

5. Natural history of asymptomatic left ventricular systolic dysfunction in the community;Wang;Circulation.,2003

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