The DOI matches its Crossref record; 47 of the 47 references it cites were found in a registry or an index.
Thyroid Status, Cardiovascular Risk, and Mortality in Older Adults
Abstract
CONTEXT: Previous studies have suggested that subclinical abnormalities in thyroid-stimulating hormone levels are associated with detrimental effects on the cardiovascular system. OBJECTIVE: To determine the relationship between baseline thyroid status and incident atrial fibrillation, incident cardiovascular disease, and mortality in older men and women not taking thyroid medication. DESIGN, SETTING, AND PARTICIPANTS: A total of 3233 US community-dwelling individuals aged 65 years or older with baseline serum thyroid-stimulating hormone levels were enrolled in 1989-1990 in the Cardiovascular Health Study, a large, prospective cohort study. MAIN OUTCOME MEASURES: Incident atrial fibrillation, coronary heart disease, cerebrovascular disease, cardiovascular death, and all-cause death assessed through June 2002. Analyses are reported for 4 groups defined according to thyroid function test results: subclinical hyperthyroidism, euthyroidism, subclinical hypothyroidism, and overt hypothyroidism. RESULTS: Individuals with overt thyrotoxicosis (n = 4) were excluded because of small numbers. Eighty-two percent of participants (n = 2639) had normal thyroid function, 15% (n = 496) had subclinical hypothyroidism, 1.6% (n = 51) had overt hypothyroidism, and 1.5% (n = 47) had subclinical hyperthyroidism. After exclusion of those with prevalent atrial fibrillation, individuals with subclinical hyperthyroidism had a greater incidence of atrial fibrillation compared with those with normal thyroid function (67 events vs 31 events per 1000 person-years; adjusted hazard ratio, 1.98; 95% confidence interval, 1.29-3.03). No differences were seen between the subclinical hyperthyroidism group and euthyroidism group for incident coronary heart disease, cerebrovascular disease, cardiovascular death, or all-cause death. Likewise, there were no differences between the subclinical hypothyroidism or overt hypothyroidism groups and the euthyroidism group for cardiovascular outcomes or mortality. Specifically, individuals with subclinical hypothyroidism had an adjusted hazard ratio of 1.07 (95% confidence interval, 0.90-1.28) for incident coronary heart disease. CONCLUSION: Our data show an association between subclinical hyperthyroidism and development of atrial fibrillation but do not support the hypothesis that unrecognized subclinical hyperthyroidism or subclinical hypothyroidism is associated with other cardiovascular disorders or mortality.
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In the citing paper
“A high TSH level within the normal range appears to be protective and has been shown to be associated with reduced mortality risk in older euthyroid individuals.149”
From Hypothyroidism (2024) · cites this paper as [149]
In the citing paper
“Cardiac AEs, including tachycardia, palpitations and atrial fibrillation, arise from increased myocardial oxygen consumption and enhanced β‐adrenergic sensitivity.”
From Risk of cardiac, neuropsychiatric and musculoskeletal adverse events with levothyroxine: Systematic review (2026) · cites this paper as [6]
In the citing paper
“Cardiovascular symptoms are the most frequent indicators of mild thyroid hormone excess in the elderly, similar to overt hyperthyroidism [52,53] .”
From The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism (2015) · cites this paper as [53]
In the citing paper
“A 2-to 3-fold increased risk of atrial fibrillation (AF) was associated with SHyper in elderly subjects in two large prospective studies [52,53] .”
From The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism (2015) · cites this paper as [53]
In the citing paper
“An increased incidence of AF has also been observed in elderly persons with low serum TSH (0.1-0.5 mIU/l) with an HR of 1.6 (95% CI: 1.0-2.5)[52] and 1.85 (95% CI: 1.14-3.00)[53] .”
From The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism (2015) · cites this paper as [53]
In the citing paper
“Contradicting this, two other studies included in this meta-analysis reported a non-significant decreased risk for stroke associated with SHyper [53,82] .”
From The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism (2015) · cites this paper as [53]
In the citing paper
“Older patients with low TSH and higher fT4 have a higher prevalence and incidence of atrial fibrillation compared with euthyroid subjects (94–98)”
From Levothyroxine therapy in elderly patients with hypothyroidism (2021) · cites this paper as [94]
In the citing paper
“Trials of levothyroxine in SCH using surrogate markers have shown improvement in LV function, vascular endothelial function, atherogenic lipid particles, or cardiac mitochondrial function (4,91,105-108).”
