Content uploaded by Sourya Acharya
Author content
All content in this area was uploaded by Sourya Acharya on Dec 26, 2018
Content may be subject to copyright.
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3539
CAROTID INTIMA-MEDIA THICKNESS (C-IMT) IN HYPOTHYROIDISM- EARLY ASSESSMENT
OF SUBCLINICAL ATHEROSCLEROSIS
Anuja Beralkar1, Sourya Acharya2, Sakshi Gagneja3, Samarth Shukla4, Sunil Kumar5, Anil Wanjari6
1Resident, Department of General Medicine, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha, Maharashtra.
2Professor, Department of General Medicine, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha,
Maharashtra.
3Assistatn Professor, Department of General Medicine, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha,
Maharashtra.
4Professor, Department of Pathology, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha, Maharashtra.
5Professor, Department of General Medicine, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha,
Maharashtra.
6Professor, Department of General Medicine, J.N. Medical College, DMIMS University, Sawangi (Meghe), Wardha,
Maharashtra.
ABSTRACT
BACKGROUND
The present study entitled “Carotid Intima Media Thickness in Hypothyroidism” was conducted in the department of General
medicine, A.V.B.R.H and J.N.M.C, Sawangi, Meghe, Wardha. C-IMT was measured by recording ultrasonographic images of both
the left and right common carotid artery with a 7‑MHz linear array transducer. Patients were examined in the supine position,
with the head turned 45° from the side during the scanning procedure.
The aim of the study is to evaluate carotid intima media thickness (C-IMT) in hypothyroidism.
MATERIALS AND METHODS
The study included 100 cases of newly detected hypothyroidism not on thyroid replacement therapy, and 50 matched healthy
controls. Body mass index (BMI), thyroid profile, lipids, blood pressure and the mean of C-IMT were determined.
RESULTS
Mean values of C-IMT, triglycerides, and total cholesterol were significantly high in hypothyroidism group versus controls. Carotid
intima-media thickness was significantly increased in SCH and overt hypothyroidism group as compared to controls (p <0.001).
On comparing all independent variables like BMI, lipids and blood pressure with dependent variable C-IMT, statistically significant
difference was found with FT4 (p=0.024), TSH (p=0.041) and with HDL (p=0.021).
CONCLUSION
In overt and subclinical hypothyroidism groups, values of diastolic blood pressure (DBP), triglycerides (TG), low density
lipoprotein (LDL) were deranged. All these may contribute to atherosclerosis and an increase in C-IMT, causing potential risk
for future cardiovascular disease, stroke. So, hypothyroidism group having deranged lipid profile and other risk factors like
obesity should be screened for atherosclerosis by measuring C-IMT. This group can be targeted for primary prevention of
coronary artery diseases (CAD) and its early management like lipid lowering agents apart from being treated for hypothyroidism.
KEYWORDS
Hypothyroidism, Subclinical, Dyslipidaemia, Arterial Hypertension, Triglyceride, Primary Prevention.
HOW TO CITE THIS ARTICLE: Beralkar A, Acharya S, Gagneja S, et al. Carotid intima–media thickness (C-IMT) in
hypothyroidism – early assessment of subclinical atherosclerosis. J. Evid. Based Med. Healthc. 2018; 5(52), 3539-3544. DOI:
10.18410/jebmh/2018/723
BACKGROUND
Diseases of thyroid gland are most common endocrinal
disorders after diabetes. India contributes to a large quantity
of thyroid disorders. Recent statistics show that 300 million
people in the world are suffering from thyroid disorders and
among them about 42 million people reside in India.1
Thyroid hormone has significant effect on cardiovascular
system and lipid profile. As cardiovascular system is
abundant in thyroid hormone receptors and is one of the
important sites of action for thyroid hormones, it is relatively
sensitive to changes in the levels of thyroid hormones.2 The
effect of hypothyroidism on vascular and haemostatic risk
Financial or Other, Competing Interest: None.
Submission 27-11-2018, Peer Review 05-12-2018,
Acceptance 15-12-2018, Published 18-12-2018.
Corresponding Author:
Dr. Sourya Acharya,
Professor, Department of Medicine,
J. N. Medical College, DMIMS University,
Sawangi (Meghe), Wardha- 442001,
Maharashtra.
