Left ventricular function by speckle-tracking echocardiography in patients with low-T3 syndrome and acute myocardial infarction.

BACKGROUND AND OBJECTIVE: Low-T3 syndrome is common in patients with acute myocardial infarction (AMI). Recent experimental and clinical data have suggested a potential negative impact of low-T3 syndrome on myocardial function in patients with AMI. The aim of this study was to assess left ventricular (LV) myocardial function in patients with low-T3 syndrome and to investigate the association between hormonal profile and the severity of LV dysfunction using speckle-tracking echocardiography (STE). MATERIALS AND METHODS: In 130 patients with first-onset ST-segment elevation acute myocardial infarction (STEMI), conventional 2D and speckle-tracking echocardiography within 48-72h after the hospitalization was performed, and blood samples for TSH, fT4, fT3, and anti-TPO levels were obtained to investigate thyroid hormone production within 24h and on the fourth day after the onset of STEMI symptoms. RESULTS: The patients were divided into two groups according to their serum level of fT3: group 1 with fT3 concentration below 3.2pmol/L (n=34) and group 2 with normal fT3 (>3.2pmol/L) level (n=96). LV ejection fraction (EF) tended to be lower in the low fT3 group. The systolic longitudinal strain did not differ between the groups, but the late diastolic longitudinal strain rate was lower in group 1 (P=0.011). The systolic basal LV rotation positively correlated with the level of fT3 (r=0.4; P<0.001), while a negative correlation was detected between myocardial rotational parameters - systolic apical rotation (r=-0.2; P<0.05), torsion (r=-0.3; P<0.001), and diastolic apical rotation rate (r=-0.3; P<0.01) - and fT3 levels. CONCLUSIONS: The late diastolic longitudinal LV strain rate and LV rotation evaluated by speckle-tracking echocardiography were impaired in patients with low-T3 syndrome after AMI.

Serum TSH values and risk of vertebral fractures in euthyroid post-menopausal women with low bone mineral density.

INTRODUCTION: There is evidence that variations of thyrotropin (TSH) even in its reference range may influence bone mineral density (BMD). In fact, low-normal TSH values have been associated with high prevalence of osteoporosis in post-menopausal women. However, data associating TSH and risk of fractures are scanty and limited to subjects with subclinical thyrotoxicosis. MATERIALS AND METHODS: In this observational study, we investigated the correlation between serum TSH and prevalence of radiological vertebral fractures in a cohort of 130 post-menopausal women with normal thyroid function. RESULTS: Osteoporosis was observed in 80 women (61.5%), whereas 49 women (37.7%) had osteopenia. Vertebral fractures were found in 49 women (37.7%), who were significantly older, with higher prevalence of osteoporosis and with lower serum TSH values as compared with women who did not fracture. Stratifying the patients according to serum TSH values, vertebral fractures were found to be significantly (p=0.004) more prevalent in first tertile (56.8%) of TSH values as compared with the second (23.3%) and third tertiles (32.6%). Multivariate logistic regression analysis demonstrated that low serum TSH maintained a significant correlation with vertebral fractures (odds ratio 2.8, C.I. 95% 1.20-6.79) even after correction for age, BMD, BMI and serum free-thyroxine values. DISCUSSION: Low-normal TSH values are associated with high prevalence of vertebral fractures in women with post-menopausal osteoporosis or osteopenia, independently of thyroid hormones, age and BMD.

[Low T3 syndrome and left ventricular diastolic function]. / Sindrome da bassa T3 e funzione diastolica del ventricolo sinistro.

