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The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 2 530-534
Copyright © 2006 by The Endocrine Society

BRIEF REPORT

Low Serum Thyrotropin Is Associated with High Plasma Fibrinogen

Marcus Dörr, Daniel M. Robinson, Henri Wallaschofski, Christian Schwahn, Ulrich John, Stephan B. Felix and Henry Völzke

Departments of Internal Medicine B (M.D., D.M.R., S.B.F.) and Internal Medicine A (H.W.), School of Dentistry (C.S.), and Institute of Epidemiology and Social Medicine (U.J., H.V.), Ernst Moritz Arndt University, D-17487 Greifswald, Germany.

Address all correspondence and requests for reprints to: Dr. Marcus Dörr, Department of Internal Medicine B, Ernst Moritz Arndt University, Friedrich Loeffler Strasse 23a, D-17487 Greifswald, Germany. E-mail: mdoerr{at}uni-greifswald.de.


   Abstract
Top
 Abstract
Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Background: Elevated plasma fibrinogen levels are associated with an increased risk of cardiovascular events. Decreased serum TSH predicts vascular mortality, which hypothetically could be explained in part by alterations in the blood coagulation system.

Objective: The objective of this study was to investigate the association between thyroid function and plasma fibrinogen levels in a general population.

Design: The population-based Study of Health in Pomerania was performed in a previously iodine-deficient area in Germany, including 4310 subjects, aged 20–79 yr. Data for 3804 individuals without thyroid disease were analyzed. Analysis revealed an association between thyroid function status and plasma fibrinogen concentration.

Results: Elevated fibrinogen levels (>3.25 g/liter) were observed in 14 subjects with increased serum TSH levels (32.6%), 973 euthyroid subjects (28.9%), 158 subjects with decreased serum TSH levels (40.7%), and six individuals with overt hyperthyroidism (54.4%). Logistic regression analysis revealed decreased serum TSH as an independent risk factor for elevated fibrinogen levels (odds ratio, 1.42; 95% confidence interval, 1.12–1.80).

Conclusions: Thyroid function is associated with plasma fibrinogen. Decreased serum TSH is an independent risk factor for elevated plasma fibrinogen levels as a possible explanation for the high cardiovascular mortality among affected subjects.


   Introduction
Top
 Abstract
 Introduction
Subjects and Methods
 Results
 Discussion
 References
 
DATA FROM A cohort study revealed an increased cardiovascular mortality in elderly subjects with low serum TSH levels compared with the general population (1). The underlying mechanisms have not been completely identified, but may be related to arrhythmias, such as atrial fibrillation, as well as to functional alterations of the cardiovascular system (2, 3). Likewise, a hyperthyroid state is associated with an increased risk of thromboembolic events (4). Recently, we demonstrated an association of thyroid function with left ventricular hypertrophy (5) and intima media thickness (6), respectively. However, such findings may only partly explain the increased vascular mortality among these subjects.

Thyroid hormones exert effects on different levels of the hemostatic system, such as modulation of fibrinolytic activity and coagulation proteins (7). In this context, particularly alterations of fibrinogen levels may play a key role. High fibrinogen is an independent risk factor for atherosclerotic and cardiovascular diseases (8, 9). Genetic determination and numerous environmental factors influence plasma fibrinogen levels, including inflammatory diseases, gender, and cigarette smoking (10, 11). Although several reports demonstrated an association of thyroid function and plasma fibrinogen levels (12, 13, 14, 15), the direction of this relation is still debatable. High plasma fibrinogen levels were demonstrated in hyperthyroid (12, 13, 14, 15) as well as in hypothyroid states (12). In contrast, uncertainty remains about an association between subclinical hyperthyroidism and plasma fibrinogen levels.

The purpose of the present analyses was to investigate whether there is an association between thyroid function and plasma fibrinogen levels among a randomly selected population independent from other determinants.


   Subjects and Methods
Top
 Abstract
 Introduction
 Subjects and Methods
Results
 Discussion
 References
 
The Study of Health in Pomerania is a cross-sectional study in a region of former iodine deficiency in northeast Germany. A random sample from the population, aged 20–79 yr, was drawn. The study population comprised 4310 subjects. Participants gave informed written consent. The study was approved by the local ethics committee. Subjects with known or possible thyroid diseases (n = 438) and those with no blood drawn (n = 68) were excluded, resulting in a study population of 3804 participants.

