ࡱ> }| m{bjbj .|b55555IIIIeI"tyyyyyTTT" " " " " " "$& "E5TTTTT "55yyN"T< 5y5y"T"1!}!y6II!!d"0"Q!,' '}!}!"'5!TTTTTTTT " "TTT"TTTT'TTTTTTTTT : Atrial Fibrillation Risk of A-fib is linearly related to free T4 levels from hypothyroidism through hyperthyroidism (Selmer 2012, Gammage 2007) Auer J, Scheibner P, Mische T, Langsteger W, Eber O, Eber B. Subclinical hyperthyroidism as a risk factor for atrial fibrillation. Am Heart J. 2001 Nov;142(5):838-42. OBJECTIVES: Atrial fibrillation is a well-known manifestation of hyperthyroidism. We studied whether subclinical hyperthyroidism with low serum thyrotropin concentrations and free thyroid hormone concentrations within the normal range in clinically euthyroid persons is a risk factor for subsequent atrial fibrillation. METHODS: We studied 23,638 persons. The subjects were classified according to their serum thyrotropin concentrations: group 1 comprised those with normal values of serum thyrotropin concentration (>0.4-5.0 mU/L) and free tri-iodothyronine and free thyroxine concentrations were within the normal range (22,300 subjects), group 2 comprised those with both low serum thyrotropin values (5-fold higher likelihood for the presence of atrial fibrillation with no significant difference between subclinical and overt hyperthyroidism. PMID: 11685172 Brabant G. [New normal ranges for TSH: when to treat?] Dtsch Med Wochenschr. 2009 Dec;134(49):2510-3. Epub 2009 Nov 25. Subclinical forms of thyroid dysfunction rest purely on a biochemical definition. An increase or decrease of TSH compared to the laboratory norm defines the condition with thyroid hormone concentrations still within the norm. Recent population based large surveys defined a much narrower range of TSH levels between 0.3 and 2.5 mU/l. As TSH determinations are subject to modulations due to endogenous and exogenous factors including substantial variations due to the laboratory methods, therapeutic intervention should not be considered when TSH levels are below the long accepted threshold of 4.5-5 mU/l. This is supported by the lack of current data on an increased morbidity under these conditions. In contrast, subtle alterations of TSH in the context of subclinical hyperthyroidism are associated with a significantly higher risk particularly of atrial fibrillation. PMID: 19941233 Dernellis J, Panaretou M. Relationship between C-reactive protein concentrations during glucocorticoid therapy and recurrent atrial fibrillation. Eur Heart J. 2004 Jul;25(13):1100-7. BACKGROUND: Little direct information is available on the effect of C-Reactive Protein (CRP) lowering on the reduction of recurrent atrial fibrillation (AF). METHODS AND RESULTS: We compared low-dose glucocorticoid therapy (16 mg methylprednisolone for 4 weeks tapered to 4 mg for 4 months) and placebo in 104 patients who had experienced persistent AF with a median concentration of CRP 1.14 mg/dL (min=0.01, max=2.58). Methylprednisolone reduced recurrent AF (primary end-point) from 50% in the placebo group to 9.6% in the glucocorticoid group and permanent AF (expanded end-point) from 29% in the placebo group to 2% in the glucocorticoid group. Survival distributions for methylprednisolone were significantly different (for both primary and expanded end-point, P < 0.001). In multivariate Cox analysis, average CRP concentrations during follow-up were significant predictors of the primary end-point, with a relative risk 6.72 (P = 0.006) and the expanded end-point, with a relative risk of 11.67 (P = 0.0006). CONCLUSIONS: CRP concentration is a risk factor for recurrent and permanent AF. Methylprednisolone successfully prevents recurrent and permanent AF. PMID: 15231367 Forfar JC, Miller HC, Toft AD. Occult thyrotoxicosis: a correctable cause of "idiopathic" atrial fibrillation. Am J Cardiol. 