From Thyroid Hormones and Cardiovascular Function and Diseases (2018) · cites this paper as [105]
In the citing paper
“In addition, several studies of older patients have shown SCH to have either a protective or no impact on CV disease risk (103-105).”
From Thyroid Hormones and Cardiovascular Function and Diseases (2018) · cites this paper as [105]
In the citing paper
“these findings have not been reproduced by all studies (13, 17, 25, 26)”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [13]
In the citing paper
“However, there is significant heterogeneity within the literature, with some large and well-conducted studies failing to reproduce these associations (13, 21), as well as unresolved questions about causality.”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [13]
In the citing paper
“in cohort studies, subclinical hyperthyroidism or lower serum TSH have been associated with many involutional disease states including dementia, osteoporosis, AF, muscle weakness, low bone density, and fracture (12–14, 18, 20, 48, 49).”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [13]
In the citing paper
“In contrast with subclinical hypothyroidism, many previous studies have shown that low serum TSH is associated with poor outcomes, either increased all-cause or vascular mortality, or AF (12–14, 17, 29, 36, 37).”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [13]
In the citing paper
“It has widely been assumed that these associations are caused by subclinical hyperthyroidism with detrimental effects of excess thyroid hormone, for instance its proarrhythmic effect on the heart leading to AF, despite the fact that serum thyroid hormones are within reference range (1, 13–15, 29, 41, 42).”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [13]
In the citing paper
“Some studies report increased overall mortality rates in SH subjects (374,379-383), especially older subjects, while others indicate no relation (384)(385)(386)(387).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [384]
In the citing paper
“Some other, smaller studies have reached similar conclusions (374,383), although other smaller studies have failed to find a correlation (380,381,384,386).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [384]
In the citing paper
“Sawin et al. (399) first reported a 2.8-fold increased risk of atrial fibrillation in SH subjects over age 60 years in 1994, and subsequent studies have confirmed that the risk of arrhythmias, particularly atrial fibrillation, is increased in SH (381,384,388,391,400,401).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [384]
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Decision Making in Subclinical Thyroid Disease
Evron, J. M., & Papaleontiou, M. (2021) · Medical Clinics of North America · doi:10.1016/j.mcna.2021.05.014 · Cited by 25
Garces-Arteaga, A., Nieto-Garcia, N., Suarez-Sanchez, F., Triana-Reina, H. R., & Ramírez‐Vélez, R. (2013) · Journal of Thyroid Research · doi:10.1155/2013/592801 · Cited by 20
Watanabe, M., Okamura, T., Kokubo, Y., Higashiyama, A., & Okayama, A. (2009) · International Journal of Epidemiology · doi:10.1093/ije/dyp212 · Cited by 20
Lu, Y., Guo, H. W., Liu, D., & Zhao, Z. (2016) · Archives of Medical Science · doi:10.5114/aoms.2016.60965 · Cited by 20
Alonso‐Ventura, V., Civeira, F., Rosas, A. A., Lou-Bonafonte, J. M., Calmarza, P., Moreno‐Franco, B., Andrés-Otero, M. J., Calvo-Gracia, F., García, P. D. D., & Laclaustra, M. (2022) · Thyroid · doi:10.1089/thy.2022.0025 · Cited by 20
Subclinical Hypothyroidism and Cardiovascular Risk
Weiss, I. A., Bloomgarden, N. A., & Frishman, W. H. (2011) · Cardiology in Review · doi:10.1097/crd.0b013e318227df87 · Cited by 20
Guía clínica del diagnóstico y tratamiento de la disfunción tiroidea subclínica
Hernández, J. J. C., Alonso, N., Blanco, A. C., Ferrater, J. C. G., Pérez, A., Morales, T. L., Corral, B. P., & Henzi, F. T. (2007) · Endocrinología y Nutrición · doi:10.1016/s1575-0922(07)71404-3 · Cited by 20
Mammen, J. S. (2023) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2022.10.008 · Cited by 20
Subclinical Hypothyroidism and Risk for Incident Ischemic Stroke Among Postmenopausal Women
Giri, A., Edwards, T. L., LeGrys, V. A., Lorenz, C., Funk, M. J., Schectman, R., HEISS, G. M., Robinson, J. G., & Hartmann, K. E. (2014) · Thyroid · doi:10.1089/thy.2014.0106 · Cited by 19
Can We Predict the Occurrence of Atrial Fibrillation?