Sociodemographic and clinical characteristics were assessed, and medication was classified according to the anatomical, therapeutic, and chemical codes. Hypertension was defined as a mean systolic/diastolic blood pressure of 140/90 mm Hg or more or self-reported use of antihypertensive drugs. Participants were classified as nonsmokers or current smokers. Alcohol intake during the previous week was used as a proxy for general intake. Subjects were divided into two categories with respect to the mean daily alcohol consumption: 0–20 g and more than 20 g. Individuals who participated in physical training for at least 1 h/wk were classified as being physically active.

Plasma fibrinogen concentrations were assayed according to Clauss (16) (Electra analyzer, Instrumentation Laboratory, Barcelona, Spain). An elevated fibrinogen level was defined as a plasma concentration more than 3.25 g/liter (the upper laboratory reference range and the 75th percentile of the population distribution). Serum TSH, free T4 (FT4) and free T3 (FT3) levels were analyzed by immunochemiluminescene procedures (FT3: LUMItest, Brahms, Berlin, Germany; TSH and FT4: LIA-mat, Byk Sangtec Diagnostica GmbH, Frankfurt, Germany). The manufacturers’ reference ranges were 0.3–3 mU/liter for TSH, 2.2–4.6 ng/liter for FT3, and 8–20 ng/liter for FT4. Participants were divided into four groups according to serum TSH levels: 1) increased serum TSH (>3.0 mU/liter); 2) euthyroid (serum TSH within the normal range); 3) decreased serum TSH (<0.3 mU/liter); and 4) overt hyperthyroidism (serum TSH, <0.1 mU/liter with elevated serum FT3 and/or FT4 levels).

Statistical analysis

The mean and SD of the mean are given for continuous data, and absolute numbers or percentages are given for nominal data as indicated. Intergroup comparison was performed by linear ANOVA (continuous data) or {chi}2 test (nominal data). Plasma fibrinogen levels were analyzed first by multivariable analyses using linear regression models. Thereafter, plasma fibrinogen levels were dichotomized and analyzed by logistic regression models. Established determinants for increased fibrinogen levels [age, sex, body mass index (BMI), diabetes mellitus, hypertension, myocardial infarction, stroke, chronic bronchitis, arthritis, phlebitis, and smoking status], and drugs influencing plasma fibrinogen (coumarins, salicylic acid and other platelet aggregation inhibitors, nonsteroidal antiinflammatory drugs, statins, fibrates, oral contraceptives, hormone replacement therapy, systemic glucocorticoids, antibiotics, angiotensin-converting enzyme inhibitors, and angiotensin II receptor antagonists) were included in the models stepwise. Using backward stepwise procedures, diabetes mellitus, hypertension, myocardial infarction, stroke, inflammatory diseases, as well as the use of salicylic acid, other platelet aggregation inhibitors, nonsteroidal antiinflammatory drugs, statins, oral contraceptives, hormone replacement therapy, antibiotics, angiotensin-converting enzyme inhibitors, and angiotensin II receptor antagonists were excluded from the final model due to a P > 0.2. The adjusted odds ratio (OR) and the 95% confidence interval (CI) were calculated. P < 0.05 was considered statistically significant. Analyses were performed with SPSS software 11.0.1 (SPSS, Inc., Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
Discussion
 References
 
The study population consisted of 3804 participants (47.4% women and 52.5% men; mean age, 49.6 ± 16.4 yr). The main characteristics of the participants with respect to thyroid function are shown in Table 1Go.