1979 Jul;44(1):9-12. Serum total thyroxine, triiodothyronine and thyrotropin response to thyrotropin-releasing hormone were measured in 75 consecutive patients presenting to a cardiology clinic with atrial fibrillation with no obvious cardiovascular cause. A lack of response of serum thyrotropin to thyrotropin-releasing hormone, indicative of thyrotoxicosis, was found in 10 patients (13 percent), not all whom had raised serum thyroid hormone levels. These 10 patients were predominantly male, had no clinical signs of thyrotoxicosis and a relative excess of nonpalpable autonomous thyroid nodules demonstrated with scintigraphy. Eight of the 10 patients had reversion to stable sinus rhythm after treatment with iodine-131 or carbimazole, either spontaneously or after direct current cardioversion. It would appear that clinically occult thyrotoxicosis can be identified consistently only with the thyrotropin-releasing hormone test and is the cause of "idiopathic" atrial fibrillation in a significant proportion of patients. PMID: 110126 Gammage MD, Parle JV, Holder RL, Roberts LM, Hobbs FD, Wilson S, Sheppard MC, Franklyn JA. Association between serum free thyroxine concentration and atrial fibrillation. Arch Intern Med. 2007 May 14;167(9):928-34. BACKGROUND: Previous studies have suggested that minor changes in thyroid function are associated with risk of atrial fibrillation (AF). Our objective was to determine the relationship between thyroid function and presence of atrial fibrillation (AF) in older subjects. METHODS: A population-based study of 5860 subjects 65 years and older, which excluded those being treated for thyroid dysfunction and those with previous hyperthyroidism. Main outcome measures included tests of thyroid function (serum free thyroxine [T(4)] and thyrotropin [TSH]) and the presence of AF on resting electrocardiogram. RESULTS: Fourteen subjects (0.2%) had previously undiagnosed overt hyperthyroidism and 126 (2.2%), subclinical hyperthyroidism; 5519 (94.4%) were euthyroid; and 167 (2.9%) had subclinical hypothyroidism and 23 (0.4%), overt hypothyroidism. The prevalence of AF in the whole cohort was 6.6% in men and 3.1% in women (odds ratio, 2.23; P<.001). After adjusting for sex, logistic regression showed a higher prevalence of AF in those with subclinical hyperthyroidism compared with euthyroid subjects (9.5% vs 4.7%; adjusted odds ratio, 2.27; P=.01). Median serum free T(4) concentration was higher in those with AF than in those without (1.14 ng/dL; interquartile range [IQR], 1.05-1.27 ng/dL [14.7 pmol/L; IQR, 13.5-16.4 pmol/L] vs 1.10 ng/dL; IQR, 1.00-1.22 ng/dL [14.2 pmol/L; IQR, 12.9-15.7 pmol/L]; P<.001), and higher in those with AF when analysis was limited to euthyroid subjects (1.13 ng/dL; IQR, 1.05-1.26 ng/dL [14.6 pmol/L; IQR, 13.5-16.2 pmol/L] vs 1.10 ng/dL; IQR, 1.01-1.21 ng/dL [14.2 pmol/L; IQR, 13.0-15.6 pmol/L]; P=.001). Logistic regression showed serum free T(4) concentration, increasing category of age, and male sex all to be independently associated with AF. Similar independent associations were observed when analysis was confined to euthyroid subjects with normal TSH values. CONCLUSIONS: The biochemical finding of subclinical hyperthyroidism is associated with AF on resting electrocardiogram. Even in euthyroid subjects with normal serum TSH levels, serum free T(4) concentration is independently associated with AF. PMID: 17502534  Heeringa J, Hoogendoorn EH, van der Deure WM, Hofman A, Peeters RP, Hop WC, den Heijer M, Visser TJ, Witteman JC. High-normal thyroid function and risk of atrial fibrillation: the Rotterdam study. Arch Intern Med. 2008 Nov 10;168(20):2219-24. BACKGROUND: Overt and subclinical hyperthyroidism are both well-known independent risk factors for atrial fibrillation. We aimed to investigate the association of high-normal thyroid function with the development of atrial fibrillation in a prospective population-based study in the elderly. METHODS: The association between thyroid-stimulating hormone (TSH) levels and atrial fibrillation was examined in 1426 subjects with TSH levels in the normal range (0.4-4.0 mU/L) and without atrial fibrillation at baseline. In 1177 of the 1426 persons in this group, we also examined the association between free thyroxine levels within the normal range (0.86-1.94 ng/dL [to convert to picomoles per liter, multiply by 12.871]) and atrial fibrillation. During a median follow-up of 8 years, 105 new cases of atrial fibrillation were identified. