Panacea Journal of Medical Sciences 2022;12(1):86–90 Content available at: https://www.ipinnovative.com/open-access-journals Panacea Journal of Medical Sciences Journal homepage: http://www.pjms.in/ Original Research Article Elevated high sensitivity c-reactive protein in patients with subclinical hypothyroidism: A case control study Anuradha Panda1, Deepak Kumar Dasmohapatra2,*, Aditya Narayan Dash3, Babita Ekka4 1Dept. of Pathology, Maharaja Krishna Chandra Gajapati Medical College and Hospital, Brahmapur, Odisha, India 2Dept. of Transfusion Medicine, Veer Surendra Sai institute of Medical Science and Research, Burla, Odisha, India 3Dept. of Cardiology, MKCG Medical College and Hospital, Brahmapur, Odisha, India 4Medical Officer, Odisha Mining Corporation, India A R T I C L E I N F O Article history: Received 10-07-2021 Accepted 22-09-2021 Available online 30-04-2022 Keywords: Subclinical hypothyroidism High sensitivity Creactive protein thyroid stimulating hormone hyperlipidemia cardiovascular disease A B S T R A C T Background: Inflammation in subclinical Hypothyroidism (SCH) imposes a significant cardiovascular risk. The aim of the present study was to assess the elevated levels of high sensitivity C-reactive protein (hs-CRP) in SCH patients. Materials and Methods: In this study, 50 cases of SCH and 50 cases of euthyroid were selected. The complete history of the subjects were taken and demographic , biochemical parameters like age, BMI, thyroid profiles, lipid profiles and hsCRP were estimated. Results: The mean TSH levels were significantly (p<0.05) elevated in SCH cases as that of the controls (8.56± 1.76 vs 2.28± 0.65 µU/ml). Further, hs-CRP level was significantly (p<0.05) higher in SCH cases as that of the controls (2.93 ±0.87 vs 1.16 ±0.45 mg/l). Meanwhile, lipid profiles were also elevated in SCH cases as that of the controls. Coefficient correlation analysis showed significant association between TSH and hs-CRP. Conclusion: Thus, increased level of hs-CRP in SCH highlights the inflammatory status and thus associated with the development of cardiovascular diseases in SCH. This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: reprint@ipinnovative.com 1. Introduction Clinically, subclinical hypothyroidism (SCH), is defined as an elevated level of serum thyroid-stimulating hormone (TSH) with a parallel normal serum free thyroxine levels (FT4) and triiodothyronine (FT3). 1 Global prevalence of SCH is reported to be around 3% to 12%. 2 In India, the estimated prevalence of SCH is 9.4%. 3 Mounting studies have shown a significant association between SCH and metabolic disorders, hypertension and cardiovascular disorders. 4,5 A recent meta-analysis displayed significant association between SCH and coronary heart disease with * Corresponding author. E-mail address: dkdm@rediffmail.com (D. K. Dasmohapatra). an increased risk of cardiovascular mortality in patients with TSH level above 10 ml U/L. 6 Wide array of inflammatory markers has been identified as independent risk factors for CVD. High-sensitivity C-reactive protein (hsCRP), is touted to be a reliable predictor of CVD as compared to the lipid profile markers. Array of observational studies displayed a strong association between hs-CRP and morbidity and mortality associated with coronary heart disease, 7,8 and also increased the prediction of cardiovascular risk by adding hs- CRP to the Framingham risk score. 9 Various clinical studies elicited marked association between hs-CRP and index of subclinical atherosclerosis, like coronary artery calcification and intima-media thickness. 10 The CRP is an acute phase https://doi.org/10.18231/j.pjms.2022.017 2249-8176/© 2022 Innovative Publication, All rights reserved. 86 Panda et al. / Panacea Journal of Medical Sciences 2022;12(1):86–90 87 reactant, produced in the liver. The mechanism of CRP induced inflammatory condition is due to the upregulated expression adhesion molecules in vascular endothelial cells triggered by CRP. 11 Conflicting scenario exists in the role of hsCRP for analysing the CVD risk in SCH. Wide range of studies showed the elevated hsCRP level in SCH. 12–15 In this backdrop, the present study was undertaken to evaluate the incidence of elevated levels of hsCRP in individuals with SCH and also to delineate the risk of developing coronary vascular events. 2. Materials and Methods This was a cross-sectional case control study conducted in Veer Surendra Sai Institute of Medical Science and Research, Burla, Odisha. The study group included patients attending the department of pathology. 