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  		TABLE 1. Clinical characteristics with respect to thyroid function status

 
Among the total study population, the mean plasma fibrinogen level was 2.98 ± 0.7 g/liter. Levels were higher in women than in men (3.01 ± 0.7 vs. 2.95 ± 0.7 g/liter; P = 0.004). Analysis revealed an association between functional thyroid status and plasma fibrinogen levels. Subjects with increased TSH levels as well as those with subclinical or overt hyperthyroidism had higher plasma fibrinogen levels (3.13 ± 0.8, 3.16 ± 0.7, and 3.31 ± 0.9 g/liter, respectively) compared with euthyroid subjects (2.96 ± 0.7 g/liter; P < 0.001). These differences remained consistent after adjustment for determinants of plasma fibrinogen (Fig. 1Go). Linear regression models identified decreased serum TSH levels as a predictor for plasma fibrinogen levels independent from previously known determinants (Table 2Go).


Figure 1
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  		FIG. 1. Plasma fibrinogen level with respect to functional thyroid status. Values are the adjusted mean ± SE. Multivariate adjustments were made for sex; age; BMI; smoking; alcohol consumption; physical activity; LDL cholesterol; triglycerides; lipoprotein(a); medication with coumarins, fibrates, and glucocorticoids; and functional thyroid status.

 

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  		TABLE 2. Correlates to plasma fibrinogen

 
Elevated plasma fibrinogen levels were observed in 14 subjects with increased serum TSH levels (32.6%), 973 euthyroid subjects (28.9%), 158 subjects with decreased serum TSH levels (40.7%), and six individuals with overt hyperthyroidism (54.5%; P < 0.001, intergroup comparison). Decreased serum TSH was an independent risk factor for elevated plasma fibrinogen levels (OR, 1.42; 95% CI, 1.12–1.80; P = 0.004). The association between overt hyperthyroidism and elevated plasma fibrinogen barely missed statistical significance (OR, 3.31; 95% CI, 0.92–11.90; P = 0.066). Increased serum TSH was not independently associated with elevated plasma fibrinogen (OR, 0.96; 95% CI, 0.45–1.89; P = 0.834; Fig. 2Go).


Figure 2
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  		FIG. 2. Association of functional thyroid status and elevated plasma fibrinogen levels. The OR ({blacksquare}) and 95% CI are shown (brackets). Multivariate adjustments were made for sex; age; BMI; smoking; alcohol consumption; physical activity; LDL cholesterol; triglycerides; lipoprotein(a); medication with coumarins, fibrates, and glucocorticoids; and functional thyroid status (reference: euthyroidism). *, P < 0.01 (binary logistic regression analysis).

 
Additional risk factors for elevated fibrinogen levels were advanced age (OR, 1.03; 95% CI, 1.02–1.04; P < 0.001), female sex (OR, 1.25; 95% CI, 1.06–1.47; P = 0.009), increased BMI (OR, 1.10; 95% CI, 1.09–1.12; P < 0.001), current smoking (OR, 2.20; 95% CI, 1.84–2.64; P < 0.001), as well as increased levels of low-density lipoprotein (LDL) cholesterol (OR, 1.18; 95% CI, 1.10–1.27; P < 0.001) and lipoprotein(a) (OR, 1.04/100 mg/liter; 95% CI, 1.01–1.07; P = 0.004) and medication with coumarins (OR, 1.90; 95% CI, 1.04–3.44; P = 0.036) and glucocorticoids (OR, 1.95; 95% CI, 1.00–3.80; P = 0.049). Alcohol consumption of more than 20 g/d (OR, 0.57; 95% CI, 0.47–0.68; P < 0.001) and medication with fibrates (OR, 0.30; 95% CI, 0.14–0.64; P = 0.002) were inversely associated with elevated plasma fibrinogen. The inverse relation between physical activity and elevated fibrinogen levels barely missed statistical significance (OR, 0.88; 95% CI, 0.75–1.03; P = 0.108).


   Discussion
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
References
 
The present study demonstrated a U-shaped association between thyroid function and plasma fibrinogen levels in a population-based sample of subjects aged 20–79 yr. This is the first study to identify decreased serum TSH levels as an independent risk factor for an elevation in plasma fibrinogen.

The main focus of our analysis was on subclinical hyperthyroidism. Among our study population, affected subjects had higher plasma fibrinogen levels compared with euthyroid subjects. Moreover, the prevalence of elevated fibrinogen levels was higher in those individuals than in euthyroid subjects. These associations persisted after appropriate adjustment for confounders of plasma fibrinogen. In contrast to overt hyperthyroidism (12, 14), the relation of subclinical hyperthyroidism to plasma fibrinogen has not been extensively studied. We assume that our results probably point to a prothrombotic state in those subjects and might supplement the hypothesis that decreased serum TSH might indicate mild thyroid excess.