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs) using Cox proportional hazards models after adjustment for age, sex, current smoking, former smoking, body mass index, systolic blood pressure, hypertension, history of myocardial infarction, presence of heart failure, left ventricular hypertrophy on the electrocardiogram, diabetes mellitus, total cholesterol level, and time of the drawing of blood samples. RESULTS: The risk of atrial fibrillation was associated with the TSH level. The multivariate adjusted HR was 1.94 (95% CI, 1.13-3.34, lowest vs highest quartile; P for trend, .02). The multivariate adjusted level of free thyroxine showed a graded association with risk of atrial fibrillation (HR, 1.62; 95% CI, 0.84-3.14, highest vs lowest quartile; P for trend, .06). CONCLUSION: Within the normal range of thyroid parameters, persons with high-normal thyroid function are at an increased risk of atrial fibrillation. PMID: 19001198 Iseri LT. Role of magnesium in cardiac tachyarrhythmias. Am J Cardiol. 1990 Jun 19;65(23):47K-50K. The efficacy of magnesium therapy in patients with ventricular tachycardia has previously been reported. Recently completed and ongoing studies validate earlier observations that potassium and magnesium supplementation may control other cardiac arrhythmias, particularly in hypomagnesemic patients. Magnesium treatment is a viable therapeutic option when other antiarrhythmic agents fail to suppress ventricular tachycardia, ventricular fibrillation, multifocal atrial tachycardia, atrial fibrillation and supraventricular tachycardia. PMID: 2353670 Krahn AD, Klein GJ, Kerr CR, Boone J, Sheldon R, Green M, Talajic M, Wang X, Connolly S. How useful is thyroid function testing in patients with recent-onset atrial fibrillation? The Canadian Registry of Atrial Fibrillation Investigators. Arch Intern Med. 1996 Oct 28;156(19):2221-4. BACKGROUND: Patients with recent-onset atrial fibrillation often undergo routine thyroid function screening to rule out thyroid disease as a cause of atrial fibrillation. METHODS: Patients with recent (< 3 months) onset of documented atrial fibrillation or flutter were enrolled in the Canadian Registry of Atrial Fibrillation from outpatient clinics, emergency departments, and hospital wards across Canada. Seven hundred twenty-six patients underwent baseline thyroid function screening and were assessed for presence of clinical thyroid disease. Serum thyrotropin level (TSH) was measured in 707 patients (97%), and thyroxine level (T4) in 407 patients (56%). RESULTS: A TSH level less than 0.1 mU/L was present in 5 patients (0.7%). A TSH level less than normal but more than 0.1 mU/L was present in 34 patients (4.7%). No patient had definite hypothyroidism (TSH > 20 mU/L), but 56 patients (7.7%) had an elevated TSH level that was less than 20 mU/L. During 1.7 years of follow-up, only 7 patients were found to have clinical hyperthyroidism, and 11 patients (1.5%) had hypothyroidism. Logistic regression analysis showed that palpitations (odds ratio, 4.9; 95% confidence interval, 1.7-14.0) and asymptomatic presentation (odds ratio, 5.5; 95% confidence interval, 1.9-16.2) were risk factors for low TSH level, and increasing age (odds ratio, 1.32 every 10 years; 95% confidence interval, 1.01-1.66) was a risk factor for high TSH level. The positive predictive value of palpitations and asymptomatic presentation for low TSH level were 9% and 8%, respectively. CONCLUSIONS: An abnormal TSH level is common in patients with recent-onset atrial fibrillation. However, clinical thyroid disease is uncommon. Routine TSH screening of patients who have atrial fibrillation has a low yield and may be better applied to those patients at higher risk of having undiagnosed clinical thyroid disease. PMID: 8885821 Kwon HM, Lee BK, Yoon YW, Seo JK, Kim HS. Clinical significance of serum TSH in euthyroid patients with paroxysmal atrial fibrillation. Yonsei Med J. 1995 Nov;36(5):448-56. Atrial fibrillation may occur in patients with a variety of cardiovascular or chronic disease as well as in normal subjects. Many authors reported that atrial fibrillation occurs in patients with thyrotoxicosis. It