Schnabel, R. B. (2012) · Clinical Cardiology · doi:10.1002/clc.20963 · Cited by 19
Population‐based studies of antithyroid drugs and sudden cardiac death
van Noord, C., Sturkenboom, M., Straus, S. M. J. M., Albert Hofman, D., Witteman, J. C. M., & Stricker, B. H. C. (2009) · British Journal of Clinical Pharmacology · doi:10.1111/j.1365-2125.2009.03474.x · Cited by 18
Rukhman, N., & Silverberg, A. B. (2010) · The Aging Male · doi:10.3109/13685538.2010.529195 · Cited by 19
Thyroid disease and vascular risk
Jabbar, A., & Razvi, S. (2014) · Clinical Medicine · doi:10.7861/clinmedicine.14-6-s29 · Cited by 19
de Miranda, É. J. F. P., Bittencourt, M. S., Santos, I. S., Lotufo, P. A., & Benseñor, I. M. (2016) · European Thyroid Journal · doi:10.1159/000448683 · Cited by 18
Zhou, Y., Zhao, L., Wang, T., Hong, J., Zhang, J., Xu, B., Huang, X., Xu, M., & Bi, Y. (2015) · Journal of Atherosclerosis and Thrombosis · doi:10.5551/jat.30338 · Cited by 18
Šarić, M. S., Jurašić, M., Sović, S., Kranjčec, B., Glivetić, T., & Demarin, V. (2017) · Romanian Journal of Internal Medicine · doi:10.1515/rjim-2017-0015 · Cited by 18
Risk factors for cardiovascular disease in subclinical hypothyroidism
Decandia, F. (2017) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-017-1617-9 · Cited by 18
The Two Faces of Janus: Why Thyrotropin as a Cardiovascular Risk Factor May Be an Ambiguous Target
Dietrich, J. W., Hoermann, R., Midgley, J. E. M., Bergen, F., & Müller, P. (2020) · Frontiers in Endocrinology · doi:10.3389/fendo.2020.542710 · Cited by 19
“Studies reported either no relation at all (12, 13) or a rather complex Ushaped association (14, 15), as has been shown in a recent population study based on the large NHANES datasets (16).”
ResultForestier, E., Vinzio, S., Sapin, R., Schlienger, J.-L., & Goichot, B. (2008) · European Journal of Endocrinology · doi:10.1530/eje-08-0519 · Cited by 18
Lipids and Lipoproteins in Atherosclerosis
Chroni, A., Leondaritis, G., & Karlsson, H. (2011) · Journal of Lipids · doi:10.1155/2011/160104 · Cited by 17
“Vice versa, overexpression of stearoyl-CoA desaturase attenuates palmitate-induced ER stress and protects from lipoapoptosis [107–109].”
BackgroundIs an Isolated TSH Elevation in Chronic Nonthyroidal Illness “Subclinical Hypothyroidism”?
Kaptein, E. M., LoPresti, J. S., & Kaptein, M. J. (2014) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2014-1850 · Cited by 17
Delshad, H., Mehran, L., Tohidi, M., Assadi, M., & Azizi, F. (2012) · PubMed · doi:10.3275/7968 · Cited by 18
Subclinical hypothyroidism and mortality in a large Austrian cohort: a possible impact on treatment?
Kovar, F. M., Fang, I.-F., Perkmann, T., Haslacher, H., Slavka, G., Födinger, M., Endler, G., & Wagner, O. F. (2015) · Wiener klinische Wochenschrift · doi:10.1007/s00508-015-0846-z · Cited by 17
Santos, O. C., Silva, N. A. O., Vaisman, M., Turano, M. D., Dytz, M. G., Huber, G. A., Bráulio, V. B., & Teixeira, P. D. F. D. S. (2014) · Journal of Endocrinological Investigation · doi:10.1007/s40618-014-0199-x · Cited by 17
Skoczyńska, A., Wojakowska, A., Turczyn, B., Zatońska, K., Wołyniec, M., Rogala, N., Szuba, A., & Bednarek-Tupikowska, G. (2016) · Medical Science Monitor · doi:10.12659/msm.898134 · Cited by 17
“Lately, it has been suggested that subclinical hyperthyroidism may be not associated with cardiovascular mortality or disorders, except for development of atrial fibrillation [10,11].”
BackgroundKalinowska, S., Trześniowska-Drukała, B., Safranow, K., Pełka-Wysiecka, J., Kłoda, K., Misiak, B., & Samochowiec, J. (2019) · Psychiatry Research · doi:10.1016/j.psychres.2019.02.029 · Cited by 17
Subclinical Hypothyroidism in the Elderly: To Treat or Not to Treat?
