The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism

Abstract

Endogenous subclinical hyperthyroidism (SHyper) is caused by Graves' disease, autonomously functioning thyroid nodules and multinodular goitre. Its diagnosis is based on a persistently subnormal serum thyroid-stimulating hormone (TSH) level with free thyroid hormone levels within their respective reference intervals. In 2014 the European Thyroid Association Executive Committee, given the controversies regarding the treatment of Endo SHyper, formed a task force to develop clinical practice guidelines based on the principles of evidence-based medicine. The task force recognized that recent meta-analyses, including those based on large prospective cohort studies, indicate that SHyper is associated with increased risk of coronary heart disease mortality, incident atrial fibrillation, heart failure, fractures and excess mortality in patients with serum TSH levels <0.1 mIU/l (grade 2 SHyper). Therefore, despite the absence of randomized prospective trials, there is evidence that treatment is indicated in patients older than 65 years with grade 2 SHyper to potentially avoid these serious cardiovascular events, fractures and the risk of progression to overt hyperthyroidism. Treatment could be considered in patients older than 65 years with TSH levels 0.1-0.39 mIU/l (grade 1 SHyper) because of their increased risk of atrial fibrillation, and might also be reasonable in younger (<65 years) symptomatic patients with grade 2 SHyper because of the risk of progression, especially in the presence of symptoms and/or underlying risk factors or co-morbidity. Finally, the task force concluded that there are no data to support treating SHyper in younger asymptomatic patients with grade 1 SHyper. These patients should be followed without treatment due to the low risk of progression to overt hyperthyroidism and the weaker evidence for adverse health outcomes.

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“…This includes a spectrum of cardiovascular risks, including atrial fibrillation and coronary heart disease morbidity and mortality (Collet et al 2012). There is also a documented association with dementia, decreased cognitive function (Annerbo & Lokk 2013) and osteoporosis (Biondi et al 2015, Polovina et al 2015.…”

De novo coronary artery disease in graves’ disease. coincidence?

“…In cases where less invasive cardiac care is warranted, it is unclear whether treating the hyperthyroid state will reduce the cardiac pathologic burden. The European Thyroid Association guidelines assert a TSH level of < 0.10 mU/L in elderly patients as treatable to decrease cardiovascular risk; however, robust studies of such recommendations have yet to be completed [18]. Future studies about medical intervention of these two common overlapping clinical entities are merited to guide future care.…”

Hypothyroidism and the Heart

“…27 Persistent subnormal TSH values need to be confirmed within 2 to 3 months from initial values. 28 Subclinical hyperthyroidism is further classified into two categories: Grade 1, with mildly low but detectable serum TSH (0.1-0.45 mIU/L), and Grade 2, with lower levels of serum TSH (< 0.1 mIU/L). The etiology of subclinical hyperthyroidism is broadly classified as exogenous or endogenous.…”