is reported that a low serum thyrotrophin concentration in an asymptomatic person with normal serum thyroid hormone concentrations can be a independent risk factor for developing atrial fibrillation. But we focused on the significance of serum thyroid stimulating hormone (TSH) in the euthyroid patient with atrial fibrillation whose serum level of T3, T4, fT4, and even TSH were absolutely within normal range. On our results, there was no significant differences in age, sexual distribution, and left ventricular ejection fraction between the patients group of paroxysmal and chronic persistent atrial fibrillation (p > 0.05), but there was larger left atrial dimension (LAD) and more cases of rheumatic heart disease in the chronic persistent atrial fibrillation group and there was more cases of lone atrial fibrillation in the paroxysmal atrial fibrillation group (p < 0.05). There was no significant differences in serum levels of T3, T4, fT4 between paroxysmal and chronic persistent atrial fibrillation, but significantly lower serum TSH was found in patients with paroxysmal atrial fibrillation (p < 0.001), and these findings were more significant after the control of hemodynamic change (p < 0.001 vs p < 0.05). The discriminant value in serum TSH between the paroxysmal and chronic atrial fibrillation group was 1.568U/mL with about 76% of predictive power. There was significantly lower serum TSH in paroxysmal atrial fibrillation in all age groups (p < 0.05). There was a significantly higher prevalence of cerebral thromboembolic events in chronic persistent (27.7%) and disease-associated (15.0% atrial fibrillation than in the paroxysmal (3.3%) and lone (4.5%) atrial fibrillation group (p < 0.001). Therefore, we suggest that serum TSH below the serum concentration of 1.5U/mL can be a risk factor for developing atrial fibrillation when the serum level of T3, T4, fT4, and even TSH were within absolutely normal range. PMID: 8546003 Marik PE, Fromm R. The efficacy and dosage effect of corticosteroids for the prevention of atrial fibrillation after cardiac surgery: a systematic review. J Crit Care. 2009 Sep;24(3):458-63. BACKGROUND: Atrial fibrillation (AF) complicates up to 60% of patients after cardiac surgery. Current prophylactic measures are inadequate. Corticosteroids down-regulate activation of the proinflammatory response (including C-reactive protein) after cardiopulmonary bypass and have been suggested to reduce the risk of postoperative AF. OBJECTIVE: The goal of this meta-analysis was to determine (i) the efficacy of corticosteroids in preventing AF after cardiac surgery and (ii) the impact of different dosage regimens on this outcome. DATA SOURCES: Sources included MEDLINE, Embase, the Cochrane Database of Systematic Reviews, and citation review of relevant primary and review articles. STUDY SELECTION: The study identified prospective, randomized, placebo-controlled clinical trials that evaluated the role of corticosteroids in preventing AF after cardiac surgery. DATA EXTRACTION: Data were abstracted on study design, study size, type of cardiac surgery, corticosteroid dosage regimen, and the incidence of AF in the first 72 hours after surgery. The total cumulated dose of corticosteroid was classified as low dose (<200 mg/d), moderate dose (200-1000 mg/d), high dose (1001-10,000 mg/d), and very high dose (10,000 mg/d) of hydrocortisone equivalents. Meta-analytic techniques were used to analyze the data. DATA SYNTHESIS: We identified 7 relevant studies that included 1046 patients. The corticosteroid regimen differed between all studies with the total cumulative dose varying from 160 to 21,000 mg of hydrocortisone equivalents; one study each used low-dose and very high-dose corticosteroid. Overall, the use of corticosteroids was associated with a significant reduction in the risk of postoperative AF, with an odds ratio of 0.42, 95% confidence interval of 0.27 to 0.68, and P = .0004. Significant heterogeneity was however noted between studies. When the low-dose and very high-dose studies were excluded, the treatment effect was highly significant (odds ratio, 0.32; 95% confidence interval, 