E-mail: souryaacharya74@gmail.com
DOI: 10.18410/jebmh/2018/723
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3540
factors for atherosclerosis has also been investigated in few
studies.3 Inspite of advances in hindering with medical care
of illness, atherosclerotic diseases remain a leading cause of
death with a worth considering clinical and economic burden
worldwide. And so the identification of additional modifiable
risk factors for atherosclerosis has significance.4
Overt hypothyroidism leads to increase in cholesterol
levels especially LDL (low density lipoprotein) and TG
(triglyceride). Both these factors have vast recognized effect
on vessel wall and as a risk factor for atherosclerosis and
cardiovascular disease. Association of atherosclerosis with
overt hypothyroidism has been well existed for long and is a
well-known fact.5 Subclinical hypothyroidism (ScH) is a
mutual condition affecting 4%-20% of the all over
population.6
Coronary endothelium dysfunction precedes
atherosclerosis has been linked to adverse cardiovascular
events, and may account for some of the increased risk in
patients with hypothyroidism. A study concluded that
hypothyroidism in women is associated with microvascular
endothelial dysfunction, even after adjusting for
confounders, and may explain some of the increased risk of
cardiovascular disease in these patients.7
Atherosclerosis is a clinical condition that eventually
leads to various complications like coronary artery disease
(CAD), stroke, increase in blood pressure. The carotid intima
media thickness (C-IMT) measurement directly correlates
with atherosclerosis.8,9 In clinical studies, the C-IMT
measurement parallels the significance of traditional
cardiovascular risk factors,10 thus highlighting the utility and
consistency of using noninvasive measurements to assess
risk factors based on vessel wall biology. Accordingly, the
clinical application of C-IMT represents a powerful,
noninvasive surrogate marker of atherosclerosis, providing a
meaningful end point measurement for clinical trials. 11 Many
epidemiological studies and clinical trials proved that carotid
intima media thickness is an indicator of subclinical
atherosclerosis along with coronary atherosclerosis.
Increase in C-IMT is associated with subclinical
atherosclerosis. Hypothyroidism is a known condition for
causing atherosclerosis. 12 This study was conducted with an
aim to assess C-IMT in case of hypothyroidism.
Aim of the Study
To evaluate C-IMT in hypothyroidism.
Objectives
1. To compare the lipid profile in ScH and overt
hypothyroidism
2. To estimate C-IMT in overt hypothyroidism
3. To estimate C-IMT in subclinical hypothyroidism
4. To compare C-IMT in both groups with normal subjects
5. To correlate BMI, blood pressure, lipid profile with C-
IMT in hypothyroidism
MATERIALS AND METHODS
The present study entitled “Carotid intima media thickness
in hypothyroidism” was conducted in the department of
General medicine, A.V.B.R.H and J.N.M.C, Sawangi Meghe,
Wardha. It is 1200 bedded tertiary care center and teaching
hospital. The study was carried out over a period of 24
months from September 2016 to September 2018.
Study Design
Cross sectional study with control group.
Sample Size
Sample size formula with designed error of margin:
N= Z alpha/22 x p (1-p))/d2
Where, Z alpha /2 is level of significance at 5%=1.96
P= Sample size is calculated based on prevalence of
hypothyroidism is around 9.1%=0.091 (prevalence is given
from 4% to 20% in different studies.)
D = desired error of margin =6%=0.06
So, N = (1.96 x 1.96 x 0.091 x (1-0.091))/0.06 x
0.06=88.27.
So, the final sample size in this study was 100 cases of
hypothyroidism.
Inclusion Criteria
Patients with clinical features suggestive of hypothyroidism
and diagnosis made as per report of thyroid profile.
Exclusion Criteria
1. Patients who were on thyroid replacement therapy.
2. Patients on antithyroid drugs (Carbimazole,
methimazole, propylthiouracil).
3. DM (Diabetes mellitus).
4. CAD (Coronary artery disease).
5. Critically ill patients.
6. CKD (chronic kidney disease).
Blood Pressure
Blood pressure was measured twice on the right arm supine
position and in sitting position with a mercury
sphygmomanometer with a standard sized cuff after a
resting period of five minutes in a sitting position.
