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Thyroid Hormone Profile in Patients with Acute Coronary Syndrome- Juniper publishers
Materials and methods: A total of 100 patients were enrolled n this study and were divided into two groups as STEMI and NSTEMI/UA group. Thyroid function tests (fT3, fT4, TSH) were done by ELISA method within 24 hours of admission. The data were analyzed by SPSS version 17 software.
Results: Euthyroid Sick Syndrome was observed in 60%, subclinical hypothyroidism in 28% and subclinical hyperthyroidism in 8% of patients with abnormal thyroid hormone profile. A higher prevalence of abnormal thyroid hormone profile was seen in elderly age group >60 years (56%) followed by age group 40-60 years (36%) and 20-40 years (8%). A statistically higher prevalence of abnormal thyroid hormone profile was seen in STEMI group (72%) as compared to NSTEMI/UA group (28%). However, the difference in prevalence of ESS was not statistically significant between STEMI and NSTEMI/UA group.
Conclusion: The overall prevalence of abnormal thyroid hormone profile was statistically significant in the STEMI group, the prevalence of ESS did not show any statistically significant difference in STEMI and NSTEMI/UA groups.
Keywords: Acute coronary syndrome; Euthyroid sick syndrome; Thyroid hormone profile; Non ST segment elevation; Unstable angina
“Euthyroid Sick Syndrome” is characterized by decreased serum T3 and /or free T3, increased serum reverse T3(rT3), plus normal serum TSH, T4, and free T4 . Patients belonging to the STEMI group showed early elevations, in addition to higher mean reverse T3(rT3) and lower mean T3 and free T3 levels . This syndrome has been reported to be found in severe chronic heart failure [10,11], in acute myocardial infarction [6,12] and as a rapidly emerging phenomenon during open-heart surgery . Additionally hypothyroidism is emerging as a risk for coronary artery disease .
Evaluation of thyroid hormone plasma levels has been done in a number of studies in patients presenting with Acute Coronary Syndrome and findings compared between Unstable Angina/Non-ST elevation MI (UA/NSTEMI) and ST Elevation acute MI (STEMI) groups [2,14]. Some studies have reported association of greater hormonal changes with more severe cardiac events (STEMI and Death) and patients with complications [2,14,15]. Implications of “Euthyroid Sick Syndrome” in terms of morbidityand mortality in ACS have also been studied by few workers . An association of Euthyroid sick syndrome in ACS with poorer prognosis has been suggested in few studies [2,10] and has special significance in patients of ACS because low T3 levels in these patients signify severe disease and can be used as a marker for early invasive management in these patients [5,7].
The clinicians consider abnormalities of thyroid function test as significant coronary risk factors such as blood pressure, diabetic state, and cholesterol level during coronary care unit hospitalization . Very limited data are available on altered serum levels of thyroid hormone in various clinical situation in Nepal [16-18]. Therefore, this hospital based study was undertaken to study the thyroid hormone profile in patients of ACS and to compare it in between STEMI and NSTEMI/UA groups.
History and detailed clinical examination performed as per the working Performa. Cases showing abnormal thyroid hormone profile were grouped into Euthyroid Sick Syndrome (Low fT3, Normal fT4 and TSH), Subclinical Hypothyroidism (High TSH plus normal fT3 and fT4) and Subclinical Hyperthyroidism ( Low TSH plus normal fT3 and fT4) . The study was carried out on the thyroid hormone profile in patients with ACS admitted to Manipal Teaching Hospital, Pokhara. Out of 100 ACS patients, 54 patients belonged to STEMI and 46 patients to NSTEMI/UA group. In patients presenting with symptoms of myocardial ischemia, angina pectoris or equivalent ischemic discomfort, the following investigations were done in all cases.
- 12- lead ECG (Electrocardiogram)
- Cardiac markers (CPK MB, Troponin I)
- Thyroid Function test (f T3, fT4, TSH) by ELISA method within 24 hours of admission.
