于楠,高莹,龚艳君,杨帆,王智,邱林,康琦,刘芳,余洋,郭晓蕙

• 1:北京大学第一医院内分泌科
• 2:北京大学第一医院心内科

摘要(Abstract)：

目的探讨甲状腺功能与冠心病及其严重程度的关系。方法回顾分析2013年1月至2015年6月在北京大学第一医院因疑诊冠心病进行冠状动脉造影检查并行甲状腺功能检测的患者558例,根据冠状动脉造影结果,分为冠心病组和非冠心病组,分析两组患者甲状腺功能状态,比较甲状腺激素水平和冠心病的关系;采集冠心病组患者的Syntax积分,分析其与甲状腺激素水平的相关性;依据促甲状腺素(TSH)水平进一步分层为升高组、正常组、减低组,分析其与冠心病病变的关系。结果本研究共纳入患者558例,男348例,女210例,平均年龄(62.7±10.9)岁。冠心病组409例(73.3%),平均年龄(63.3±11.0)岁。非冠心病组149例(26.7%),平均年龄(61.2±10.7)岁。两组患者的性别、年龄比较,差异无统计学意义。冠心病组低T3综合征患者比例明显高于非冠心病组(3.4%比1.3%,P=0.018),其他甲状腺功能异常状态两组比较,差异均无统计学意义(均P>0.05)。在非低T3综合征患者中分析,冠心病组游离三碘甲状腺原氨酸(FT3)水平低于非冠心病组[(4.52±0.57)pmol/L比(4.65±0.63)pmol/L,P=0.015]。两组患者游离四碘甲状腺原氨酸(FT4)、三碘甲状腺原氨酸(T3)、四碘甲状腺原氨酸(T4)、TSH水平比较,差异均无统计学意义(均P>0.05)。非低T3综合征的冠心病,395例患者中根据Syntax积分,低分组264例,中分组59例,高分组72例。FT3水平三组患者比较差异有统计学意义(F=6.260,P=0.002)而TT3、TT4、FT4、TSH水平,三组患者比较差异均无统计学意义。根据冠状动脉病变支数分组,单支病变组160例,双支病变组111例,三支病变组124例,FT3水平三组患者比较差异有统计学意义(F=5.691,P=0.004),TT3、TT4、FT4、TSH水平,三组患者比较差异均无统计学意义。所有患者均进行了TG、TCHO、HDL-C、LDL-C检测,经检验,所有患者的FT3、FT4、TT3、TT4、TSH水平与血脂各组份均未见显著相关性。按正常值范围将FT3、FT4、TT3、TT4、TSH分别分为升高组、正常组、减低组,与冠心病诊断进行卡方检验,FT3、FT4、TT3、TT4差异均无统计学意义,TSH分层与冠心病诊断存在统计学意义(P=0.040)。进一步两两比较,TSH减低组与TSH正常组差异无统计学意义,高TSH组冠心病患者(85.7%)高于TSH正常组(68.6%),差异有统计学意义(P=0.022)。结论甲状腺功能在冠心病组和非冠心病组中差异较小,仅见FT3减低且与冠心病及其严重程度相关。TSH升高可能是影响冠心病发病的因素之一。

关键词(KeyWords)： 冠心病;甲状腺功能;三碘甲状腺原氨酸

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 于楠,高莹,龚艳君,杨帆,王智,邱林,康琦,刘芳,余洋,郭晓蕙