Various mechanisms regarding the interaction of thyroid hormones and blood coagulation may explain our findings. Firstly, enhanced fibrinogen synthesis by activation of liver function may have contributed to the elevated plasma fibrinogen levels. Such effects have been demonstrated in hyperthyroid subjects (13, 15) and in vitro (17), respectively. Secondly, a direct effect of thyroid hormones on plasma protein regulation was assumed (18). Recent in vitro studies and in vivo rat models demonstrated an important role of T3 in the direct up-regulation of coagulation proteins such as fibrinogen (18). Finally, elevated plasma fibrinogen levels might be due to a chronic inflammatory state induced by inflammatory diseases of the thyroid. Thus, autoimmune thyroid diseases may cause hyperthyroid disorders as well as an increase in inflammatory plasma proteins. However, our study was performed in a previously iodine-deficient region where the commonest cause of subclinical hyperthyroidism is nodular goiter, an aseptic disease.

Our results suggest that high plasma fibrinogen levels might be a supplementary factor, contributing to the increased cardiovascular mortality in subjects with decreased serum TSH levels (1), taking into account that fibrinogen is a major risk factor of cardiovascular morbidity and mortality (8, 9). The association of decreased serum TSH levels and elevated plasma fibrinogen levels might be of particular interest for populations living in iodine-deficient regions. Just as among our study population, the prevalence of subclinical hyperthyroidism is much higher in these areas than in iodine-replete regions (19). Subclinical hyperthyroidism remains an underestimated issue, whose importance is discussed very controversially (20, 21).

Among our study population, subjects with overt hyperthyroidism also tended to have higher plasma fibrinogen levels compared with euthyroid subjects. Although this finding was limited by the small number of subjects studied, it is in good agreement with other reports (12, 14), because decreased fibrinolytic activity is common in overt hyperthyroidism and after thyroid hormone treatment (14, 22). Although our data for overt hypothyroidism are limited by the small number of affected subjects, higher plasma fibrinogen levels may reflect a hypercoagulable state. This finding is in good agreement with previous studies (12) and might be explained by the inflammatory response of autoimmune thyroid disease as the underlying cause of thyroid failure, but data are contradictory, because an increased bleeding tendency (23) has also been reported.

In agreement with past data, advanced age (11), female sex (24), increased BMI (10, 11), current smoking (8, 10, 11), as well as increased levels of LDL cholesterol (11) and lipoprotein(a) (11) were positively associated with plasma fibrinogen levels among our study population, whereas alcohol consumption, physical activity (10), and medication with fibrates (25) were inversely associated with plasma fibrinogen levels.

However, due to the cross-sectional design of our study, no final conclusion can be drawn regarding causal mechanisms linking the thyroid function and the coagulation system and its impact on cardiovascular events. These questions probably will be answered by longitudinal studies.

Conclusion

We conclude that thyroid function is associated with plasma fibrinogen levels. Decreased serum TSH levels are a risk factor for elevated plasma fibrinogen levels independent of a wide range of confounding variables. This relation may be a possible explanation for a higher cardiovascular mortality among affected subjects.


   Acknowledgments
 
The Community Medicine Research net encompasses several research projects that share data from the population-based Study of Health in Pomerania (www.medizin.uni-greifswald.de/cm). The contributions to data collection made by field workers, technicians, interviewers, and computer assistants are gratefully acknowledged.


   Footnotes
 
The work is part of the Community Medicine Research net of University of Greifswald, Germany, which is funded by the Federal Ministry of Education and Research (Grant ZZ9603), the Ministry of Cultural Affairs, as well as the Social Ministry of the Federal State of Mecklenburg-West Pomerania.

First Published Online November 22, 2005

Abbreviations: BMI, Body mass index; CI, confidence interval; FT4, free T4; FT3, free T3; LDL, low-density lipoprotein; OR, odds ratio.

Received August 8, 2005.

Accepted November 15, 2005.


   References
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 

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