Palpatory method was carried out prior to the
auscultatory method for determination of systolic blood
pressure. Both systolic and diastolic blood pressure were
recorded in mmHg.
Blood pressure will be cross checked 2 times.
In the case of hypertension (≥ 140/90 mmHg), the
measurement was repeated after 5 minutes.
Anthropometric Measurements
Weight in kilograms was recorded with subjects standing
motionless on the standard weighing machine, without
shoes or any heavy accessory. Height in centimeters was
measured with patients standing without foot wear, against
a wall mounted scale with the head positioned erect so that
the top of the external auditory meatus was in level with the
lower level of the bony cavity of orbit. BMI was calculated
by using formula – weight in kilograms / (height in meter) 2
Obesity and overweight were determined by Asian criteria.13
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3541
Laboratory Investigations
Fasting Lipid Profile-
Blood samples were collected by venepuncture in the
morning after an overnight fast of about 8 hours. Serum
levels of total cholesterol (TC), high-density lipoprotein
cholesterol (HDL-C), and triglycerides (TG) were determined
by using a photometric method (Abbott diagnostics C16000
chemistry analyser).
Calculation of the value of low-density lipoprotein
cholesterol (LDL-C) was performed using the Friedewald
formula.14
Thyroid Profile
Morning fasting sample, after fasting for 8 hours at 6 am
was withdrawn and sent for thyroid function test. FT3, FT4,
TSH were tested. Tests were done by immunoassay system
by CENTAUR CP named equipment by SIEMEN’S company in
central laboratory of the hospital.
Values were interpreted according to laboratory values
of FT3, FT4, TSH. Normal range of thyroid profile-FT3- 2.3-
4.2 pg/ml, FT4- 0.89-1.76 ng/dl, TSH- 0.25-5 µIU/ml
After data collection appropriate statistical test will be
applied for interpretation of data.
Colour Doppler of Neck
C-IMT was measured by recording ultrasonographic images
of both the left and right common carotid artery with a 7‑
MHz linear array transducer. Patients were examined in the
supine position, with the head turned 45° from the side
during the scanning procedure. The reference point for the
measurement of C-IMT was the beginning of the dilatation
of the carotid bulb, with loss of the parallel configuration of
the near and far walls of the common carotid artery. An
R‑wave‑triggered optimal longitudinal image of the far wall
was frozen. On this image, the sonographer traced the
leading edges corresponding to the transition zones between
lumen‑intima and media‑adventitia over a length of 1 cm
proximal to the reference point at its thickest point, not
including plaques. The mean c- IMT of the four
measurements was calculated in each patient. Values more
than 0.5 mm of mean values are considered to be towards
higher value like if mean is 7.6 mm of both sides then it is
taken as 8 mm and values less than 0.5 mm of mean are
taken towards lower value like carotid intima media
thickness is 6.4 mm then that is taken as 6 mm.
All examinations and measurement were performed by
same examiner to exclude examiners bias.
Statistical Analysis
Statistical analysis was done by using descriptive and
inferential statistics using one-way ANOVA, multiple
comparison: Tukey test and multiple regression analysis and
software used in the analysis were SPSS 22.0 version and
Graph Pad Prism 6.0 version and p<0.05 is considered as
level of significance. In this study, comparison of each
parameter in all three groups was done by descriptive
statistics. One-way ANOVA test was used to see source of
variation between groups and within groups. Multiple
comparison: TUKEY TEST was done to compare individual
group with another group. Chi square test (χ2) was used to
test association of different study variables with the study
group. Z-test (standard normal deviation) was used to test
to test the significant difference between groups. t – test
was used to compare means. Odds ratio and 95%
confidence intervals were calculated to find out risk factor.
P<0.05 was considered statistically significant.
RESULTS
Baseline
Characteristics
Subclinical
Overt
Hypothyroidism
Control
Mean
SD
Mean
SD
Mean
SD
p-value
Age (yrs.)