BACKGROUND: Recent data suggest that low triiodothyronine (T3) syndrome may contribute to the pathophysiology of cardiac diseases. Because the development of diastolic dysfunction occurs early in a failing heart, we evaluated whether patients with low T3 syndrome show abnormalities in diastolic function, also in absence of overt cardiovascular disease. METHODS: Thirty-four patients with low T3 syndrome and 34 controls with normal levels of free T3 (FT3) underwent a complete Doppler echocardiographic examination. Criteria of exclusion from the study were the presence of cardiovascular disease or traditional cardiovascular risk factors, a primitive thyroid disease, cachexia, and the use of drugs affecting the thyroid function. RESULTS: Patients with low T3 syndrome, if compared with controls, show evidence of left ventricular diastolic dysfunction, documented by prolongation of the isovolumic relaxation time (120 vs 75 ms, p < 0.0001) and a reduction in the early diastolic mitral flow velocity/late diastolic mitral flow velocity ratio (0.66 vs 2.05, p < 0.0001), mainly due to the increased A-wave (0.96 vs 0.40 m/s, p < 0.0001). These alterations increase proportionally with FT3 reduction. CONCLUSIONS: Patients with low T3 syndrome show evidence of impaired left ventricular relaxation. Doppler echocardiography may be a useful non-invasive technique for the assessment of diastolic performance in these patients.

Hyperthyroidism-associated coronary vasospasm with myocardial infarction and subsequent euthyroid angina.

A 40-year-old African-American woman presented with atypical chest pain, an acute non-ST segment elevation myocardial infarction, and angiographic evidence for severe ostial vasospasm of the left main and right coronary arteries. Subsequently, she was diagnosed with hyperthyroidism and treated with antithyroid therapy and oral nitrates. Repeat angiography revealed resolution of the vasospasm; however, the chest pain recurred in the euthyroid state. Hyperthyroidism-associated coronary vasospasm is a rare disorder that characteristically causes angina in young Asian women and resolves with correction of hyperthyroidism. We present an atypical case of an African-American woman presenting with a myocardial infarction who developed recurrent angina while euthyroid.

Thyroid sonography as an effective tool to discriminate between euthyroid sick and hypothyroid dogs.

The diagnosis of canine hypothyroidism and its differentiation from euthyroid sick syndrome still is a major diagnostic challenge. In this study, ultrasonography was shown to be an effective tool for the investigation of thyroid gland diseases. Healthy control dogs (n = 87), dogs with euthyroid sick syndrome (n = 26), thyroglobulin autoantibody-positive (TgAA-positive, n = 30) hypothyroid dogs, and TgAA-negative (n = 23) hypothyroid dogs were examined by thyroid ultrasonography. Maximal cross sectional area (MCSA), thyroid volume, and echogenicity were measured. Statistical analysis identified highly significant (P < .001) differences between euthyroid and hypothyroid dogs both in thyroid volume and in MCSA, whereas no significant differences in thyroid size were detected between healthy euthyroid dogs and dogs with euthyroid sick syndrome. In euthyroid and euthyroid sick dogs, parenchymal echotexture was homogeneous and hyperechoic, whereas relative thyroid echogenicity of both TgAA-positive and TgAA-negative hypothyroid dogs was significantly lower (P < .001). When using arbitrarily chosen cutoff values for relative thyroid volume, MCSA, and echogenicity, thyroid volume especially was found to have highly specific predictive value for canine hypothyroidism. In summary, the data reveal that thyroid sonography is an effective ancillary diagnostic tool to differentiate between canine hypothyroidism and euthyroid sick syndrome.

99mTc-sestamibi thyroid uptake in euthyroid individuals and in patients with autoimmune thyroid disease.

