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The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 5 1785-1788
Copyright © 2006 by The Endocrine Society

Growth Hormone Treatment and Aortic Dimensions in Turner Syndrome

Carolyn A. Bondy, Phillip L. Van, Vladimir K. Bakalov and Vincent B. Ho

Developmental Endocrinology Branch (C.A.N., P.L.V., V.K.B.), National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Radiology (V.B.H.), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814

Address all correspondence and requests for reprints to: C. A. Bondy, National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, CRC 1-3330, Bethesda, Maryland 20892. E-mail: bondyc{at}mail.nih.gov.


   Abstract
Top
 Abstract
Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Background: In recent years many girls with Turner syndrome (TS) have been treated with supraphysiological doses of GH to increase adult height. In addition to promoting statural growth, GH may have direct effects on the cardiovascular system.

Objective: We sought to determine whether GH treatment affects aortic diameter in girls with TS because there is an increased risk for aortic dilation and dissection in this syndrome.

Methods: In a retrospective, cross-sectional study, we compared ascending and descending aortic diameters measured by magnetic resonance imaging in GH-treated (n = 53) vs. untreated (n = 48) patients with TS participating in a National Institutes of Health protocol between 2001 and 2004.

Results: The average duration of GH treatment was 4.7 with SE 0.4 yr (range 2–11 yr). The two groups were similar in age and weight, but GH-treated subjects were on average 8 cm taller (P = 0.002). The diameter of the ascending aorta was increased by 7.3% and descending aorta by 8.9% in the GH-treated group. However, after correction for age, height, weight, and presence of bicuspid aortic valve and coarctation, using a multiple regression, neither history of GH treatment nor the length of GH treatment had an effect on the aortic diameter. Weight (P = 0.02), height (P = 0.001), and presence of bicuspid aortic valve (P = 0.0001) were associated with larger ascending aortic diameter, whereas age (P = 0.008), height (P = 0.02), and history of coarctation (P = 0.006) were associated with larger descending aortic diameter.

Conclusions: GH treatment of girls with TS does not seem to affect ascending or descending aortic diameter above the increase related to the larger body size.


   Introduction
Top
 Abstract
 Introduction
Subjects and Methods
 Results
 Discussion
 References
 
TURNER SYNDROME (TS) is defined as complete or partial absence of one sex chromosome in a phenotypic female (1). It is the most common chromosomal disorder in women, occurring in approximately 1 in 2000 live female births (2). The most prevalent features are short stature and ovarian failure, and the most medically significant feature is congenital heart disease with a high risk for aortic dilation and dissection (1, 3). The short stature in TS is attributed for the most part to haploinsufficiency for the pseudoautosomal gene SHOX (4, 5). Although girls with TS are not usually GH deficient, treatment with exogenous recombinant human GH is widely used to augment adult height (6, 7, 8, 9). The most recent clinical studies demonstrate an increase of 5–13 cm, depending on the dose and duration of treatment, and the dosages used to promote stature increase in TS are higher than used in GH-deficient states.

In addition to promoting longitudinal bone growth, GH has significant effects on the cardiovascular system (10). GH excess in acromegaly causes a hyperdynamic state with increased heart rate and cardiac output in early stages, followed by cardiac hypertrophy and eventually cardiomyopathy (10). GH treatment of GH-deficient adults and children increases left ventricular mass and cardiac output (11, 12). Young adult normal volunteers treated with GH in doses similar to those used in TS (0.06 mg/kg·d) demonstrated an increase in cardiac output and left ventricular mass in just 4 wk (13). Supraphysiological doses of GH might lead to alteration in aortic dimensions secondary to increased cardiac output or by direct effects of GH on the aortic wall (14, 15, 16, 17, 18).

Given the high prevalence of congenital heart defects and in particular problems of the aortic valve and aorta (19, 20), there has been concern over potential adverse effects of supraphysiological doses of GH on the cardiovascular system in TS. Two echocardiography studies reported normal left ventricular morphology and function in GH-treated girls with TS (21, 22). To our knowledge, there has been no investigation of the effects of GH treatment on aortic dimensions in TS. Therefore, in the present, retrospective study, we examined ascending and descending aorta diameters using magnetic resonance imaging (MRI) in a group of girls with TS who received GH treatment vs. a group that did not.