38.04
13.71
39.76
14.57
47.38
15.39
0.35 (NS)
BMI (kg/m2)
26.62
2.69
26.00
2.14
24.26
1.56
0.003 (S)
FT3 (pg/ml)
3.05
0.53
1.26
0.40
3.04
0.49
0.0001 (S)
FT4 (ng/dl)
1.29
0.36
0.89
0.32
1.11
0.23
0.0001 (S)
TSH (µIU/ml)
8.80
5.16
34.24
10.50
3.60
0.65
0.0001 (S)
TC (mg%)
185.42
24.91
205.40
20.43
45.96
3.99
0.001 (ns)
TG (mg%)
151.12
25.78
182.24
38.15
133.58
13.14
0.0001 (S)
HDL (mg%)
51.69
4.42
44.04
5.59
45.96
3.99
0.0001 (S)
LDL (mg%)
116.37
22.58
135.92
12.71
23.68
4.88
0.0001 (S)
VLDL (mg%)
17.32
6.31
26.32
10.51
23.68
4.88
0.001 (ns)
SBP (mmHg)
123.56
10.18
125.12
13.56
119.94
9.86
0.356 (ns)
DBP (mmHg)
80.84
14.03
88.96
13.68
72.00
12.68
0.0001 (S)
CIMT (mm)
0.825
0.272
0.836
0.267
0.503
0.090
0.0001 (S)
Table 1. Baseline Characteristics of Cases and Control Group
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3542
Unstandardized Coefficients
Standardized Coefficients
t
p-Value
B
Std. Error
Beta
CIMT
-0.419
0.553
Age(yrs.)
0.000
0.002
-0.012
0.104
0.918, NS
BMI
0.011
0.011
0.124
1.050
0.298, NS
FT3
0.006
0.061
0.012
0.097
0.923, NS
FT4
-0.193
0.084
-0.259
2.307
0.024, S
TSH
0.014
0.007
0.270
2.091
0.041, S
TG
0.000
0.001
0.014
0.100
0.920, NS
HDL
0.013
0.005
0.267
2.366
0.021, S
LDL
-0.0002
0.001
0.000
0.000
1.000, NS
VLDL
0.000
0.005
-0.003
0.024
0.981, NS
SBP
0.004
0.005
0.145
0.851
0.398, NS
DBP
0.001
0.003
0.050
0.294
0.770, NS
Table 2. Multiple Regression Analysis for CIMT in Subclinical Hypothyroidism
On comparing all independent variables like BMI, lipid profile and blood pressure with dependent variable C-IMT,
statistically significant difference was found with FT4 (p=0.024), TSH(p=0.041) and with HDL(p=0.021) whereas with other
variables it shows no significant difference.
DISCUSSION
It is a well-known fact that the patients with hypothyroidism
have an increased risk of atherosclerosis. Carotid intima
media thickness is an indicator subclinical atherosclerosis. So
the present study was carried out to correlate carotid intima
media thickness with hypothyroidism and lipid profile. In this
study, mean age in subclinical hypothyroidism (ScH) was
38.04 years ± 13.71, in overt hypothyroid group it was 39.76
years ± 14.57 and 47.38 years ± 15.39 in control group. In
our study, male to female ratio in cases was 1:12.5 Thus, it
can be interpreted that the hypothyroidism population had
more females than males.
The mean of BMI of cases was 26.62 ± 2.69 kg/m2 and
in controls it was 24.26 ± 1.56 kg/m2. A similar study carried
out by Yeqing Gu et al;15 found that BMI of cases was in
range of 25.0- 25.3 kg/m2 and BMI in control group was
found to be 23.3 to 25.1 kg/m2. Frank M. Bengel et al 16
found that, in cases of hypothyroidism BMI ranges between
25.54 ± 2.18 kg/m2. Another study carried out by Harikumar
K et al;17 concluded that obesity and hypothyroidism often
co-exist. The data suggests that a greater number of
hypothyroidism populations were overweight or obese as
compared to controls.
In our study FT3 level was significantly reduced in cases
of overt hypothyroidism, but no significant difference is
found in control and subclinical group. Study carried out by
Ismail DoguKilic et al; mean of FT3 levels in subclinical
hypothyroid was 2.45 ± 0.59, and in control group it was
2.58 ± 0.58.
On comparing mean FT4 in three groups, a study
carried out by Ismail DoguKilic et al; FT4 levels in cases were
1.04 ± 0.41 and in normal individuals it was 1.09 ± 0.20,
which was not significant in controls and subclinical group.
