Abstract
Objective
To describe the incidence, risk factors, and outcomes of incident atrial fibrillation
(AF) in Graves disease (GD).
Patients and Methods
Patients with GD between January 1, 2009, and December 31, 2019, were included retrospectively.
We defined GD-related AF as AF diagnosed less than or equal to 30 days before or any
time after GD. Late-onset AF was defined as incident AF diagnosed more than 90 days
after GD.
Results
Of 1371 patients with GD, AF occurred in 139 patients. Late-onset AF occurred in 32
(23.0%) of AF cases, of which 16 (50.0%) had attained euthyroidism. Independent risk
factors were age (HR, 1.05; 95% CI, 1.03-1.06 per year), overt hyperthyroidism (free
T4 >1.7 ng/dL; HR, 2.75; 95% CI, 1.38 to 5.46), and male sex (HR, 2.30; 95% CI, 1.54
to 3.43) for early AF. These were age (HR, 1.08; 95% CI, 1.05 to 1.119 per year),
chronic obstructive pulmonary disease (HR, 3.47; 95% CI, 1.36 to 5.54), and heart
failure (HR, 5.86; 95% CI, 2.39 to 14.38) for late AF. Atrial fibrillation in GD was
associated with higher mortality (HR, 16.32; 95% CI, 4.66 to 56.58), acute coronary
syndrome/stable angina events (HR, 3.89; 95% CI, 1.23 to 12.31), and cardiac hospitalizations
(HR, 15.39; 95% CI, 8.17 to 29.00) when adjusted to age, sex, and pre-existing AF.
Conclusion
Late-onset AF comprised one-quarter of GD-related AF cases requiring surveillance
even after restoring euthyroidism. Risk factors for AF in GD are similar to those
in the general population although overt hyperthyroidism conferred the highest risk,
especially for early AF. Treatment with thionamide was associated with late AF.
Abbreviations and Acronyms:
ACS (acute coronary syndrome), AF (atrial fibrillation), ATD (antithyroid drug), COPD (chronic obstructive pulmonary disease), ECG (electrocardiogram), FT4 (free T4), GD (Graves disease), RAI (radioiodine ablation), SR (sinus rhythm), TIA (transient ischemic attack), TSH (thyroid stimulating hormone), VF (ventricular fibrillation), VT (ventricular tachycardia)To read this article in full you will need to make a payment
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References
- 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis.Thyroid. 2016; 26: 1343-1421
- Atrial fibrillation and hyperthyroidism: a literature review.Indian Heart J. 2017; 69: 545-550
- Hyperthyroidism and risk of atrial fibrillation or flutter: a population-based study.Arch Intern Med. 2004; 164: 1675-1678
- Thyrotoxic heart failure: a review of clinical status and meta-analysis of electrocardiogram diagnosis and medical clinical management methods.Integr MolMed. 2018; 5 (doi: 10.15761/IMM.1000350)
- Cardiovascular morbidity and mortality after treatment of hyperthyroidism with either radioactive iodine or thyroidectomy.Thyroid. 2018; 28: 1111-1120
- Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.Circulation. 1998; 98: 946-952
- Incidence, risk factors, natural history and outcomes of heart failure in patients with Graves' disease.Heart. 2022; 108: 868-874
- Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28: 1-39.e14
- Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists.Stroke. 2009; 40: 2276-2293
- Incidence, type of atrial fibrillation and risk factors for stroke: a population-based cohort study.Clin Epidemiol. 2017; 9: 53-62
- Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes.Circ Res. 2017; 120: 1501-1517
- Thyroid hormones, oxidative stress, and inflammation.Mediators Inflamm. 2016; 20166757154
- Duration of hyperthyroidism and lack of sufficient treatment are associated with increased cardiovascular risk.Thyroid. 2019; 29: 332-340
- The spectrum of thyroid disease and risk of new onset atrial fibrillation: a large population cohort study.BMJ. 2012; 345e7895
- Management of atrial fibrillation in the post-thyrotoxic state.Am J Med. 1982; 72: 903-906
- Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter.Am J Cardiol. 1991; 68: 41-46
- Stroke in thyrotoxicosis with atrial fibrillation.Stroke. 1988; 19: 15-18
- Increased risk of ischemic stroke and systemic embolism in hyperthyroidism-related atrial fibrillation: a nationwide cohort study.Am Heart J. 2021; 242: 123-131
Article info
Publication history
Published online: March 13, 2023
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
