Association between over- and under-replacement with thyroid hormone and incident heart failure

Whether over- or under-replacement with thyroid hormone is associated with incident heart failure remains unclear.

Elucidate the relationship between thyroid hormone over- and under-replacement and incident heart failure.

Retrospective cohort study of 641 504 adults who initiated thyroid hormone treatment between 2004 and 2017 at the Veterans Health Administration. Two cohorts of adults aged ≥18 years treated with thyroid hormone were separately studied: 638 323 adults with at least 2 outpatient thyroid stimulating hormone (TSH) measurements, and 338 249 adults with at least 2 outpatient free thyroxine (FT4) measurements, between thyroid hormone initiation and incident heart failure or study conclusion. Associations between time-varying TSH and FT4 exposure and incident heart failure as the outcome were analyzed.

Overall, 564 152/641 504 (87.9%) patients were men. Median age was 66 years. Incident heart failure occurred in 81 286/641 504 (12.7%) patients. Following adjustment for age, sex, and cardiovascular risk factors (eg, smoking, hypertension), under-replacement (eg, TSH > 20 mIU/L, adjusted odds ratio [AOR], 1.93, 95% CI, 1.84-2.02; FT4 < 0.7 ng/dL, AOR 1.08; 95% CI, 1.04-1.12) and over-replacement (eg, TSH < 0.1 mIU/L, AOR, 1.06; 95% CI, 1.01-1.12; FT4 > 1.9 ng/dL, AOR, 1.23; 95% CI, 1.14-1.32) were associated with increased incident heart failure compared to euthyroidism. Incident heart failure risk was cumulative over time with both thyroid hormone over- and under-replacement, but association was strongest with under-replacement (eg, TSH > 5.5 mIU/L associated with a 5.8-fold increase in incident heart failure over 5 years).

Our findings suggest that thyroid hormone treatment intensity may be a modifiable risk factor for heart failure.