In our study, statistically significant difference was found
between control and overt hypothyroidism group (p=0.013,
s) and no significant difference was found in control and
subclinical group (p=0.008, ns) and significant difference
was found between overt hypothyroidism and subclinical
group (p=0.0001, s).
In this study the mean of TSH level among three groups
was significantly variable. (F=31.55, p-value=0.0001s).
Study carried out by Krstevska B and Velkoska et al,18 TSH
in cases was 7.9 mU/l ± 3 .6 1mU/l and in control group it
was 5.1 mU/l ± 0, 8(p <0, 0001s). On comparing mean TSH
in three groups, it was found that between control and overt
hypothyroidism groups significant difference was found
(p=0.0001, s). And also, in control and subclinical groups
significant difference was found (p=0.0001, s) and
significant difference was found between overt
hypothyroidism and subclinical groups (p=0.0001, s).
In our study mean DBP levels in control group was 72
mmHg ± 12.68, in overt hypothyroidism group mean DBP in
patient was 88.84 mmHg ± 13.68 and in patients of ScH, it
was 80.84 mmHg ±14.03. Study carried out by Paulo H. N.
Harada et al19 the mean of Systolic blood pressure in control
group was 125 mmHg and in cases it was 126 mmHg
<0.001(NS), Mean of diastolic blood pressure in DBP in
controls was 77 mmHg and in cases it was 92 mmHg.
diastolic pressure (mmHg). Krstevska B and Velkoska et al 18
they have found that, systolic blood pressure in systolic
pressure (mmHg) 128 mmHg ± 20, 7 121, 8 mmHg ± 16, 5
0, 11 Diastolic blood in cases were 81, 66 mmHg ± 12.3 and
in control group it was 78, 6 mmHg ± 9.1 which was
significant.
Hypothyroidism is a recognized cause of secondary
hypertension. Studies on the prevalence of hypertension in
hypothyroidism have demonstrated elevated blood pressure
values. The possible factors for the elevated diastolic blood
pressure may be an increased peripheral vascular resistance
and low cardiac output. The hypothyroid patients have
significant volume changes, initiating a volume- dependent,
low plasma renin activity mechanism which further
contribute to hypertension.20 In another study carried out by
Tienlens E et al; concluded that hypothyroidism causes
aortic stiffness and hypertension (usually diastolic) and
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3543
thyroid hormone therapy decreases aortic stiffness,
promoting decreased blood pressure in about 50% of these
patients.21
On comparing mean HDL, VLDL and Tg levels, all were
significantly increased in hypothyroidism and ScH group as
compared to controls.
Yeqing Gu et al, found that increase in TG and LDL
levels were increased as compared to euthyroid population
along with decrease in HDL levels. Changhwan Seo et al;22
have compared lipid profile in patients of hypothyroidism on
thyroid replacement therapy and pts of hypothyroidism who
are not on therapy. They have found that there is definite
dyslipidaemia in the group who were not on therapy. (i.e.
increase in TG and LDL.)
Mean C-IMT levels in control group was 0.503 mm ±
0.090, in overt group mean CIMT in patient was 0.836 mm
± 0.267 and in subclinical group it was 0.825 mm ± 0.272.
Significant difference was found between control and overt
hypothyroidism group (p=0.0001, s) and in control and
subclinical group (p=0.0001s) and no significant difference
was found between overt hypothyroidism and subclinical
group (p=0.979Ns).
Similarly, Takamura N et al23 found that C-IMT is
independently associated with thyroid function and
increased cardiovascular risk in subjects with low thyroid
function. Jayanta Paul et al;24 also found that there is
increased C-IMT in hypothyroid patients and hence they are
prone to cardiovascular events. Monzani F et al25 were the
first to show increase in C-IMT in hypothyroidism. As
hypothyroidism has effects on endothelium of arteries and
C-IMT directly correlates to subclinical atherosclerotic
changes involved in thickening of arterial walls. Kim SK et
al;26 also showed relationship between hypothyroidism and
C-IMT. Varun Vijayan et al;27 study concluded the same.