Mooradian, A. D. (2010) · American Journal of Therapeutics · doi:10.1097/mjt.0b013e3181e0ca9c · Cited by 18
Portella, R. B., Pedrosa, R. C., Coeli, C. M., Buescu, A., & Vaisman, M. (2007) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2007.02879.x · Cited by 17
Invited Commentary: Cardiovascular mortality in subclinical hyperthyroidism: an ongoing dilemma
Biondi, B. (2010) · European Journal of Endocrinology · doi:10.1530/eje-09-1095 · Cited by 17
Wang, J., Xiuyun, M., Qu, S., Li, Y., Han, L., Sun, X., Li, P., Liu, X., & Xu, J. (2013) · Europe PMC (PubMed Central) · Cited by 16
Association of Thyroid Status with Health-Related Quality of Life in Korean Older Adults
Han, M., Choi, S., Kim, S., Ko, A., Son, J. S., & Park, S. M. (2020) · Korean Journal of Family Medicine · doi:10.4082/kjfm.19.0054 · Cited by 16
Triolo, M., de Boer, J. F., Annema, W., Kwakernaak, A. J., Tietge, U. J. F., & Dullaart, R. P. F. (2013) · Clinical Endocrinology · doi:10.1111/cen.12138 · Cited by 17
Hypothyroidism and Thyroiditis
Brent, G. A., & Weetman, A. P. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-29738-7.00013-7 · Cited by 16
A Sensitive and One-Step Quantification of Thyroid Stimulating Hormone Using Nanobiosensor
Saxena, R., & Srivastava, S. (2019) · Materials Today Proceedings · doi:10.1016/j.matpr.2019.06.600 · Cited by 16
Deyneli, O., Akpınar, İ., Meriçliler, Ö. S., Gözü, H. I., Yıldız, M. E., & Akalın, N. S. (2014) · Annales d Endocrinologie · doi:10.1016/j.ando.2014.06.002 · Cited by 16
Barca, M. F., Gruppi, C. J., de Oliveira, M. T., Romão, R., Cardia, M., Rubio, I. G. S., Knobel, M., & Medeiros-Neto, G. A. (2007) · Endocrine · doi:10.1007/s12020-007-9020-3 · Cited by 16
Metadata
- Authors
- Cappola, A. R., Fried, L. P., Arnold, A. M., Danese, M. D., Kuller, L. H., Burke, G. L., Tracy, R. P., & Ladenson, P. W.
- Affiliations
- University of Pennsylvania Health System (US)
- Johns Hopkins University (US)
- University of Washington (US)
- University of Pittsburgh (US)
- Wake Forest University (US)
- University of Vermont (US)
- Corresponding author
- Cappola, Anne R.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2006-03-01
- Volume
- 295
- Issue
- 9
- Pages
- 1033
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W1965686740
- Cited by
- 862
- References
- 47
- Citations by year
- 2026: 13 · 2025: 26 · 2024: 41 · 2023: 46 · 2022: 39 · 2021: 35 · 2020: 40 · 2019: 32 · 2018: 42 · 2017: 45 · 2016: 44 · 2015: 39 · 2014: 61 · 2013: 62 · 2012: 64
- FWCI
- 32.60
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Funders
- American Heart Association
- National Institutes of Health (n01hc085082-026, n01hc085081-021, n01hc085079-024, n01hc015103-009, n01hc085084-005, n01hc085085-011, n01hc085083-027, n01hc085080-026, n01hc085086-022, n01hc035129-010)
- National Institute on Aging (N01HC85079, N01 HC‐15103, N01‐HC‐35129, K23AG19161, N01‐HC‐85086, K23AG019161)
- National Heart, Lung, and Blood Institute (N01-HC-85081, N01HC85085, N01 HC085086, N01HC-85083, N01HC15103, N01 HC085079, N01HC85082, N01 HC85086, N01 HC035129, N01HC85080, N01 HC015103, N01-HC85079, N01-HC85084, N01HC35129)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hormonal and reproductive studies
- Keywords
- subclinical hypothyroidism, overt hypothyroidism, thyroid-stimulating hormone, atrial fibrillation, cardiovascular disease, coronary artery disease, cerebrovascular disease, cardiovascular mortality, all-cause mortality, older adults, thyroid function, Cardiovascular Health Study, sex differences, hormone replacement therapy
- MeSH terms
- Aged, Atrial Fibrillation, Cardiovascular Diseases, Female, Humans, Hyperthyroidism, Hypothyroidism, Male, Risk Factors, Thyroid Gland, Thyrotropin, Proportional Hazards Models
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