0.21 to 0.50; P < .00001) with insignificant heterogeneity. CONCLUSIONS: Moderate-dosage corticosteroid (hydrocortisone) should be considered for the prevention of AF in high-risk patients undergoing cardiac surgery. Although the optimal dose, dosing interval, and duration of therapy is unclear, a single dose given at induction may be adequate. The interaction between corticosteroids, beta-blockers, and amiodarone requires further study. PMID: 19327322 Nielsen FH, Milne DB, Klevay LM, Gallagher S, Johnson L. Dietary magnesium deficiency induces heart rhythm changes, impairs glucose tolerance, and decreases serum cholesterol in post menopausal women. J Am Coll Nutr. 2007 Apr;26(2):121-32. OBJECTIVE: To determine whether or not dietary magnesium restriction to about 33% of the Recommended Dietary Allowance (RDA) causes changes in glucose, cholesterol and electrolyte metabolism that could lead to pathologic consequences. DESIGN: The length of the experiment was 136 days. Subjects were fed a basal Western-type diet that provided 4.16 mmol (101 mg) magnesium per 8.4 MJ (2000 kcal) for 78 days then replenished with magnesium by supplementing the diet with 200 mg magnesium as the gluconate per day for 58 days. If a subject exhibited adverse heart rhythm changes before 78 days of depletion were completed, she entered the repletion period early. SETTING: The metabolic research unit of the Grand Forks Human Nutrition Research Center. SUBJECTS: A total of 14 post menopausal women were recruited by advertisement throughout the United States. Thirteen women (ages 47 to 75 years) completed the study. RESULTS: During magnesium depletion, heart rhythm changes appeared in 5 women and resulted in 4 prematurely entering the magnesium repletion period (42 to 64 days of depletion instead of 78). Three women exhibited atrial fibrillation and flutter that responded quickly to magnesium supplementation. Magnesium deprivation resulted in a non-positive magnesium balance that became highly positive with magnesium repletion. Magnesium deprivation decreased red blood cell membrane magnesium, serum total cholesterol and erythrocyte superoxide dismutase concentrations, increased the urinary excretion of sodium and potassium, and increased serum glucose concentration. CONCLUSIONS: Magnesium balance may be a suitable indicator of magnesium depletion under experimental conditions. Magnesium deficiency resulting from feeding a diet that would not be considered having an atypical menu induces heart arrhythmias, impairs glucose homeostasis, and alters cholesterol and oxidative metabolism in post menopausal women. A dietary intake of about 4.12 mmol (100 mg) Mg/8.4 MJ is inadequate for healthy adults and may result in compromised cardiovascular health and glycemic control in post menopausal women.PMID: 17536123 Piotrowski AA, Kalus JS. Magnesium for the treatment and prevention of atrial tachyarrhythmias. Pharmacotherapy. 2004 Jul;24(7):879-95. Atrial tachyarrhythmias, including atrial fibrillation and flutter, occur frequently. Magnesium has been studied in the early conversion and prevention of atrial tachyarrhythmias, as well as in prevention of atrial tachyarrhythmias after coronary artery bypass graft surgery. Early conversion of atrial tachyarrhythmias and control of heart rate may be greater with magnesium than with common antiarrhythmic agents. Magnesium appears to be less useful for preventing recurrent atrial tachyarrhythmias; however, discrepancies in study methodologies make interpretation of results difficult. The use of magnesium for prevention of postoperative atrial arrhythmias has produced conflicting results, likely due to differences in study design. From the limited data available, magnesium appears to have some inherent antiarrhythmic properties. Certain patient populations may derive benefit from magnesium for the treatment of atrial tachyarrhythmias. However, further study is necessary to define the role of magnesium clearly for the treatment or prevention of atrial tachyarrhythmias. PMID: 15303452 Selmer C, Olesen JB, Hansen ML, Lindhardsen J, Olsen AM, Madsen JC, Faber J, Hansen PR, Pedersen