- Complete blood count
- Random blood glucose level (Fasting and Post prandial in selected cases)
- Blood urea, serum creatinine, electrolytes (Na+, K+ )
- Fasting lipid profile
- X-ray Chest
- Echocardiography (in selective cases)/li>
Depending on the ECG findings and result of cardiac markers, the patients of ACS were categorized into following two groups as per American Heart Association (AHA) criteria.
UA is defined as angina pectoris or equivalent ischemic discomfort with at least one of three features:
- It occurs at rest (or with minimal exertion), usually lasting >10 minutes.
- It is severe and of new onset (i.e., within the prior 4-6 weeks); and/or
- It occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously).
This study depicts changes in thyroid hormone profile were observed in 25(25%) of the patients where 15(60%) had Euthyroid Sick Syndrome, 7(28%) had subclinical hypothyroidism, 2(8%) had subclinical hyperthyroidism and 1(4%) had low fT4 with nomal fT3 and normal TSH. In a study of 400 patients of ACS by Qari FA, thyroid dysfunction was reported in 23.3% of patients . Khalil OA et al.  in their study of 196 patients of ACS, reported changes in thyroid hormone profile in 23% of their patients . Mathur P et al.  in their study of 85 patients and Bayrak A et al.  in their study among 110 patients of ACS reported changes in thyroid hormone profile in 31.7% and 23.6% of patients respectively [5,24]. A prevalence of 25% reported in our study is almost in accord with the above studies. But in contrast to these studies, Adawiyah J et al.  reported a much higher prevalence of 53% of thyroid hormone dysfunction in their study among 85 patients . The higher prevalence in their study is likely to be due to different inclusion criteria.
There was no statistically significant difference in prevalence of abnormal thyroid hormone profile in males and females group in this study being present in 27.5% in males and 21.42 % in females (p =0.322). Not many figures are available about difference in prevalence in males and females in other studies.
A higher prevalence of abnormal thyroid hormone profile was seen in patients of STEMI group as compared to NSTEMI/UA group being 18 out of 25 (72%) in STEMI group and 7 out of 25 (28%) in NSTEMI/UA group. The difference is statistically significant (p=0.031). Euthyroid Sick Syndrome was observed in 15 out of 25 patients (60%) showing abnormal thyroid hormone profile in our study. Khalil OA et al.  in their study reported Euthyroid Sick Syndrome in 68.9% cases while Adawiyah J et al.  found 43.5% of cases in the study [4,25]. Our findings are likely in accordance with findings of Khalil OA et al. . But, Lower prevalence of Euthyroid Sick Syndrome have been reported in studies of other authors as 21.8% by Mathur P et al. , 21.67% by Potdar S et al. , 18.6% by Pimentel RC et al. , 10.2% by Qari FA  and 1.8% by Bayrak A et al. .
Out of total 15 patients with thyroid hormone profile of ESS, 10 (66.67%) belonged to STEMI group while 5(33.33%) belonged to NSTEMI/UA group. The difference is not statistically significant (p=0.217). Tuzun D et al.  in their study of 94 patients did not find any significant difference in prevalence of ESS between STEMI and NSTEMI/UA groups . Higher prevalence 12 out of 18(66.66%) were in NSTEMI/UA group and it was 6 out of 18 (33.34%) in STEMI group in the study conducted by Mathur P et al. .
In our study, 7 out of 25(28%) had subclinical hypothyroidism. In agreement to our study, Khalil OA noted 24.5% had subclinical hypothyroidism . Lovely NS et al.  reported hypothyroidism in patients suffering from ischemic heart disease . In our study, 2 out of 25(8%) had subclinical hyperthyroidism. In agreement to our study Khalil OA et al reported 6.6% had subclinical hyperthyroidism .
For more Journals in Juniper Publishers please click on https://juniperpublishers.com/journals.php
For more articles in Journal of Thyroid Research please click on: https://juniperpublishers.com/jetindex.php