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Low Serum Thyrotropin Concentrations as a Risk Factor for Atrial Fibrillation in Older Persons
Open accessAbstract
BACKGROUND: Low serum thyrotropin concentrations are a sensitive indicator of hyperthyroidism but can also occur in persons who have no clinical manifestations of the disorder. We studied whether low serum thyrotropin concentrations in clinically euthyroid older persons are a risk factor for subsequent atrial fibrillation. METHODS: We studied 2007 persons (814 men and 1193 women) 60 years of age or older who did not have atrial fibrillation in order to determine the frequency of this arrhythmia during a 10-year follow-up period. The subjects were classified according to their serum thyrotropin concentrations: those with low values (< or = 0.1 mU per liter; 61 subjects); those with slightly low values (> 0.1 to 0.4 mU per liter; 187 subjects); those with normal values (> 0.4 to 5.0 mU per liter; 1576 subjects); and those with high values (> 5.0 mU per liter; 183 subjects). RESULTS: During the 10-year follow-up period, atrial fibrillation occurred in 13 persons with low initial values for serum thyrotropin, 23 with slightly low values, 133 with normal values, and 23 with high values. The cumulative incidence of atrial fibrillation at 10 years was 28 percent among the subjects with low serum thyrotropin values (< or = 0.1 mU per liter), as compared with 11 percent among those with normal values; the age-adjusted incidence of atrial fibrillation was 28 per 1000 person-years among those with low values and 10 per 1000 person-years among those with normal values (P = 0.005). After adjustment for other known risk factors, the relative risk of atrial fibrillation in elderly subjects with low serum thyrotropin concentrations, as compared with those with normal concentrations, was 3.1 (95 percent confidence interval, 1.7 to 5.5; P < 0.001). The 10-year incidence of atrial fibrillation in the groups with slightly low and high serum thyrotropin values was not significantly different from that in the group with normal values. CONCLUSIONS: Among people 60 years of age or older, a low serum thyrotropin concentration is associated with a threefold higher risk that atrial fibrillation will develop in the subsequent decade.
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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 [52]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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 [52]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
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 [52]
The cited source says what the claim attributes to it.
In the citing paper
“Excess thyroid hormone can also increase the risk of arrhythmias24 25 and muscle weakness23 in older people, which can contribute to a greater risk of falls.”
From Levothyroxine dose and risk of fractures in older adults: nested case-control study (2011) · cites this paper as [24]
The cited source says what the claim attributes to it.
In the citing paper
“lower serum TSH levels are associated with increased risk of atrial fibrillation (AF) (60)”
From Liothyronine and Desiccated Thyroid Extract in the Treatment of Hypothyroidism (2020) · cites this paper as [60]
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 [97]
In the citing paper
“Twenty years ago, a low serum TSH level was first associated with an increased risk of atrial fibrillation (AF) (12)”
From Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study (2016) · cites this paper as [12]
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 [12]
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 [12]
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 [399]
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McLeod, D. S. A., Carruthers, K., & Kevat, D. (2015) · Drugs & Aging · doi:10.1007/s40266-015-0256-y · Cited by 17
“[45] measured serum TSH at a single timepoint in the original cohort of patients aged[60 years in the Framingham Heart Study.”
Thyroid nodule: A potentially malignant lesion; optimal management from a surgical perspective
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“These conditions are often associated with other pathologies such as hematologic [13–15], cardiovascular [16,17], gastrointestinal [18,19], metabolic [20,21], and, last but not least, reproductive It is in fact well known that thyroid function has a close link and interplay with female fertility…”
Does Combination T4 And T3 Therapy Make Sense?
McDermott, M. T. (2012) · Endocrine Practice · doi:10.4158/ep12076.ra · Cited by 15
Thromboembolic complications of thyroid storm
Min, T., Benjamin, S., & Cozma, L. G. (2014) · Endocrinology Diabetes and Metabolism Case Reports · doi:10.1530/edm-13-0060 · Cited by 15
Radioiodine treatment of non-toxic multinodular goitre: effects of combination with lithium
Vannucchi, G. M., Chiti, A., Mannavola, D., Dazzi, D., Rodari, M., Tadayyon, S., Beck‐Peccoz, P., & Fugazzola, L. (2005) · European Journal of Nuclear Medicine and Molecular Imaging · doi:10.1007/s00259-005-1818-8 · Cited by 15
“Furthermore, this therapy carries a risk, especially in elderly patients, of atrial fibrillation [3] or bone loss [4] as a consequence of subclinical hyperthyroidism.”