OD, Torp-Pedersen C, Gislason GH. The spectrum of thyroid disease and risk of new onset atrial fibrillation: a large population cohort study. BMJ. 2012 Nov 27;345:e7895. OBJECTIVES: To examine the risk of atrial fibrillation in relation to the whole spectrum of thyroid function in a large cohort of patients. DESIGN: Population based cohort study of general practice patients identified by linkage of nationwide registries at the individual level. SETTING: Primary care patients in the city of Copenhagen. SUBJECTS: Registry data for 586 460 adults who had their thyroid function evaluated for the first time by their general practitioner during 2000-10 and who were without previously recorded thyroid disease or atrial fibrillation. MAIN OUTCOME MEASURE: Poisson regression models used to estimate risk of atrial fibrillation by thyroid function. RESULTS: Of the 586 460 individuals in the study population (mean (SD) age 50.2 (16.9) years, 39% men), 562 461 (96.0%) were euthyroid, 1670 (0.3%) had overt hypothyroidism, 12 087 (2.0%) had subclinical hypothyroidism, 3966 (0.7%) had overt hyperthyroidism, and 6276 (1.0%) had subclinical hyperthyroidism. Compared with the euthyroid individuals, the risk of atrial fibrillation increased with decreasing levels of thyroid stimulating hormone (TSH) from high normal euthyroidism (incidence rate ratio 1.12 (95% CI 1.03 to 1.21)) to subclinical hyperthyroidism with reduced TSH (1.16 (0.99 to 1.36)) and subclinical hyperthyroidism with supressed TSH (1.41 (1.25 to 1.59)). Both overt and subclinical hypothyroidism were associated with a lower risk of atrial fibrillation. CONCLUSION: The risk of atrial fibrillation was closely associated with thyroid activity, with a low risk in overt hypothyroidism, high risk in hyperthyroidism, and a TSH level dependent association with risk of atrial fibrillation across the spectrum of subclinical thyroid disease. PMID: 23186910 Tang RB, Liu DL, Dong JZ, Liu XP, Long DY, Yu RH, Hu FL, Wu JH, Liu XH, Ma CS. High-normal thyroid function and risk of recurrence of atrial fibrillation after catheter ablation. Circ J. 2010;74(7):1316-21. Epub 2010 May 27. BACKGROUND: It has been shown that the concentration of serum free thyroxine (FT(4)) is independently associated with atrial fibrillation (AF), even in euthyroid persons. This study investigated the effect of a high-normal level of FT(4) on recurrence after catheter ablation of AF. METHODS AND RESULTS: The 244 consecutive patients with paroxysmal AF and who underwent circumferential pulmonary vein isolation (PVI) were prospectively enrolled. Exclusion criteria included prior or current thyroid dysfunction on admission, amiodarone medicatio9 |C"frqH$'$|$$%#%b%l%1''''ɽ룕ugugugugugu^h 6CJaJh h 56CJaJh h 6CJaJh h(h(6CJaJh(h @h7DO56CJaJh @h7DO6CJaJh=91h=9156CJaJh=91h=916CJaJh=91h(h}B56CJaJh(h}B6CJaJh}Bh7DOh`khh7DO5CJ(aJ(#9 CrqH''(/0E2a3:xgd9Fxgd0pxgd xgd(xgd=91xgd}B  & Fxgd`kxgd7DO $xa$gd7DO'''/(0((./#///0E2a366679::;CCCDLuMfNgNWOSިި|sj^h h 6CJaJh h aJh7DO6CJaJh @hC56CJaJh @hC6CJaJhCh9Fh9F56CJaJh9Fh9F6CJaJh0ph0p6CJaJh0ph9Fh=9156CJaJh9Fh=916CJaJh9Fh=91h h:) 6CJaJjh:) 6CJUaJ:;CDgNWOW0Xz\]_h@il{m{xgd xgd`kxgd xgdCxgd9F STW0Xz\]_h@iakxvzzzz({){k{l{m{ȿsjh`kh aJh?>h 56CJaJh?>h?>56CJaJh?>6CJaJh?>56CJaJh h 56CJaJUh h 6CJaJh h aJh`kh`k6CJaJh`kh`kaJh h aJh h 6CJaJh h 56CJaJn for 3 months before admission. After a mean follow-up of 416+/-204 (91-856) days, the recurrence rates were 14.8%, 23.0%, 33.3%, 38.7% from the lowest FT(4) quartile to the highest FT(4) quartile, respectively (P=0.016). After adjustment for age, sex, left atrial diameter, and PVI, there was an increased risk of recurrence in the subjects with the highest FT(4) quartile compared with those with the lowest quartile (hazard ratio 3.31, 95% confidence interval 1.45-7.54, P=0.004). As a continuous variable, FT(4) was also an independent predictor of recurrence (hazard ratio 1.10, 95% confidence interval 1.02-1.18, P=0.016). (FT4 Range 10-28.2, Q1 <13.4, Q4 >18.4) CONCLUSIONS: Patients with high-normal thyroid function were at an increased risk of AF recurrence after catheter ablation. 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