Peixoto et al;28 conducted cross- sectional analysis of
the Brazilian longitudinal study of adult health. Study
included 8623 individuals out of which 8095 were euthyroid
and 528 were hypothyroid cases. It was observed that ScH
is associated with IMT as continuous variable (p=0.36) and
IMT is >75th percentile. Gao N et al;29 in a meta-analysis
demonstrated higher carotid IMT level in pts with ScH
compared with euthyroids. Edip U et al;30 study included 38
children diagnosed with ScH and a control group comprising
38 healthy, euthyroid children. In the patient group, CIMT
was also significantly higher compared to the control group
(p=0.001).
CONCLUSION
This cross-sectional study was aimed to evaluate C-IMT as a
noninvasive tool to detect atherosclerotic vessel involvement
in hypothyroidism. Study concluded that, C-IMT is increased
in both overt and subclinical hypothyroidism group as
compared to control group. This study found that majority
of cases of hypothyroidism was overweight and obese. In
overt and subclinical hypothyroidism group, values of DBP,
TG and LDL were increased. HDL was decreased. All these
may affect C-IMT. So patients of hyperthyroidism having
deranged lipid profile and other risk factors like obesity
should be screened for atherosclerosis by measuring C-IMT.
These groups can be targeted for primary prevention of CAD
and its early management like lipid profile lowering agents
apart from being treated for hypothyroidism.
REFERENCES
[1] Narmadha MP, Nimmy NJ, Aneesh PM, et al. A Survey
on the prevalence of thyroid disorder induced by
demography and food habits in South Indian
population. Indian Journal of Pharmacy Practice
2012;5(2):49-52.
[2] Ismail DK, Fenkcі S, Fulya A, et al. Non-invasive
indicators of atherosclerosis in subclinical
hypothyroidism. Indian Journal of Endocrinology and
Metabolism 2013;17(2):271-275.
[3] Lekakis J, Papamichael C, Alevizaki M, et al. Flow-
mediated, endothelium-dependent vasodilation is
impaired in subjects with hypothyroidism, borderline
hypothyroidism, and high-normal serum thyrotropin
(TSH) values. Thyroid 1997;7(3):411-414.
[4] Hak AE, Pol HA, Visser TJ, et al. Subclinical
hypothyroidism is independent factor for
atherosclerosis and myocardial infarction in elderly
women: the Rotterdam study. Ann Intern Med
2000;132(4):270-278.
[5] Cappola AR, Ladenson PW. Hypothyroidism and
atherosclerosis. J Clin Endocrinol Metab
2003;88(6):2438-2444.
[6] Valentina VN, Marijan B, Chedo D, et al. Subclinical
hypothyroidism and risk to carotid atherosclerosis.
Arq Bras Endocrinol Metab 2011;55(7):475-480.
[7] Sara JD, Zhang M, Gharib H, et al. Hypothyroidism is
associated with coronary endothelial dysfunction in
women. J Am Heart Assoc 2015;4(8):e002225.
[8] Wong M, Edelstein J, Wollman J, et al. Ultrasonic-
pathological comparison of the human arterial wall.
Verification of intima-media thickness. Arterioscler
Thromb 1993;13(4):482-486.
[9] Gamble G, Beaumont B, Smith H. B-mode ultrasound
images of the carotid artery wall: correlation of
ultrasound with histological measurements.
Atherosclerosis 1993;102(2):163-173.
[10] Touboul PJ, Hernández-Hernández R, Küçükolu S, et
al. Carotid artery intima media thickness, plaque and
Framingham cardiovascular score in Asia,
Africa/Middle East and Latin America: the PARC-AALA
study. Int J Cardiovasc Imaging 2007;23(5):557-567.
[11] Lorenz MW, Markus HS, Bots ML, et al. Prediction of
clinical cardiovascular events with carotid intima-
media thickness: a systematic review and meta-
analysis. Circulation 2007;115(4):459-467.
[12] Hurst RT, Ng DW, Kendall C, et al. Clinical use of
carotid intima-media thickness: review of the
literature. J Am Soc Echocardiogr 2007;20(7):907-
914.
[13] Aziz N, Kallur SD, Nirmalan PK. Implications of the
revised consensus body mass indices for Asian-
Jebmh.com Original Research Article
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 5/Issue 52/Dec. 24, 2018 Page 3544
Indians on clinical obstetric practice. J Clin Diagn Res
2014;8(5):OC01-OC03.
