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

Okosieme, Onyebuchi; Taylor, Peter; Evans, Carol; Thayer, Daniel; Chai, Aaron; Khan, Ishrat; Draman, Mohd Shazli; Tennant, Brian P.; Geen, John; Sayers, Adrian; French, Robert; Lazarus, John; Premawardhana, Lakdasa; Dayan, Colin

doi:10.1016/s2213-8587(19)30059-2

Cited by 95 publications

(81 citation statements)

References 35 publications

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“…Recent observations have shown the importance of achieving good control of hyperthyroidism in a timely fashion to improve longterm cardiovascular and mortality outcomes. 15,16 In this context, it would be unfortunate if patients were deprived of the option of rapid, effective control of their hyperthyroidism with radioiodine, due to concerns of cancer risk. Overall, on the basis that current evidence shows no excess cancer risk, it would be reasonable to continue with current approaches to the management of hyperthyroidism, whilst further, appropriately controlled studies are undertaken.…”

Section: Joint Statement From the Society For Endocrinology And The Bmentioning

confidence: 99%

Joint statement from the Society for Endocrinology and the British Thyroid Association regarding ‘Association of Radioactive Iodine Treatment with cancer mortality in patients with hyperthyroidism’

Taylor

Okosieme

Chatterjee

et al. 2019

Clinical Endocrinology

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Section: Joint Statement From the Society For Endocrinology And The Bmentioning

confidence: 99%

Joint statement from the Society for Endocrinology and the British Thyroid Association regarding ‘Association of Radioactive Iodine Treatment with cancer mortality in patients with hyperthyroidism’

Taylor

Okosieme

Chatterjee

et al. 2019

Clinical Endocrinology

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“…This position represents a departure from current practice and is largely based on the superior cost-effectiveness and efficacy of radioiodine compared to thionamides [6]. The importance of treatment efficacy has also been highlighted by a number of recent observational studies that have shown an increase in longterm cardiovascular mortality in poorly controlled patients with hyperthyroidism [7][8][9][10]. However, a recent large-scale study in patients with hyperthyroidism reported increased cancer mortality in association with radioiodine treatment [11].…”

Section: Introductionmentioning

confidence: 99%

Should radioiodine now be first line treatment for Graves’ disease?

2020

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Background: Radioiodine represents a cost-effective treatment option for Graves' disease. In the UK, it is traditionally reserved for patients who relapse after initial thionamide therapy. In a change from current practice, the new guidelines of the National Institute for Health and Care Excellence (NICE) recommends that radioiodine should now be first line therapy for Graves' disease. However, the safety of radioiodine with respect to long-term mortality risk has been the subject of recent debate. This analysis examines evidence from treatment related mortality studies in hyperthyroidism and discusses their implications for future Graves' disease treatment strategies. Main body: Some studies have suggested an excess mortality in radioiodine treated cohorts compared to the background population. In particular, a recent observational study reported a modest increase in cancer-related mortality in hyperthyroid patients exposed to radioiodine. The interpretation of these studies is however constrained by study designs that lacked thionamide control groups or information on thyroid status and so could not distinguish the effect of treatment from disease. Two studies have shown survival advantages of radioiodine over thionamide therapy, but these benefits were only seen when radioiodine was successful in controlling hyperthyroidism. Notably, increased mortality was associated with uncontrolled hyperthyroidism irrespective of therapy modality. Conclusions: Early radioiodine treatment will potentially reduce mortality and should be offered to patients with severe disease. However, thionamides are still suitable for patients with milder disease, contraindications to radioiodine, or individuals who choose to avoid permanent hypothyroidism. Ultimately, a patient individualised approach that prioritises early and sustained control of hyperthyroidism will improve long-term outcomes regardless of the therapy modality used.

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“…Hyperthyroidism has been associated with a marked excess cardiovascular mortality in several observational studies [1][2][3][4][5]. In long-term follow-up, Graves' disease (GD) patients have a 23% excess risk of mortality and a 65% increased risk of acute myocardial infarction [5]. The mechanisms underlying these associations are incompletely understood.…”

Section: Introductionmentioning

confidence: 99%

Arterial Stiffness and Blood Pressure in Patients Newly Diagnosed with Graves’ Disease Compared with Euthyroid Controls

et al. 2020

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Introduction and Objective: The excess cardiovascular morbidity and mortality in hyperthyroidism and Graves' disease (GD) is inadequately understood. We aimed to elucidate whether well-established cardiovascular risk factors such as arterial stiffness in terms of pulse wave velocity (PWV) and blood pressure differ in GD and controls. Methods: This was a cross-sectional study comparing 55 hyperthyroid patients with newly diagnosed GD and 55 euthyroid, populationbased controls matched for age, sex and menopausal status. PWV and blood pressure were measured in office (Sphygmo-Cor Xcel) and 24-h ambulatory settings (Arteriograph). Differences between groups were assessed using adjusted linear regression analysis. Results: Compared to controls, GD patients showed higher PWV in the 24-h but not in the office setting with an adjusted 24-h PWV difference of 1.0 (95% CI: 0.6-1.5) m/s. PWV was higher in GD at both day and night, and nightly PWV dipping was lower (-5.5, 95% CI: -10.4 to -0.6%). Furthermore, central and brachial pulse pressure was significantly higher in both the office and 24-h setting, whereas nightly central pulse pressure dipping was significantly lower in GD (-5.4, 95% CI: -10.5 to -0.2%). Mean arterial pressure did not differ between the groups. Conclusions: Despite comparable blood pressure, GD is associated with a higher 24-h PWV that was not detected in the office setting. Pulse pressure was higher in GD, whereas mean arterial pressure did not differ between the groups. Longitudinal studies should pursue whether higher PWV might be a piece to the puzzle of understanding the increased risk of cardiovascular disease in hyperthyroidism and GD.

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

Cited by 95 publications

References 35 publications

Joint statement from the Society for Endocrinology and the British Thyroid Association regarding ‘Association of Radioactive Iodine Treatment with cancer mortality in patients with hyperthyroidism’

Joint statement from the Society for Endocrinology and the British Thyroid Association regarding ‘Association of Radioactive Iodine Treatment with cancer mortality in patients with hyperthyroidism’

Should radioiodine now be first line treatment for Graves’ disease?

Arterial Stiffness and Blood Pressure in Patients Newly Diagnosed with Graves’ Disease Compared with Euthyroid Controls

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