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Free access

Long-term prognosis after medical treatment of Graves' disease in a northern Swedish population 2000–2010

Eric Mohlin, Helena Filipsson Nyström, and Mats Eliasson

Objective

To investigate the long-term prognosis of patients with Graves' disease (GD) after antithyroid drug (ATD) treatment and follow-up outside of highly specialised care.

Design and methods

Medical records of all patients diagnosed with first-time GD in 2000–2010 with at least 6 months ATD treatment at a central hospital and follow-up in primary health care in the county of Norrbotten in northern Sweden were retrospectively reviewed. Patients were followed for relapse until 31st December 2012. We included 219 patients (mean age 46 years, 82.5% women) with follow-up of maximum 10 years and 829 observed patient years. Data were analysed using Kaplan–Meier estimates and log-rank test.

Results

During the observation period, 43.5% of the patients had relapsed into active GD. The cumulative relapse rates were 22.6, 30.2, 36.9 and 41.5% after 6 months, 1, 3 and 5 years respectively. The presence of goitre (P=0.014) predicted relapse. Previous smoking was protective against relapse (P=0.003). The levels of free thyroxine or free tri-iodothyronine, age, gender, current smoking and ophthalmopathy did not predict relapse. Agranulocytosis was found in 1.7% (95% CI 0.7–4.0%).

Conclusion

A long-term remission of 56.5%, in an iodine-sufficient area where ATD is offered to most patients in the real world of central and district hospitals, is higher than in most studies. Relapse was most common during the first year, and prognosis was excellent after 4 years without relapse. The protective effect of previous smoking merits further research.

Open access

Morning plasma cortisol as a cardiovascular risk factor: findings from prospective cohort and Mendelian randomization studies

Andrew A Crawford, Stefan Soderberg, Clemens Kirschbaum, Lee Murphy, Mats Eliasson, Shah Ebrahim, George Davey Smith, Tommy Olsson, Naveed Sattar, Debbie A Lawlor, Nicolas J Timpson, Rebecca M Reynolds, and Brian R Walker

Objective

The identification of new causal risk factors has the potential to improve cardiovascular disease (CVD) risk prediction and the development of new treatments to reduce CVD deaths. In the general population, we sought to determine whether cortisol is a causal risk factor for CVD and coronary heart disease (CHD).

Design and methods

Three approaches were adopted to investigate the association between cortisol and CVD/CHD. First, we used multivariable regression in two prospective nested case-control studies (total 798 participants, 313 incident CVD/CHD with complete data). Second, a random-effects meta-analysis of these data and previously published prospective associations was performed (total 6680 controls, 696 incident CVD/CHD). Finally, one- and two-sample Mendelian randomization analyses were performed (122,737 CHD cases, 547,261 controls for two-sample analyses).

Results

In the two prospective nested case–control studies, logistic regression adjusting for sex, age, BMI, smoking and time of sampling, demonstrated a positive association between morning plasma cortisol and incident CVD (OR: 1.28 per 1 SD higher cortisol, 95% CI: 1.06–1.54). In the meta-analysis of prospective studies, the equivalent result was OR: 1.18, 95% CI: 1.06–1.31. Results from the two-sample Mendelian randomization were consistent with these positive associations: OR: 1.06, 95% CI: 0.98–1.15.

Conclusions

All three approaches demonstrated a positive association between morning plasma cortisol and incident CVD. Together, these findings suggest that elevated morning cortisol is a causal risk factor for CVD. The current data suggest strategies targeted at lowering cortisol action should be evaluated for their effects on CVD.