BackgroundEvaluation of Endocrine Function
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Subclinical Thyroid Dysfunction and the Heart
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Duration of the P Wave and P Wave Dispersion in Subclinical Hyperthyroidism
Çetinarslan, B., Akkoyun, M., Cantürk, Z., Tarkun, İ., Kahranman, G., & Komşuoğlu, B. (2003) · Endocrine Practice · doi:10.4158/ep.9.3.200 · Cited by 15
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“TSH suppression by T4 or T3 may induce adverse effects, particularly on the heart (Biondi et al., 1993; Sawin et al., 1994) and bones (Wartofsky, 1993; Fabers et al.”
BackgroundTirzepatide-Induced Rapid Weight Loss–Related Thyrotoxicosis
Karakus, K. E., Shah, V. N., & Aktürk, H. K. (2024) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2024.2919 · Cited by 14
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Graves’ disease, multinodular goiter and subclinical hyperthyroidism
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Thyrotoxic atrial fibrillation.
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“Atrial fibrillation occurs in 10-15% of elderly patients with long-standing uncontrolled hyperthyroidism[16] and is associated with significant morbidity resulting from embolic events[17] rather than hepatic failure.”
Cardiovascular Consequences of Subclinical Thyroid Dysfunction: More Smoke but No Fire
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Outcomes and Management of Stressor-Associated Atrial Fibrillation
Haimovich, J. S., Kany, S., Ajufo, E. C., Andrade, J. G., Benjamin, E. J., Healey, J. S., Kirchhof, P. F., Lubitz, S. A., McIntyre, W. F., Rienstra, M., et al. (2025) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2025.07.031 · Cited by 13
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P-wave dispersion in endogenous and exogenous subclinical hyperthyroidism
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Circulating microRNA-1a is a biomarker of Graves’ disease patients with atrial fibrillation
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Diagnosis and treatment of hypothyroidism in old people
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Metformin-induced thyrotropin suppression is not associated with cardiac effects
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Association of thyroid-stimulating hormone with lipid concentrations: an 11-year longitudinal study
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Metadata
- Authors
- Sawin, C. T., Geller, A., Wolf, P. A., Belanger, A. J., Baker, E., Bacharach, P., Wilson, P., Benjamin, E. J., & D'Agostino, R. B.
- Affiliations
- Boston University (US)
- Veterans Health Administration (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 1994-11-10
- Volume
- 331
- Issue
- 19
- Pages
- 1249-1252
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2335515807
- Cited by
- 1,259
- References
- 31
- Citations by year
- 2026: 16 · 2025: 20 · 2024: 27 · 2023: 25 · 2022: 46 · 2021: 37 · 2020: 27 · 2019: 38 · 2018: 41 · 2017: 44 · 2016: 48 · 2015: 45 · 2014: 44 · 2013: 63 · 2012: 65
- FWCI
- 16.14
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc038038-022, 5r01hl040423-06)
- National Heart, Lung, and Blood Institute (R01-HL-40423-04, N01-HC-38038)
- National Institute of Neurological Disorders and Stroke (2-R01-NS-17950-12, R01NS017950)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- thyroid-stimulating hormone, subclinical hyperthyroidism, older adults, hyperthyroidism, arrhythmia risk, thyroid function, incidence, risk factors, euthyroid patients, parathyroid hormone, parathyroidectomy, parathyroid hormone replacement, hypoparathyroidism
- MeSH terms
- Age Factors, Aged, Atrial Fibrillation, Female, Follow-Up Studies, Humans, Hyperthyroidism, Male, Middle Aged, Risk Factors, Thyrotropin, Thyroxine, Incidence, Confidence Intervals
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