   Subjects and Methods
Top
 Abstract
 Introduction
 Subjects and Methods
Results
 Discussion
 References
 
Study subjects

The TS natural history protocol was approved by the National Institute of Child Health and Human Development Institutional Review Board. All adult participants and parents of minor children gave written informed consent and minors informed assent. The protocol includes studies of bone mineral density (23), metabolic function (23, 24), and cardiovascular imaging (25). Study subjects with TS were recruited primarily through notices on the National Institutes of Health Web site (http://turners.nichd.nih.gov/). Inclusion criteria were phenotypic female older than 6 yr of age and a 50-cell peripheral karyotype in which more than 70% of cells demonstrated loss of all or part of the second sex chromosome. All study participants aged 30 yr and under and their caregivers were queried about history of GH use. There were 101 patients aged 7–30 yr for which we obtained information on history of GH use, including age of initiation and duration of treatment. As to the dose of GH used, we obtained reliable information only for those subjects currently using, and this was in the standard range for treating girls with TS, i.e. 0.03–0.05 mg/kg·d. Most subjects had undergone several alterations in dose during the course of treatment, and the recall of patients and/or parents for past doses was quite poor, so we did not attempt to use GH dose in our analyses.

MRI

All patients were imaged on a 1.5 Tesla MRI scanner equipped with a high performance gradient subsystem using a phased array coil. Imaging included axial and coronal electrocardiogram-gated black blood T1-weighted spin echo or fast spin echo, left-anterior-oblique fast gradient echo, and oblique cine phase contrast pulse sequences. The use of magnetic resonance for cardiovascular imaging is recommended by the American Heart Association (26) and has been found to have high accuracy and reliability with superiority to echocardiography (27). For each subject, ascending and descending aortic diameters were measured on the same axial black-blood image at the level of the right pulmonary artery. Measurement of diameter of ascending aorta at this location is commonly used (28) because ascending aorta at this level is typically vertical, which makes the measurements highly reliable. In addition, nonsyndromic patients with functionally normal bicuspid aortic valve had the greatest dilatation of the ascending aorta at the level of the pulmonary artery. Cine phase contrast images were prescribed through the aortic valve for determination of valve morphology (i.e. bicuspid or tricuspid). All the measurements were performed by a single experienced radiologist (V.B.H.).

Statistics

Data are presented as means with SE or proportions. Comparisons of age, height, and weight between groups were by ANOVA. Comparison of nominal variables was done by {chi}2 test. The effect of GH use on the diameters of ascending and descending aorta was evaluated after taking into account potentially confounding factors such as age, height, weight, presence of bicuspid aortic valve (BAV) and history of coarctation, in multiple regression analyses. All analyses were performed using StatView, version 5.0.1, or JMP, version 5 (SAS Institute Inc., Cary, NC).


   Results
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 Abstract
 Introduction
 Subjects and Methods
 Results
Discussion
 References
 
The characteristics of the study subjects are presented in Table 1Go. The GH-treated and untreated groups were similar in age and weight, but the treated group was significantly taller, as expected. Subjects had to have been treated for at least 2 full years with GH to be included in the GH-treated group and not treated at all with GH to be in the untreated group. The mean duration of treatment in the GH group was 4.7/0.4 yr (mean/SE) and range 2–11 yr. The average age of initiation of treatment was 9.4/0.5 yr.


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  		TABLE 1. Characteristics of GH-treated and untreated groups

 
The diameter of the ascending aorta at the level of the right pulmonary artery was approximately 7% greater and the diameter of the descending aorta at the same level was approximately 9% greater in the GH-treated group (Fig. 1AGo). The ratio of ascending to descending diameters was similar in the two groups: 1.50/0.23 in the treated vs. 1.54/0.27 in the untreated group (P = 0.44). The ascending aortic diameter was greater than 3 cm in 13 study subjects; five of these were untreated and eight were GH treated (P = 0.4). Exclusion of individuals with history of aortic coarctation from analyses did not materially change the results (data not shown).


Figure 1
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  		FIG. 1. A, Aortic diameters in GH-treated (hatched bars) and untreated (solid bars) girls with TS. The box includes the 25th to 75th percentiles and whiskers include the 10th to 90th percentiles. The horizontal line in the box indicates the median, and all observations less than the 10th and greater than the 90th centiles are shown as points. Asc., Ascending aorta; desc., descending aorta. B, Correlation between height and ascending aortic diameter in GH-treated (open circles) and untreated (solid circles) girls with TS. The relation between height and ascending aortic diameters is similar in the two groups with the R2 = 0.38 for treated (P = 0.0001) and R2 = 0.24 (P = 0.0002) for untreated groups. The relation between height and descending aortic diameter was similar.