PURPOSE: We investigated the biokinetics of (99m)Tc-sestamibi in the thyroid of euthyroid volunteers (EVs) and in patients with autoimmune thyroid diseases and determined the best time interval between (99m)Tc-sestamibi injection and calculation of uptake. METHODS: Forty EVs, 30 patients with Graves' disease (GD), 15 patients with atrophic Hashimoto's thyroiditis (AHT) and 15 patients with hypertrophic Hashimoto's thyroiditis (HHT) underwent (99m)Tc-sestamibi thyroid scintigraphy. Dynamic images were acquired for 20 min, and static images were obtained 20 min, 60 min and 120 min post injection. Five-, 20-, 60- and 120-min uptake, time to maximal uptake (T(max)) and T(1/2) of tracer clearance were calculated. Thyroid hormones and antibodies were measured. (99m)Tc-pertechnetate uptake was investigated in GD patients. RESULTS: T(max) was approximately 5 min in all four groups. The mean T(1/2) value for EVs was similar to the GD value and lower than the HHT and AHT values. The mean (+/-SD) 5-min uptake was 0.13% (+/-0.05%) for EVs. The 5-min uptake in GD was higher than that in EVs(P<0.001) and correlated with free thyroxine (r=0.54) and with (99m)Tc-pertechnetate uptake (r=0.68). Uptake in HHT was higher than that in AHT (P=0.0003) and EVs (P=0.002). Uptake in AHT was lower than uptake in EVs (P=0.0001). CONCLUSION: Five minutes is the optimal time interval between (99m)Tc-sestamibi injection and calculation of thyroid uptake. Five-minute uptake differentiates euthyroid individuals from GD patients. There is a high correlation between (99m)Tc-sestamibi and (99m)Tc-pertechnetate uptake in GD. The reduced (99m)Tc-sestamibi uptake in AHT patients is probably due to glandular destruction and fibrosis. Inflammatory infiltrate and high mitochondrial density in thyrocytes possibly explain the increased uptake in GD and HHT.

Salivary gland scintigraphy in Sjögren's syndrome: are quantitative indices the answer?

We evaluated the role of quantitative indices derived from dynamic 99mTc-pertechnetate salivary scintigraphy in the differentiation between a group of patients with Sjögren's syndrome (SS), a group of patients without xerostomia, but with underlying autoimmune disorders, and a group of controls. Seventeen patients with SS (group A), 18 patients with autoimmune disorders (group B) and 15 controls (group C) underwent dynamic salivary gland scintigraphy. Functional indices for the parotid and submandibular glands were calculated and comparisons were made between the groups. There were no significant differences between the three groups in terms of the maximum accumulation (MA), maximum secretion (MS) and pre-stimulatory oral index (PRI). The uptake ratios (URs) for both the right and left parotid glands and the left submandibular gland in group A were significantly lower than those in group C, but no different from those in group B. The URs for the parotid glands in group B were significantly less than those in group C. The percentage uptake by the right parotid gland at 4 min (U4) was significantly lower in group A than in groups B or C, and lower than the percentage uptake by the left parotid gland at 4 min in group A. The rest of the U4 values and all of the uptakes at 14 min (U14) were not significantly different between the three groups. The time taken for the right parotid gland to reach peak activity (Tmax) was significantly less in group A than in the other groups, but other glands showed no significant differences. It can be concluded that MA, MS and PRI cannot be used to differentiate between the three groups. The URs in groups A and B were no different, but were significantly lower than those in group C. However, the extensive overlap between xerostomic patients and normal controls for all the quantitative indices calculated imposes a severe limitation on their discriminatory power.

[Treatment of euthyroid struma. Comparable volume reduction with 400 micrograms iodine, 100 micrograms levothyroxine combined with 100 micrograms iodine or individually dosed levothyroxine]. / Behandlung der euthyreoten Struma. Vergleichbare Volumenreduktion mit 400 micrograms Jodid, 100 micrograms Levothyroxin kombiniert mit 100 micrograms Jodid oder individuell dosiertem Levothyroxin.

AIM: In patients with euthyroid goitre, the efficacy of treatment with 400 micrograms iodine and 100 micrograms levothyroxine combined with 100 micrograms iodine was compared to that of the previous standard of therapy, individually dosed levothyroxine. PATIENTS AND METHODS: A total of 78 patients presenting with euthyroid diffuse goitre (> or = 25 ml) were prospectively enrolled, randomised and treated for 6 months. The course of thyroid volume was followed using thyroid volumetry. RESULTS: Data of 69 patients were included in the final evaluation (57 women, 12 men, age 31 +/- 1 years, thyroid volume 31.5 +/- 1.4 ml, 23 per treatment group). In the patients treated with individually dosed levothyroxine, the thyroid volume decreased by about 39% (95%-confidence limit [CL]-31% to -41%). However, the volume reductions achieved in the patients treated with 400 micrograms iodine or 100 micrograms levothyroxine/100 micrograms iodine were not significantly different (p = 0.35, variance analysis, mono-iodine -34%, 95%-CL -29% to -43%, 100 micrograms levothyroxine/100 micrograms iodine -39%, 95%-CL -32% to -45%). CONCLUSIONS: In patients with euthyroid diffuse goitre, treatment with mono-iodine or combination of levothyroxine with iodine should have principally the same status as the previous standard of therapy, individually dosed levothyroxine. In the view of the authors, its preferential treatment with mono-iodine appears most reasonable.

