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Autonomic Nervous System Function in Chronic Exogenous Subclinical Thyrotoxicosis and the Effect of Restoring Euthyroidism

Departments of Endocrinology and Metabolism (C.F.A.E.-R., E.P.M.C., K.A.H., J.W.A.S., J.A.R.), Leiden University Medical Center, 2300 RC, Leiden, The Netherlands; and Centre for Human Drug Research (R.C.S., J.B.), 2333 CL, Leiden, The Netherlands

Address all correspondence and requests for reprints to: E.P.M. Corssmit, Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands. E-mail: e.p.m.corssmit{at}lumc.nl.

	Abstract

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Context: Knowledge on the relationship between the autonomic nervous system and subclinical hyperthyroidism is mainly based upon cross-sectional studies in heterogeneous patient populations, and the effect of restoration to euthyroidism in subclinical hyperthyroidism has not been studied.

Objective: We investigated the long-term effects of exogenous subclinical hyperthyroidism on the autonomic nervous system and the potential effects of restoration of euthyroidism.

Design: This was a prospective single-blinded, placebo-controlled, randomized trial.

Setting: The study was performed at a university hospital.

Patients: A total of 25 patients who were on more than 10-yr TSH suppressive therapy after thyroidectomy was examined.

Intervention: Patients were studied at baseline and subsequently randomized to a 6-month thyroid hormone substitution regimen to obtain either euthyroidism or maintenance of the subclinical hyperthyroid state.

Main Outcome Measures: Urinary excretion of catecholamines and heart rate variability were measured. Baseline data of the subclinical hyperthyroidism patients were compared with data obtained in patients with hyperthyroidism and controls.

Results: Urinary excretion of norepinephrine and vanillylmandelic acid was higher in the subclinical hyperthyroidism patients compared with controls and lower compared with patients with overt hyperthyroidism. Heart rate variability was lower in patients with hyperthyroidism, intermediate in subclinical hyperthyroidism patients, and highest in the healthy controls. No differences were observed after restoration of euthyroidism.

Conclusions: Long-term exogenous subclinical hyperthyroidism has effects on the autonomic nervous system measured by heart rate variability and urinary catecholamine excretion. No differences were observed after restoration to euthyroidism. This may indicate the occurrence of irreversible changes or adaptation during long-term exposure to excess thyroid hormone that is not remedied by 6-month euthyroidism.

	Introduction

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Overt hyperthyroidism has profound effects on the heart, including tachycardia and/or arrhythmias, increased systolic pressure, increased systolic function, left ventricular hypertrophy, and diastolic dysfunction (1, 2, 3). These effects are thought to be the result of direct effects of thyroid hormone on the cardiovascular system and the interaction of thyroid hormones with the sympathetic nervous system (2, 4). This interaction has resulted from a sympathovagal imbalance, characterized by increased sympathetic activity in the presence of diminished vagal tone, which coincides with increased urinary excretion of catecholamines (5, 6, 7). Therefore, the current consensus is that manifestations of altered autonomic nervous system function play a role in the pathophysiology and clinical presentation of thyrotoxicosis.

For subclinical hyperthyroidism, defined as low serum TSH concentrations despite normal free T₄ (FT4) and T₃ concentrations, cardiovascular effects may also occur, but these are less well known and seemingly less severe. The most consistent findings include increased heart rate, supraventricular arrhythmias, and abnormalities of left ventricular morphology and function (2, 8, 9, 10). Altered autonomic nervous system function in subclinical hyperthyroidism is also less well defined. Petretta (9), Goichot (11), and Portella (12) et al., using measures of heart rate variability, found evidence that in patients with endogenous subclinical hyperthyroidism, a reduction of cardiac parasympathetic control is present, and this is supported by findings on heart rate turbulence by Osman et al. (13). However, in the study by Goichot et al. (11), there were no differences in the heart rate variability measure (the ratio of low frequency power over high frequency power) that is commonly used to characterize the balance between vagal and sympathetic influences in these patients. In addition, it seems that the most prominent differences between patients with (subclinical) hyperthyroidism and controls were present during a challenge of the autonomic nervous system. Apart from this, the interpretation of these findings is difficult because studies on the role of the possibly altered autonomic nervous system abnormalities and the cardiovascular consequences of subclinical hyperthyroidism are complicated by several factors. First, subclinical hyperthyroidism is a heterogeneous clinical syndrome with many possible etiologies, with as a sole common denominator, the (biochemical) definition of low TSH and normal T₃/T₄ concentrations. Second, the duration and course of the underlying disease are often not known, and, therefore, it cannot be excluded that the underlying disease itself, treatment with thyreostatic medication, and use of β-blockers may have influenced cardiovascular parameters independent of serum T₄ levels.

