Risk of Thromboembolism in Non-Valvular Atrial Fibrillation With or Without Clinical Hyperthyroidism

Lin, Yu‐Sheng; Tsai, Hsin-Yu; Lin, Chih-Kuang; Wu, Victor Chien‐Chia; Chen, Tien-Hsing; Yang, Teng-Yao; Aboyans, Victor; Chen, Mien‐Cheng

doi:10.5334/gh.871

Cited by 5 publications

(12 citation statements)

References 30 publications

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“…In this study, atrial fibrillation was found in 9% of individuals with thyrotoxicosis in Africa. Other studies, outside Africa, have quoted a prevalence rate of 5-15% for atrial fibrillation in thyrotoxicosis and this is similar to the outcome of the present study [118,119]. Thyrotoxicosis causes a reduction in the repolarization phase of the atria and this predisposes the atrium to fibrillation [120].…”

Section: Discussionsupporting

confidence: 90%

Thyrotoxicosis in Africa: a systematic review and meta-analysis of the clinical presentation

2022

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Background Thyrotoxicosis is a common endocrine disorder. The clinical presentation is variable, and it is often misdiagnosed or diagnosed late in Africa. This study was aimed at collating and analyzing the clinical characteristics of the disease across the continent so as to enhance correct and timely diagnosis. Methods The study is a systematic review with a meta-analysis. Studies, done in Africa, which documented the clinical features of thyrotoxicosis were selected. African Journal Online (AJOL), PubMed, SCOPUS and Google Scholar, Research Square, SciELO, and medRxiv were systematically searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study quality was assessed using the Newcastle-Ottawa scale. Heterogeneity was determined using I2 statistic and Cochran’s Q test. LFK index and the symmetry of the Doi plot were used to assess publication bias. Results The eligible studies were 59 and the total sample size was 9592. The most common symptoms of thyrotoxicosis on the continent included palpitations (69%), weight loss (65%), heat intolerance (64%), tiredness (49%), increased appetite (49%), hyperhidrosis (48%), and insomnia (47%). The most common signs were thyromegaly (88%), tachycardia (67%), sweaty palms (54%), hand tremor (49%), and exophthalmos (49%). Atrial fibrillation, heart failure, and thyrotoxic heart disease were found in 9, 12, and 22% respectively. Other findings were hypertension (25%) and diabetes (9%). Conclusion Clinical presentation of thyrotoxicosis varies, and understanding these peculiarities would mitigate misdiagnosis and delayed diagnosis in Africa.

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Section: Discussionsupporting

confidence: 90%

Thyrotoxicosis in Africa: a systematic review and meta-analysis of the clinical presentation

2022

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“…In our study, 2.8% of patients referred to the hospital with AF also had hyperthyroidism. This rate is compatible with other studies in Taiwan and other countries [ 14 , 29 , 30 ], and female patients were predominant [ 12 , 15 , 30 ]. The annual stroke/TIA incidence of 1.74% per year among nonusers with a mean CHA2DS2-VASc score of 1.8 was numerically lower in Taiwanese and in a Swedish cohort which had a CHA2DS2-VASc score of 2 [ 13 , 31 ].…”

Section: Discussionsupporting

confidence: 92%

“…The annual stroke/TIA incidence of 1.74% per year among nonusers with a mean CHA2DS2-VASc score of 1.8 was numerically lower in Taiwanese and in a Swedish cohort which had a CHA2DS2-VASc score of 2 [ 13 , 31 ]. The reason could be that patients with hyperthyroidism-related AF are not at a higher risk of ischemic stroke than those with non-thyroid AF [ 12 , 30 ]. In most AF patients with hyperthyroidism, spontaneous reversion to sinus rhythm often occurs after restoration of thyroid function [ 2 , 29 ].…”

Section: Discussionmentioning

confidence: 99%

“…In most AF patients with hyperthyroidism, spontaneous reversion to sinus rhythm often occurs after restoration of thyroid function [ 2 , 29 ]. Antithyroid therapy were prescribed to decrease the arrhythmogenic activity under the guidance of Taiwan National Health Insurance program [ 9 , 16 , 30 ]. However, a national cohort study demonstrated the incidence of thromboembolic events may be not influenced by antithyroid therapies among patients with hyperthyroidism-related AF [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