[Ultrasound-guided alcohol instillation in treatment of autonomous thyroid adenoma]. / Sonographisch gesteuerte Alkoholinstillation zur Behandlung des autonomen Schilddrüsenadenoms.

In 16 patients with unifocal thyroid autonomy suffering from hyperthyroidism and in 2 patients and euthyrosis 2-4 ml 96% alcohol was instilled to destroy the autonomous thyroid tissue while permanently monitoring the procedure by means of sonography. 17 of the patients were suffering from struma nodosa. Localization of the focally autonomous adenoma was possible, together with differentiation against concomitant thyroid nodes with normal or reduced function, by coinciding the findings obtained via colour Doppler sonography and scintiscanning. In one female patient local pain occurred during instillation that had to be alleviated by means of analgetics; there were no other noticeable side effects. 12 of 16 patients suffering from hyperthyroidism were euthyrotic 5 weeks after the first alcohol instillation; the thyrostatic dose had to be reduced in 4 patients. B-image sonography showed a reduction in size of the instilled adenomas and echo-poor and partly cystic transformation. Colour Doppler sonography revealed a marked reduction of internal vascularisation with preserved marginal vessels. Scintiscan control no longer visualised the autonomic foci (n = 10) or only with reduced activity (n = 7). Sonographically monitored on-target instillation of alcohol into autonomic thyroid adenoma is an effective, low-risk and low-cost procedure that can also be applied to outpatients by physicians well-versed in colour Doppler sonography and sonographic puncture technique. Colour Doppler sonographic localization of autonomic foci is methodically mandatory in patients suffering from struma multinodosa.

[Quantitative determination of echogenicity of diffuse inflammatory thyroid gland diseases]. / Quantitative Bestimmung der Echogenität diffus entzündlicher Schilddrüsenerkrankungen.

Grey level was measured in 93 ultrasonic scans of the thyroid gland in order to quantify hypoechogenicity in diffuse inflammatory thyroid disease. Using a modern ultrasound device (256 grey-scale steps and 7.5-MHz parallel scan), grey levels were measured in normal thyroid glands and euthyreotic goiters as well as in thyroiditis or Graves' disease using a programmed setting of the device. Highly significant differences were found between normal thyroid glands and thyroiditis or Graves' disease. Sensitivity of the method was 65% in discriminating Graves' disease and 91% in discriminating thyroiditis; specificity was 95%. The clinical value of the method for follow-up studies in inflammatory diseases of the thyroid gland still has to be established.

TcTU before and after exogeneous TSH suppression in diagnosing thyroid autonomy.

In 104 euthyroid patients with goiter and suspected thyroid autonomy two thyroid scintiscans with quantification of the TcTU were performed before (TcTUo) and after exogeneous TSH suppression (TcTUs). In 15 patients with subnormal TSH before suppression the TcTUs revealed no difference to the TcTUo. In contrast to the TcTUo, in euthyroid patients the TcTUs is not relevantly influenced by individual iodine supply. In euthyroid goitreous patients with normal TSH a TcTUo less than 2.0% resulted in a TcTUs less than 1.1% in all 22 cases and, therefore, in these patients a scintiscan after TSH suppression is not necessary, because no relevant mass of functional autonomous tissue can be expected. In all other patients with normal TSH only the TcTUs is relevant for identification of thyroid autonomy. Autonomy with a TcTUs greater than 1.5% and, consequently, with a suspected higher risk of hyperthyroidism after iodine contamination was found in 19% (17/89) of the goitreous patients with normal TSH.