These considerations suggest that the most appropriate population to study the consequences of subclinical hyperthyroidism is patients treated for differentiated thyroid carcinoma (DTC) in whom, after thyroidectomy, continuous suppression of TSH occurs with individualized doses of levothyroxine (L-T₄). In these patients, subclinical hyperthyroidism is solely the result of exogenous L-T₄. Therefore, we performed a prospective, randomized, placebo-controlled study to assess autonomic nervous function in patients with DTC with longer than 10-yr exogenous subclinical hyperthyroidism and to investigate whether restoration to euthyroidism affects autonomic nervous function. Autonomic nervous function was assessed using urinary catecholamine excretion, heart rate variability measurements during rest, and by measuring the response in heart rate to a standardized mental stress test.

	Subjects and Methods

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The ethics committee of Leiden University Medical Center (LUMC) approved the study protocol, and written informed consent was obtained from all subjects. The study was performed in compliance with the principles of the Declaration of Helsinki.

Subjects

Patients treated for DTC were recruited from the outpatient clinic of the Department of Endocrinology of the LUMC, a tertiary referral center for DTC. Patients were included who had been diagnosed with DTC, and had received initial therapy consisting of total thyroidectomy and radioiodine ablative therapy. Cure was documented by the absence of measurable serum thyroglobulin during TSH stimulation as well as by a negative total-body scintigraphy with 4 mCi iodine-131. Patients had been on TSH suppressive therapy, defined as TSH levels below the lower reference values for normal serum levels of TSH (0.4 mU/liter), for at least 10 yr. The adequacy of this therapy was documented by yearly TSH measurements. Patients were excluded when they used medication affecting the sympathetic nervous system or when they were currently treated for or had experienced major cardiovascular events as uncontrolled hypertension or a myocardial infarction.

The study was a prospective, single-blinded randomized study of 6-month duration with two parallel groups. After inclusion, patients were randomized in a single-blinded fashion (patients were blinded) to a maintenance group or an intervention group. Only the treating physician prescribing the study medication was aware of the randomization. The other research staff involved in study related activities was also blinded to treatment. In the maintenance group, the existing TSH-suppressive therapy was continued (target TSH level < 0.4 mU/liter). In the intervention group, it was attempted to reach a restoration of euthyroidism by decreasing the L-T₄ dose target TSH levels within the normal reference range (0.4–4.8 mU/liter). This was achieved by replacing in all patients the standard L-T₄ therapy in part by study medication according to an algorithm. Study medication consisted of either L-T₄ 25 µg or identically looking placebo tablets. Serum TSH levels were checked every 6 wk in every patient, and study medication was adjusted if necessary to obtain the target TSH levels.

Patients were compared with data obtained in patients with overt hyperthyroidism and healthy controls using similar methodology (5).

Before and after 6 months, identical assessments were performed. After an overnight fast, subjects were admitted to the clinical research unit, where the urine collected over the previous 48 h was handed in. After a medical history and physical examination, blood samples to assess thyroid hormone status were taken. At least 30 min after blood sampling, continuous electrocardiogram (ECG) and blood pressure measurements were made while the subject was in supine position for at least 15 min. During this period the patients were acquainted with the test procedures that were about to follow. The measurements consisted of a one-lead ECG registration (recording 600 subsequent beats). The subjects were instructed to relax, breathe regularly, not speak, and to stay awake. ECG signals were sampled at a rate of 500 Hz, and the arterial pulse wave was at a rate of 300 Hz. The signals were digitized using a customized laboratory interface (model 1401; Cambridge Electronic Design, Cambridge, UK) and analyzed with software supplied with the interface. Each registration was screened for artifacts and subsequently analyzed for heart rate variability parameters in the time domain: mean R-R interval; the coefficient of variation (CV) of the successive R-R intervals (reflecting total variability); and the SD of differences between adjacent R-R intervals (SDSD) reflecting "beat-to-beat" and, therefore, vagally mediated variability, as previously described (5) and according to the applicable guidelines (14). The registrations were also analyzed for heart rate variability parameters in the frequency domain according to the same guidelines (14). Upon completion of the recording at rest, another 5-min recording was started during which the subjects were subjected to a mental stress test (15). During this test the subjects had to perform a standardized arithmetic test about which they had been instructed before. The registration made during this test was used to determine the percent increase in heart rate from baseline.