[14] Isik-Balci Y, Agladioglu S, Agladioglu K, et al.
Impaired hemorheological parameters and increased
carotid intima-media thickness in children with
subclinical hypothyroidism. Horm Res Paediatr
2016;85(4):250-256.
[15] Gu Y, Wang Y, Zhang Q, et al. The association
between thyroid function and incidence of metabolic
syndrome in euthyroid subjects: Tianjin chronic low-
grade systemic inflammation and health cohort study.
Clin Endocrinol (Oxf) 2018;88(5):735-743.
[16] Bengel FM, Nekolla SG, Ibrahim T, et al. Effect of
thyroid hormones on cardiac function, geometry, and
oxidative metabolism assessed noninvasively by
positron emission tomography and magnetic
resonance imaging. J Clin Endocrinol Metab
2000;85(5):1822-1827.
[17] Kumar HK, Verma A, Muthukrishnan J, et al. Obesity
and hypothyroidism: symbiotic coexistence. Arch
Intern Med 2008;168(19):2168.
[18] O'Leary DH, Polak JF, Kronmal RA, et al. Carotid-
artery intima and media thickness as a risk factor for
myocardial infarction and stroke in older adults.
Cardiovascular Health Study Collaborative Research
Group. N Engl J Med 1999;340(1):14-22.
[19] Harada PHN, Buring JE, Cook NR, et al. Impact of
Subclinical Hypothyroidism on Cardiometabolic
Biomarkers in Women. J Endo Soc 2017;1(2):113-
123.
[20] Streeten DH, Anderson GH, Howland T, et al. Effect
of thyroid function on blood pressure. Recognition of
hypothyroid hypertension. Hypertension
1988;11(1):78-83.
[21] Tielens E, Visser TJ, Hennemann G, et al.
Cardiovascular effects of hypothyroidism. Ned
Tijdschr Geneeskd 2000;144(15):703-706.
[22] Seo C, Kim S, Lee M, et al. Thyroid hormone
replacement reduces the risk of cardiovascular
diseases in diabetic nephropathy patients with
subclinical hypothyroidism. Endocr Pract
2018;24(3):265-272.
[23] Takamura N, Akilzhanova A, Hayashida N, et al.
Thyroid function is associated with carotid intima-
media thickness in euthyroid subjects. Atherosclerosis
2009;204(2):77-81.
[24] Paul J, Dasgupta S, Ghosh MK, et al. Relationship
between hypothyroidism and carotid artery intima
media thickness, and prevalence of hypothyroidism in
rheumatoid arthritis patient: an observational study.
Thyroid Research and Practice 2012;9(2):45-47.
[25] Monzani F, Caraccio N, Kozàkowà M, et al. Effect of
levothyroxine replacement on lipid profile and intima-
media thickness in subclinical hypothyroidism: a
double‑blind, placebo-controlled study. J Clin
Endocrinol Metab 2004;89(5):2099-2106.
[26] Kim SK, Kim SH, Park KS, et al. Regression of the
increased common carotid artery-intima media
thickness in subclinical hypothyroidism after thyroid
hormone replacement. Endocr J 2009;56(6):753-758.
[27] Vijayan V, Jayasingh K, Jayaraman G, et al.
Assessment of carotid intima-media thickness in
hypothyroidism and the effect of thyroid replacement
therapy. IJAM 2018;5(2):2349-3925.
[28] Peixoto D, Miranda E, Bittencourt M. Subclinical
hypothyroidism is associated with higher carotid
intima media thickness in cross-sectional analysis of
the Brazilian longitudinal study of adult health (ELSA-
Brasil). Nutr Metab Cardiovasc Dis 2016;26(10):915-
921.
[29] Gao N, Zhang W, Zhang YZ, et al. Carotid intima-
media thickness in patients with subclinical
hypothyroidism: a meta-analysis. Atherosclerosis
2013;227(1):18-25.
[30] Unal E, Akın A, Yıldırım R, et al. Association of
subclinical hypothyroidism with dyslipidemia and
increased carotid intima-media thickness in children.
J Clin Res Pediatr Endocrinol 2017;9(2):144-149.