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Associations of Warfarin Use with Risks of Ischemic Cerebrovascular Events and Major Bleeding in Patients with Hyperthyroidism-Related Atrial Fibrillation

et al. 2022

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The use of oral anticoagulants for patients with new-onset hyperthyroidism-related atrial fibrillation (AF) is controversial. We aimed to evaluate the clinical benefits of warfarin therapy in this population. This retrospective cohort study used a data-cut of Taiwan Health and Welfare Database between 2000 and 2016. We compared warfarin users and nonusers among AF patients with hyperthyroidism. We used 1:2 propensity score matching to balance covariates and Cox regression model to calculate hazard ratios (HRs). The primary outcome was risk of ischemic stroke/transient ischemic attack (TIA), and the secondary outcome was major bleeding. After propensity score matching, we defined 90 and 168 hyperthyroidism-related AF patients with mean (SD) age of 59.9 ± 13.5 and 59.2 ± 14.6 in the warfarin-treated group and untreated group separately. The mean (SD) CHA2DS2-VASc scores for the two groups were 2.1 ± 1.6 and 1.8 ± 1.5, respectively. Patients with hyperthyroidism-related AF receiving warfarin had no significant risk of ischemic stroke/TIA (adjusted HR: 1.16, 95% confidence interval [CI]: 0.52–2.56, p = 0.717) compared to nonusers. There was a comparable risk of major bleeding between those receiving warfarin or not (adjusted HR: 0.91, 95% CI: 0.56–1.47, p = 0.702). The active-comparator design also demonstrated that warfarin use had no significant association with the risk of stroke/TIA versus aspirin use (adjusted HR: 2.43; 95% CI: 0.68–8.70). In conclusion, anticoagulation therapy did not have a statistically significant benefit on ischemic stroke/TIA nor risk of bleeding, among patients with new-onset hyperthyroidism-related AF under a low CHA2DS2-VASc score, by comparing those without use.

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“…Two recent retrospective nationwide database-derived studies using propensity score-matched analyses in the developed region in Asia had contradictory findings in the risk of thromboembolism associated with hyperthyroid AF [ 12 , 21 ]. Cautious interpretation of these findings, while acknowledging the inherent limitations and bias of retrospective analysis of coded information is advised.…”

Section: Discussionmentioning

confidence: 99%

Yearly Incidence of Stroke and Bleeding in Atrial Fibrillation with Concomitant Hyperthyroidism: A National Discharge Database Study

Zhang

Bisson

Fauchier

et al. 2022

JCM

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Background: Hyperthyroidism is associated with atrial fibrillation (AF), and the latter is a major risk factor for stroke. Aim: We aimed to investigate the yearly incidence of stroke and bleeding in AF patients with and without concomitant hyperthyroidism from the French National Hospital Discharge Database. Methods: Admissions with AF between January 2010 and December 2019 were retrospectively identified and retrieved from the French national database. Incidence rates of ischaemic stroke and bleeding were compared in AF patients with and without concomitant hyperthyroidism. The associations of risk factors with ischaemic stroke were assessed by Cox regression. Results: Overall 2,421,087 AF patients, among whom 32,400 had concomitant hyperthyroidism were included in the study. During the follow-up (mean: 2.0 years, standard deviation SD: 2.2 years), the yearly incidence of ischaemic stroke was noted to be 2.6 (95% confidence interval CI: 2.5–2.8) in AF patients with concomitant hyperthyroidism, and 2.3 (95%CI: 2.3–2.4) in non-thyroid AF patients. Hyperthyroidism was noted as an independent risk factor for ischaemic stroke (adjusted hazard ratio aHR: 1.133, 95%CI: 1.080–1.189) overall, particularly within the first year of hyperthyroidism diagnosis (aHR 1.203, 95%CI 1.120–1.291), however, the association became non-significant in subsequent years (aHR 1.047, 95%CI 0.980–1.118). Major bleeding incidence was lower in the hyperthyroid AF group in comparison to the non-thyroid AF group (incidence ratio: 5.1 vs. 5.4%/year, p < 0.001). The predictive value of CHA2DS2VASc and HAS-BLED scores for ischaemic stroke and bleeding events, respectively, did not differ significantly between AF patients with or without concomitant hyperthyroidism. Conclusions: Hyperthyroidism seems to be an independent risk factor of ischaemic stroke in AF patients, particularly within the first year of hyperthyroidism diagnosis.

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Risk of Thromboembolism in Non-Valvular Atrial Fibrillation With or Without Clinical Hyperthyroidism

Cited by 5 publications

References 30 publications

Thyrotoxicosis in Africa: a systematic review and meta-analysis of the clinical presentation

Thyrotoxicosis in Africa: a systematic review and meta-analysis of the clinical presentation

Associations of Warfarin Use with Risks of Ischemic Cerebrovascular Events and Major Bleeding in Patients with Hyperthyroidism-Related Atrial Fibrillation

Yearly Incidence of Stroke and Bleeding in Atrial Fibrillation with Concomitant Hyperthyroidism: A National Discharge Database Study

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