Assays

Thyroid hormones, TSH, and urinary creatinine and catecholamines concentrations were determined using standardized routine methodology at the clinical chemistry laboratories of the LUMC.

FT4 was measured on an IMx (Abbott Laboratories, Abbott Park, IL; intraassay variability: 2.5–7.6%, interassay variability: 5.6–12.4%). Total T₄ was determined on the TDx (Abbott Laboratories; interassay CVs: 2.4–5.9%). Free T₃ (FT3) was measured by RIABEAD (Abbott Laboratories; interassay CVs of 2.0–4.4%). Serum TSH was determined with a Modular Analytics E-170 system (Roche Diagnostic Systems, Basel, Switzerland; interassay variability: 0.88–10.66%). Reference values for FT4, FT3, and TSH are respectively 10–24 pmol/liter, 2.5–5.4 pmol/liter, and 0.4–4.8 mU/liter. Urinary norepinephrine (NE), dopamine (DOPA), and vanillylmandelic acid (VMA) were determined by routine HPLC methodology.

Statistical analysis

Data are expressed as mean ± SD. For assessment of the treatment effect between groups, the variables were log transformed to meet the requirements for ANOVA. Subsequently, the transformed data were analyzed using analysis of covariance (ANCOVA) (SAS Proc MIXED; SAS Institute Inc., Cary, NC) with the baseline value as a covariate. Treatment least-square means were back transformed resulting in geometrical mean treatment estimates corrected for differences in the baseline values. Contrasts and 95% confidence intervals (CIs) between treatments were back transformed resulting in geometrical mean ratios, which were subsequently translated into percent increase of the therapy treatment relative to the maintenance treatment.

The data obtained at baseline in the subclinical hyperthyroidism patient cohort were compared with data obtained in patients with overt hyperthyroidism and healthy controls using ANOVA and unpaired Student’s t test assuming unequal variances. The latter data were obtained using similar methodology and were reported earlier by our group (5). These data were also used to perform a post hoc power analysis (using power = 80% and = 5%) to calculate the required sample size per group for detecting relevant changes in the study parameters. Relevant changes were defined as the change required for normalizing the values obtained in the subclinical hyperthyroidism patients to the values observed in healthy controls.

All analyses were performed using SAS software (V9.1.2; SAS Institute).

	Results

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Patient characteristics

A total of 34 patients who fulfilled all inclusion criteria was included in the study. Four patients left the study before randomization: one because of abdominal surgery, two patients withdrew consent because of the perceived burden of the study, and one patient did not present at the randomization visit. During the study three patients from the intervention group were withdrawn: one (at 12 wk) because of fatigue, headache, and diarrhea; a second patient left (at 6 wk) because of pregnancy; and the third patient was excluded because of apparent incompliance. Despite lowering the T₄ dose, serum FT4 levels increased throughout the study. Two patients in the maintenance group (persistent low TSH) were also excluded for apparent incompliance; TSH levels increased despite being in the TSH suppression group. Thus, 25 subclinical hyperthyroidism patients completed the study, with 12 patients in the intervention group and 13 in the maintenance group. A summary of the subject characteristics is given in Table 1.