 
Height is a key determinant of aortic diameter (Fig. 1BGo), and height is obviously correlated with age and years of GH treatment. Other variables expected to influence the size of aortic diameters in TS include age, weight, presence of BAV, and history of aortic coarctation. Therefore, multiple regression analyses were used to assess the effect of GH treatment taking into account the above covariates (Table 2Go). GH treatment, analyzed either as a nominal variable (history of GH use for 2 yr or more: yes/no) or as a continuous variable (years of GH use) did not account for significant variation in diameters of the ascending (P = 0.88 and P = 0.40), descending aorta (P = 0.23 and P = 0.92), or the ascending to descending ratio (P = 0.3, and P = 0.4). The diameter of the ascending aorta was significantly influenced by weight (P = 0.016), height (P = 0.004), and presence of BAV (P = 0.0003). The diameter of the descending aorta was significantly influenced by age (P = 0.008), height (P = 0.021), and history of coarctation (P = 0.006).


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  		TABLE 2. Effects of years of GH treatment on aortic diameter, controlling for age, height, weight, and presence of BAV

 

   Discussion
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
References
 
This study investigated the effect of GH treatment on the aorta in girls with TS by comparing aortic diameters in treated vs. untreated groups. The average duration of GH treatment in our study subjects was approximately 5 yr, and the average height differential between treated and untreated groups was about 8 cm. Both ascending and descending aortic diameters were increased in the GH-treated individuals, but multivariate analysis indicated that this increase is explained by the increase in height without evidence for any additional impact of GH treatment on the cardiovascular system. The ratio of ascending to descending aorta diameters was not altered in the GH-treated group and was actually somewhat less, or more normal, than previously reported for women with TS (28). Thus, it does not appear that GH treatment has adverse effects on aortic structure in TS, at least not over several years. More long-term follow-up is necessary to be certain that there are no residual effects on aortic wall structure or function.

GH treatment at supraphysiological doses might be expected to promote hyperdynamic cardiac function and potentially hypertrophy, given the findings in early acromegaly (29) and GH-treated normal volunteers (13, 30). Hyperdynamic left ventricular activity exerts stress on the aorta and thereby enhances risk for aneurysmal dilation, hence the use of ß-adrenergic blockade in patients at risk for aortic aneurysm or dissection. In addition to effects on the myocardium, GH affects arterial connective tissue composition (16, 17) and elasticity (14). However, studies to date, including the present work, have not found evidence for adverse effects on the cardiovascular system associated with GH treatment in girls with TS (21, 22). The studies on GH effects on left ventricular morphology and function in TS relied on untreated normal girls for control data (21, 22). This could be problematic because the cardiovascular system in TS is intrinsically different from that of normal girls. The present study did have an age-matched control group of untreated girls with TS, and our findings of no dilation of the aorta in the GH-treated group beyond that explained by somatic growth is reassuring.

An important limitation to our study was that our groups were not randomized to treatment, so there could be differences between the groups affecting the outcome. For example, there could be a bias against GH treatment of girls at risk for dilation or dissection due to the presence of a BAV or a history of surgically corrected coarctation. The presence of a bicuspid aortic valve is associated with dilation of the ascending but not descending aorta (31). Twenty-five of our study subjects had a BAV, none with significant valvular dysfunction, approximately equally distributed in the two groups (Table 1Go). The presence of a BAV did contribute to enlargement of the ascending aorta in TS subjects, as reported for normal adults (31). Similarly, the presence of aortic coarctation repair predicted an enlargement of the descending aorta, and the prevalence was similar in both study groups. Nevertheless, there could be some unknown selection bias in treatment groups represented in the present study. Major reasons for nontreatment in our study subjects were delayed diagnosis and financial considerations.

In summary, the present study compared ascending and descending aortic diameters in GH-treated vs. untreated girls with TS. The treated group demonstrated a strong GH effect with average height gain of approximately 8 cm with an average of 5 yr of treatment. The fact that aortic diameter was proportionate to body size (height and weight) but not years of GH treatment in treated girls indicates that GH treatment is not producing adverse effects on aortic structure, at least over the period of observation in this study. Long-term follow-up, however, is required to be certain that there are no long-term consequences of childhood GH treatment on aortic structure or function.


   Acknowledgments
 
We are grateful to Eileen Lange, R.N., Mim Ari, M.S., Irene Ceniceros, Carol Malone, P.A., and Doug Rosing, M.D., for implementing the study protocol and providing expert care for our study subjects.


   Footnotes
 
This work was supported by the intramural research program of the National Institute of Child Health and Human Development, National Institutes of Health.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Uniformed Services University of the Health Sciences or the Department of Defense.

The authors have nothing to declare.

First Published Online February 28, 2006

Abbreviations: BAV, Bicuspid aortic valve; MRI, magnetic resonance imaging; TS, Turner syndrome.

Received December 5, 2005.

Accepted February 17, 2006.


   References
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 

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