参考文献(References)：

• [1]Cini G,Carpi A,Mechanick J,et al.Thyroid hormones and the cardiovascular system:pathophysiology and interventions.Biomed Pharmacother,2009,63(10):742-753.
• [2]高莹,郭晓蕙.老年人甲状腺功能异常与心血管疾病.中华老年多器官疾病杂志,2013,12(4):263-269.
• [3]Rybin V,Steinberg SF.Thyroid hormone represses protein kinase C isoform expression and activity in rat cardiac myocytes.Circ Res,1996,79(3):388-398.
• [4]Montalescot G,Sechtem U,Achenbach S,et al.2013 ESC guidelines on the management of stable coronary artery disease:the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.Eur Heart J,2013,34(38):2949-3003.
• [5]Asvold BO,Bj?ro T,Nilsen TI,et al.Thyrotropin levels and risk of fatal coronary heart disease:the HUNT study.Arch Intern Med,2008,168(8):855-860.
• [6]牟英,刘云兵,龚倩.甲状腺功能减退与冠心病关联性的临床分析.临床和实验医学杂志,2015,14(7):1411-1413.
• [7]Gounden V,Jonklaas J,Soldin SJ.A pilot study:subclinical hypothyroidism and free thyroid hormone measurement by immunoassay and mass spectrometry.Clin Chim Acta,2014,430:121-124.
• [8]Fallah R,Mirouliaei M,Bashardoost N,et al.Frequency of subclinical hypothyroidism in 5-to 15-year-old children with migraine headache.J Pediatr Endocrinol Metab,2012,25(9-10):859-862.
• [9]Sert A,Pirgon O,Aypar E,et al.Subclinical hypothyroidism as a risk factor for the development of cardiovascular disease in obese adolescents with nonalcoholic fatty liver disease.Pediatr Cardiol,2013,34(5):1166-1174.
• [10]刘安民,童伟林,谭钰珍,等.亚临床甲状腺功能减退的临床研究.医学综述,2014,20(14):79-82.
• [11]田瑗,刘龙,王莹,等.亚临床甲状腺功能减退症与冠心病及其危险因素的相关性研究.国际内分泌代谢杂志,2015,35(5):298-301.
• [12]Klein I,Ojamaa K.Thyroid hormone and the cardiovascular system.N Engl J Med,2001,344(7):501-509.
• [13]Zargar AH,Ganie MA,Masoodi SR,et al.Prevalence and pattern of sick euthyroid syndrome in acute and chronic non-thyroidal illness--its relationship with severity and outcome of the disorder.J Assoc Physicians India,2004,52:27-31.
• [14]Walsh JP,Bremner AP,Bulsara MK,et al.Subclinical thyroid dysfunction as a risk factor for cardiovascular disease.Arch Intern Med,2005,165(21):2467-2472.
• [15]Iervasi G,Molinaro S,Landi P,et al.Association between increased mortality and mild thyroid dysfunction in cardiac patients.Arch Intern Med,2007,167(14):1526-1532.
• [16]Tseng FY,Lin WY,Lin CC,et al.Subclinical hypothyroidism is associated with increased risk for all-cause and cardiovascular mortality in adults.J Am Coll Cardiol,2012,60(8):730-737.
• [17]Tang YD,Kuzman JA,Said S,et al.Low thyroid function leads to cardiac atrophy with chamber dilatation,impaired myocardial blood flow,loss of arterioles,and severe systolic dysfunction.Circulation,2005,112(20):3122-3130.
• [18]Monzani F,Caraccio N,KozàkowàM,et al.Effect of levothyroxine replacement on lipid profile and intima-media thickness in subclinical hypothyroidism:a double-blind,placebocontrolled study.J Clin Endocrinol Metab,2004,89(5):2099-2106.
• [19]Singh S,Duggal J,Molnar J,et al.Impact of subclinical thyroid disorders on coronary heart disease,cardiovascular and all-cause mortality:a meta-analysis.Int J Cardiol,2008,125(1):41-48.
• [20]Yun KH,Jeong MH,Oh SK,et al.Relationship of thyroid stimulating hormone with coronary atherosclerosis in angina patients.Int J Cardiol,2007,122(1):56-60.
• [21]Weischer M,Bojesen SE,Cawthon RM,et al.Short telomere length,myocardial infarction,ischemic heart disease,and early death.Arterioscler Thromb Vasc Biol,2012,32(3):822-829.
• [22]Wang F,Tan Y,Wang C,et al.Thyroid-stimulating hormone levels within the reference range are associated with serum lipid profiles independent of thyroid hormones.J Clin Endocrinol Metab,2012,97(8):2724-2731.
• [23]Wanjia X,Chenggang W,Aihong W,et al.A high normal TSH level is associated with an atherogenic lipid profile in euthyroid non-smokers with newly diagnosed asymptomatic coronary heart disease.Lipids Health Dis,2012,11:44.
• [24]Xu C,Yang X,Liu W,et al.Thyroid stimulating hormone,independent of thyroid hormone,can elevate the serum total cholesterol level in patients with coronary heart disease:a crosssectional design.Nutr Metab(Lond),2012,9(1):44.
• [25]Hak AE,Pols HA,Visser TJ,et al.Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women:the Rotterdam Study.Ann Intern Med,2000,132(4):270-278.
• [26]Wartofsky L,Burman KD.Alterations in thyroid function in patients with systemic illness:the“euthyroid sick syndrome”.Endocr Rev,1982,3(2):164-217.
• [27]Coceani M,Iervasi G,Pingitore A,et al Thyroid hormone and coronary artery disease:from clinical correlations to prognostic implications.Clin Cardiol,2009,32(7):380-385.
• [28]Telkova IL,Tepliakov AT.Changes of thyroid hormone levels in the progression of coronary arteriosclerosis Klin Med(Mosk),2004,82(4):29-34.
• [29]Pingitore A,Landi P,Taddei MC,et al.Triiodothyronine levels for risk stratification of patients with chronic heart failure.Am J Med,2005,118(2):132-136.
• [30]?zcan KS,Osmonov D,Toprak E,et al.Sick euthyroid syndrome is associated with poor prognosis in patients with ST segment elevation myocardial infarction undergoing primary percutaneous intervention.Cardiol J,2014,21(3):238-244.
• [31]Friberg L,Drvota V,Bjelak AH,et al.Association between increased levels of reverse triiodothyronine and mortality after acute myocardial infarction.Am J Med,2001,111(9):699-703.
• [32]Pavlou HN,Kliridis PA,Panagiotopoulos AA,et al.Euthyroid sick syndrome in acute ischemic syndromes.Angiology,2002,53(6):699-707.
• [33]Iervasi G,Pingitore A,Landi P,et al.Low-T3 syndrome:a strong prognostic predictor of death in patients with heart disease.Circulation,2003,107(5):708-713.
• [34]Molinaro S,Iervasi G,Lorenzoni V,et al.Persistence of mortality risk in patients with acute cardiac diseases and mild thyroid dysfunction.Am J Med Sci,2012,343(1):65-70.
• [35]Auer J,Berent R,Weber T,et al.Thyroid function is associated with presence and severity of coronary atherosclerosis.Clin Cardiol,2003,26(12):569-573.
• [36]Erta?F,Kaya H,Soydin?MS.Low serum free triiodothyronine levels are associated with the presence and severity of coronary artery disease in the euthyroid patients:an observational study.Anadolu Kardiyol Derg,2012,12(7):591-596.
• [37]Mc Quade C,Skugor M,Brennan DM,et al.Hypothyroidism and moderate subclinical hypothyroidism are associated with increased all-cause mortality independent of coronary heart disease risk factors:a Pre CIS database study.Thyroid,2011,21(8):837-843.
• [38]薛超,卞玲,王长谦,等.甲状腺功能及FT3与冠状动脉病变关系的研究.心血管康复医学杂志,2014,10(5):506-509.
• [39]Sianos G,Morel MA,Kappetein AP,et al.The SYNTAX Score:an angiographic tool grading the complexity of coronary artery disease.Euro Intervention,2005,1(2):219-227.