The mean ± SD L-T₄ dose in the maintenance group was 164 ± 34 µg/d before randomization and remained virtually unchanged at 173 ± 28 µg/d at the second assessment. In the intervention group, the L-T₄ dose was reduced from 185 ± 39 µg/d to 129 ± 37 µg/d to restore euthyroidism. The thyroid hormone levels are summarized in Table 2. Thyroid hormone concentrations were not different between the groups at baseline. Particularly, the range of TSH concentrations was 0.003–0.339 mU/liter in the maintenance group and 0.003–0.302 mU/liter in the intervention group. At the end of the study, TSH concentrations were higher in the intervention group (range: 0.218–6.09 mU/liter), whereas these remained virtually unchanged in the maintenance group (0.005–0.210 mU/liter). Eight patients in the intervention group became euthyroid 2 months after T₄ dosage reduction, one patient 3 months after T₄ dosage reduction, and two patients 4 months after T₄ dosage reduction. In these latter patients, FT4 levels decreased significantly every month, whereas TSH levels stayed behind. FT3 concentrations decreased by 42% (95% CI 19–69%) and FT4 concentrations by 29% (95% CI 12–48%) in the intervention group compared with the maintenance group. One patient in the intervention group had a persistently low TSH (<0.4 mU/liter) for the duration of the study. After 6 months, this patient had a TSH of 0.218 mU/liter, however, her baseline TSH was 0.0025 mU/liter. Because her FT4 decreased from 21–14 pmol/liter, we considered the intervention in this patient successful, although her TSH at 6 months was still less than 0.4 mU/liter. Two patients in the intervention group had a TSH more than 4.8 mU/liter (5.80 and 6.09) at the end of the study. FT4 levels were 18.8 and 26.7 mmol/liter.

The urinary excretion of NE, DOPA, and VMA (normalized for creatinine) is summarized in Table 2. To illustrate the effects of longitudinal follow-up and the intervention, the urinary excretion of VMA for both groups is depicted in Fig. 1. This shows that in general the urinary excretion is remarkably stable during a 6-month follow-up period without treatment. Restoration to euthyroidism did not result in significant reductions in catecholamine excretion.

View larger version (8K): [in this window] [in a new window]   FIG. 1. Scatter plots showing the urinary VMA excretion (left) and the SDSD measurements (right) illustrating that, except for the occasional outlier, both parameters were remarkably stable for the patients whether treated or not. creat, Creatinine; ms, msec.

The R-R interval in the intervention group increased from a mean value of 899 ± 135 msec to 956 ± 135 msec (P = 0.04). In the patients in whom thyroid suppression was continued, the R-R interval before the study was 849 ± 29 msec, and this was not changed at the end of the study (869 ± 25 msec). Between the groups the change in R-R interval was not significantly different (6.7%; 95% CI –0.5, 14.4%; P = 0.07). Both the time domain parameter reflecting the overall variability (CV) and the parameter reflecting the vagal influence on heart rate (SDSD) remained unchanged both within and between the treatment groups. The differences between the groups in CV and SDSD at the end of the treatment period were 3.6 (95% CI –18.9, 32.3%) and 9.8% (95% CI –25.0, 60.8%), respectively. The measurements of the SDSD for both groups are also depicted in Fig. 1. The data in the frequency domain were also not different between the groups (data not shown). All data are summarized in Table 3. The difference in the increase in heart rate observed during the mental stress test was 9.0% (95% CI –37.4; 32.3%) between the groups.

First, it is noteworthy that the groups were comparable (ranges in age and weight show great overlap), albeit there were minor differences, particularly in weight, which is obviously not surprising because patients with overt hyperthyroidism tend to lose weight (Table 1). There was a difference between the groups regarding gender distribution with a female predominance in the comparison groups. However, there are no indications that gender is an important determinant of autonomic nervous system function (16).

There was a slight difference in age between the groups, and it has been shown that increasing age is related to a decline in heart rate variability related parameters (17). However, the difference in age between the groups was small and even overlapping, making it unlikely that this may have caused important differences in the heart rate variability presented here.

Table 4 summarizes the results obtained at baseline in the current study and the data obtained in patients with overt hyperthyroidism and healthy controls.

ANOVA showed significant differences between the groups for the measures of heart rate variability; the P value was less than 0.001 for the R-R interval, a P value of 0.0018 was observed for the CV, and for SDSD the P value was less than 0.001. Patients with hyperthyroidism had on average a lower R-R interval of 280 msec (+201/+359; P < 0.0001) than the patients with subclinical hyperthyroidism. This was accompanied with lower measures of heart rate variability; the CV was 1.50% (+0.30/+2.70; P = 0.0088) lower, and the SDSD was 22.14 msec lower (+8.95/+35.33; P = 0.0002). Comparing the patients with subclinical hyperthyroidism to the healthy controls showed that the R-R interval was 33 msec lower (–48/+114; P = 0.402). The CV in heart rate was 1.88% (–0.04/+3.72; P = 0.08) lower, and the SDSD was 12.92 msec (–4.13/+29.98; P = 0.142) lower. The findings are summarized in Fig. 2, which shows that the patients with subclinical hyperthyroidism have intermediate urinary excretion of NE compared with patients with thyrotoxicosis and controls. In addition, the measures for overall heart rate variability and the parameter reflecting the vagally mediated component of heart rate variability (SDSD) are between the values of the patients with frank hyperthyroidism and control subjects.

View larger version (13K): [in this window] [in a new window]   FIG. 2. Graph (mean ± SD) for urinary NE excretion (mmol/mmol creatinine), urinary VMA excretion (mmol/mmol creatinine), overall heart rate variability [CV of R-R intervals (int) in percentage], and the vagal component of heart rate variability (SDSD in msec) for patients with overt hyperthyroidism, subclinical hyperthyroidism, and control subjects. The values for urinary VMA excretion were multiplied 10 times for legibility reasons. The values for CV were multiplied five times for legibility reasons. HRV, Heart rate variability.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This study was performed to investigate the long-term effects of exogenous subclinical hyperthyroidism on the autonomic nervous system and the potential effects of restoration of euthyroidism. The autonomic nervous system was characterized by the assessment of the urinary catecholamine excretion and by heart rate variability parameters. Our study is the first prospective, placebo-controlled randomized study in which the effects of restoration of euthyroidism on the autonomic nervous system in patients with long-term exogenous subclinical hyperthyroidism were studied. The main finding of the study was that restoration to euthyroidism in patients with long-term subclinical hyperthyroidism due to TSH suppression had no appreciable influence on the autonomic nervous system. Urinary catecholamine excretion, the heart rate variability parameters in the time domain, and the response to a mental stress test remained virtually unchanged between the patients who remained on TSH suppression and those in whom biochemical euthyroidism was restored.

If the current data are compared with data obtained using similar methodology reported earlier by our group (5), values for activation of the autonomic nervous system in the current patient group with subclinical hyperthyroidism seem to be in between the group of patients with thyrotoxicosis and healthy controls. There were some differences between the groups, particularly with regard to age and gender distribution. However, these are not confounding factors. It has been shown that the autonomic nervous system and its activity are not substantially influenced by gender (16). Admittedly, there are reports indicating that increasing age is associated with a decrease in heart rate variability (17, 18) due to an age-related decline in parasympathetic regulation (19). However, these reports show that this decline occurs over the age range of 20–80 yr and that the change in heart rate variability occurring in the age range of the population that we studied is very small (17).

We could show that urinary NE excretion in the patients with subclinical hyperthyroidism was indeed lower compared with patients with overt hyperthyroidism and higher compared with the healthy controls. This seems at odds with data reported by Mercuro et al. (20), who showed that plasma NE concentrations were significantly lower in patients with exogenous subclinical hyperthyroidism than in controls. However, these data are based on plasma NE concentrations in a single sample of venous forearm blood, whereas it is known that catecholamine levels are more appropriately determined in arterial(ized) blood, inasmuch as extraction from venous circulation occurs across various organs (21, 22), whereas the urinary excretion of catecholamines and their metabolites is considered to reflect better their average plasma concentrations and whole body turnover in plasma (22, 23). We also showed that the heart rate, its total variability (CV), and the vagally mediated influence on heart rate variability (SDSD) of the patients were between the values found for patients with thyrotoxicosis and healthy controls.

However, interestingly, restoration to the euthyroid state in subclinical hyperthyroidism patients did not result in relevant changes in most autonomic nervous system parameters. Apparently, restoring a biochemical euthyroid state in patients who have been subclinical hyperthyroid for more than 10 yr is not reflected in a state of the autonomic nervous system that is identical to the situation in healthy euthyroid subjects.

It is important to note that in the present study, the intervention of restoring euthyroidism in the patients was successful. TSH concentrations normalized, and FT3/FT4 concentrations decreased by approximately 40 and 30%, respectively, and became in the normal ranges used by the laboratories of our hospital. Obviously, it is of crucial importance that the study was sufficiently powered to detect relevant differences. Because it was impossible to perform a priori power analysis because of a lack of data, a population size was chosen that at least would allow exploratory analyses. Subsequently, the data that were obtained were used to perform a post hoc power analysis. This analysis showed that the present study was sufficiently powered to detect differences that would have changed most of the parameters in the subclinical hyperthyroidism patients to the normal values for these parameters. To demonstrate normalization of the urinary NE and VMA excretion, two groups of 17 or seven patients, respectively, would have been needed. In addition, for the heart rate variability parameters, it seems that the study was sufficiently powered because for normalization of the R-R interval, two groups of seven patients were required, and for normalization of the overall heart variability (CV), two groups of six patients would have sufficed. Admittedly, more patients (namely 22 patients per group) would have been necessary to also demonstrate normalization of the parameter that is commonly used to characterize the beat-to-beat variability. Nevertheless, we would like to argue that the current study was sufficiently powered for most of the parameters. We feel that our approach in which the restoration to euthyroidism in a homogenous group of patients with exogenous subclinical hyperthyroidism was studied, in a seemingly sufficiently powered randomized experiment, is the most appropriate approach to study the effects of subclinical hyperthyroidism on the autonomic nervous system.

Notwithstanding this, the interpretation of these findings is not straightforward. It could be that irreversible changes or adaptation occurs during long-term exposure to excess thyroid hormone. If the latter would be true, this would imply that restoration of the autonomic nervous system set point takes a longer time than half a year. This may explain the difference with studies with a shorter duration in overt hyperthyroidism (5, 6) or subclinical hyperthyroidism (13). In addition, another probably crucial difference between our and other studies is that in our study the population of patients with subclinical hyperthyroidism was homogenous regarding etiology and duration of the syndrome, whereas in other studies more heterogeneous patient populations or populations with endogenous subclinical hyperthyroidism are studied.

In conclusion, long-term exogenous subclinical hyperthyroidism affects the autonomous nerve system as measured by heart rate variability and urinary catecholamine excretion. No differences were observed 6 months after restoration of euthyroidism. This may indicate irreversible changes or adaptation during long-term exposure to excess thyroid hormone that is not remedied by 6-month euthyroidism. To explore this further, additional research is needed.

	Footnotes

 
J.W.A.S. is the recipient of a grant from the Dutch Cancer Foundation.

Disclosure Statement: The authors have nothing to disclose.

First Published Online April 8, 2008

Abbreviations: ANCOVA, Analysis of covariance; CI, confidence interval; CV, coefficient of variation; DOPA, dopamine; DTC, differentiated thyroid carcinoma; ECG, electrocardiogram; FT3, free T₃; FT4, free T₄; LUMC, Leiden University Medical Center; L-T₄, levothyroxine; NE, norepinephrine; SDSD, SD of differences between adjacent R-R intervals; VMA, vanillylmandelic acid.

Received January 14, 2008.

Accepted April 2, 2008.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

1. Fazio S, Palmieri EA, Lombardi G, Biondi B 2004 Effects of thyroid hormone on the cardiovascular system. Recent Prog Horm Res 59:31–50[Abstract/Free Full Text]
2. Klein I 1990 Thyroid hormone and the cardiovascular system. Am J Med 88:631–637[CrossRef][Medline]
3. Polikar R, Burger AG, Scherrer U, Nicod P 1993 The thyroid and the heart. Circulation 87:1435–1441[Abstract/Free Full Text]
4. Levey GS, Klein I 1990 Catecholamine-thyroid hormone interactions and the cardiovascular manifestations of hyperthyroidism. Am J Med 88:642–646[CrossRef][Medline]
5. Burggraaf J, Tulen JH, Lalezari S, Schoemaker RC, De Meyer PH, Meinders AE, Cohen AF, Pijl H 2001 Sympathovagal imbalance in hyperthyroidism. Am J Physiol Endocrinol Metab 281:E190–E195
6. Cacciatori V, Bellavere F, Pezzarossa A, Dellera A, Gemma ML, Thomaseth K, Castello R, Moghetti P, Muggeo M 1996 Power spectral analysis of heart rate in hyperthyroidism. J Clin Endocrinol Metab 81:2828–2835[Abstract/Free Full Text]
7. Chen JL, Chiu HW, Tseng YJ, Chu WC 2006 Hyperthyroidism is characterized by both increased sympathetic and decreased vagal modulation of heart rate: evidence from spectral analysis of heart rate variability. Clin Endocrinol (Oxf) 64:611–616[CrossRef][Medline]
8. Biondi B, Palmieri EA, Lombardi G, Fazio S 2002 Effects of subclinical thyroid dysfunction on the heart. Ann Intern Med 137:904–914[Abstract/Free Full Text]
9. Petretta M, Bonaduce D, Spinelli L, Vicario ML, Nuzzo V, Marciano F, Camuso P, De Sanctis V, Lupoli G 2001 Cardiovascular haemodynamics and cardiac autonomic control in patients with subclinical and overt hyperthyroidism. Eur J Endocrinol 145:691–696[Abstract]
10. Smit JW, Eustatia-Rutten CF, Corssmit EP, Pereira AM, Frolich M, Bleeker GB, Holman ER, van der Wall EE, Romijn JA, Bax JJ 2005 Reversible diastolic dysfunction after long-term exogenous subclinical hyperthyroidism: a randomized, placebo-controlled study. J Clin Endocrinol Metab 90:6041–6047[Abstract/Free Full Text]
11. Goichot B, Brandenberger G, Vinzio S, Perrin AE, Geny B, Schlienger JL, Simon C 2004 Sympathovagal response to orthostatism in overt and in subclinical hyperthyroidism. J Endocrinol Invest 27:348–352[Medline]
12. Portella RB, Pedrosa RC, Coeli CM, Buescu A, Vaisman M 2007 Altered cardiovascular vagal responses in nonelderly female patients with subclinical hyperthyroidism and no apparent cardiovascular disease. Clin Endocrinol (Oxf) 67:290–294[CrossRef][Medline]
13. Osman F, Franklyn JA, Daykin J, Chowdhary S, Holder RL, Sheppard MC, Gammage MD 2004 Heart rate variability and turbulence in hyperthyroidism before, during, and after treatment. Am J Cardiol 94:465–469[CrossRef][Medline]
14. 1996 Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 17:354–381
15. Jern S, Pilhall M, Jern C, Carlsson SG 1991 Short-term reproducibility of a mental arithmetic stress test. Clin Sci (Lond) 81:593–601[Medline]
16. Hansen AM, Garde AH, Christensen JM, Eller NH, Netterstrom B 2001 Reference intervals and variation for urinary epinephrine, norepinephrine and cortisol in healthy men and women in Denmark. Clin Chem Lab Med 39:842–849[CrossRef][Medline]
17. Byrne EA, Fleg JL, Vaitkevicius PV, Wright J, Porges SW 1996 Role of aerobic capacity and body mass index in the age-associated decline in heart rate variability. J Appl Physiol 81:743–750[Abstract/Free Full Text]
18. Tsuji H, Venditti Jr FJ, Manders ES, Evans JC, Larson MG, Feldman CL, Levy D 1996 Determinants of heart rate variability. J Am Coll Cardiol 28:1539–1546[Abstract]
19. Pfeifer MA, Weinberg CR, Cook D, Best JD, Reenan A, Halter JB 1983 Differential changes of autonomic nervous system function with age in man. Am J Med 75:249–258[CrossRef][Medline]
20. Mercuro G, Panzuto MG, Bina A, Leo M, Cabula R, Petrini L, Pigliaru F, Mariotti S 2000 Cardiac function, physical exercise capacity, and quality of life during long-term thyrotropin-suppressive therapy with levothyroxine: effect of individual dose tailoring. J Clin Endocrinol Metab 85:159–164[Abstract/Free Full Text]
21. Baumgartner H, Wiedermann CJ, Hortnagl H, Muhlberger V 1985 Plasma catecholamines in arterial and capillary blood. Naunyn Schmiedebergs Arch Pharmacol 328:461–463[CrossRef][Medline]
22. Esler M, Jennings G, Lambert G, Meredith I, Horne M, Eisenhofer G 1990 Overflow of catecholamine neurotransmitters to the circulation: source, fate, and functions. Physiol Rev 70:963–985[Free Full Text]
23. Tulen JH, Man in't Veld AJ, Van Roon AM, Moleman P, Van Steenis HG, Blankestijn PJ, Boomsma F 1994 Spectral analysis of hemodynamics during infusions of epinephrine and norepinephrine in men. J Appl Physiol 76:1914–1921[Abstract/Free Full Text]

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