50 Patients with subclinical hypothyroidism (SCH) based on thyroid status (increased level of TSH, FT3 and FT4) were designated as cases based on the exclusion criteria. Further, 50 patients who were euthyroid based on serum TSH, FT3 and FT4 levels were designated as controls based on the exclusion criteria. Patients encountered with diabetes, hypertension, renal and liver disorders, coronary heart disease, undergoing thyroxine replacement therapy, affected with systemic infections were excluded from the study. Further, patients on NSAIDS, antibiotics, HRT and statins (which can increase hsCRP were also excluded from the study). Further the from the selected SCH cases the complete history was collected thorough general and systemic examination was done as per proforma. Under strict aseptic techniques, blood samples were collected after overnight fast, and analysed for the following required parameters. The above mentioned procedure was repeated for controls. The collected blood samples were centrifuged at 10,000 rpm for 10 minutes and the serum was collected in vials and stored at −80◦C until the analysis. Samples were analysed for thyroid hormones, hsCRP, and haematological parameters, Fasting Blood Sugar, Renal Function Tests, Liver Function Tests and Lipid Profiles. The reference range for the above mentioned parameters were as follows, Thyroid profile: TSH: 0.34–4.25 mIU/l, Free T4: 0.7–1.24 ng/dl and Free T3: 2.4–4.2 pg/ml; Fasting Plasma Glucose: 75-100 mg/dl; Lipid Profiles: Total Cholesterol: Less than 200 mg/dl; Triglycerides: 30-200 mg/dl; HDL Cholesterol: 40-60 mg/dl. High Sensitivity C-Reactive Protein (based on the risk for atherosclerosis): Low Risk: Less than 1 mg/l; Intermediate Risk: 1-2.9 mg/l; High Risk: More than or equal to 3 mg/l. 2.1. Data analysis The data were expressed as Mean ± SD. Statistical analysis was done using unpaired students-t-test. A p value <0.05 was considered as statistically significant. The correlation between the parameters was carried out using Pearson’s correlation. 3. Results In the present study, among the SCH cases most of them were between the age group of 21-30 years (34%), followed by 31-40 years (5.5%), 41-50 years (28%). Thus majority of the cases constitute between 21-50 years. In the control subjects maximum numbers were in the age between 31-40 years (36%). Further the mean age among the SCH cases and control was found to be 39.44±5.5 and 39.76± 6.5 and it was statistically non-significant (p>0.05). In the present study, the female preponderance was higher constituting around 90% in both the SCH cases and controls. In the present the mean height of SCH cases and control was found to be 1.59 m ± 0.07 and 1.64± 0.09 respectively (p> 0.05) and it was not significant. The mean weight was found to be (62.76± 7.65 vs 65.87 ± 8.32; p> 0.05) among the SCH cases and controls. Further, the BMI was found to be (26.76 ± 3.76 vs 27.87±3.56 p> 0.05; Non-significant) among the SCH cases and controls. The biochemical profiles of SCH cases and controls were displayed in Table 1. In the present study TSH levels were significantly (p<0.05) elevated in SCH cases as that of the control (8.56± 1.76 vs 2.28± 0.65 µU/ml). However, no significant differences (p>0.05) were seen in the levels of free T4 and T3 between the SCH cases and controls. In addition to the TSH levels, significantly higher levels of the hsCRP were observed in SCH cases when compared with controls (2.93 ±0.87 vs 1.16 ±0.45 mg/L; p < 0.05) respectively. Furthermore, the lipid profiles total cholesterol and triglycerides were significantly (p < 0.05) higher in SCH cases as that of the controls (176.65± 41.25 vs 135.87 ±51.24 mg/dl; 154.72 ±49.25 vs 125.65 ±24.8 mg/dl) respectively. Meanwhile, HDL cholesterol was significantly (p < 0.05) lower in SCH cases as that of the control (35.76± 7.2 vs 46.96 ±8.52 mg/dl). As per American Diabetes Association (ADA)/Centers for Disease Control and Prevention (CDC) and National Academy of Clinical Biochemistry (NACB) experts the risk stratification of CVD for hsCRP is <1, 1 to 3, >3 mg/L for low, moderate, and high risk respectively. In this study, most of the SCH cases (50%) were at moderate risk of developing CVD with hsCRP level between 1-3mg/dl. Meanwhile 14% of the SCH cases were at high risk of developing CVD with hsCRP level between > 3 mg/dl. The coefficient correlation analysis of hs-CRP with age, BMI, thyroid profiles and lipid profiles were shown in Table 2. In the present study, coefficient correlation analysis 88 Panda et al. / Panacea Journal of Medical Sciences 2022;12(1):86–90 Table 1: Biochemical parameters of controls and SCH cases in the present study Parameters Control (N=50) (mean±S.D) SCH cases (N=50) (mean±S.D) p -value TSH (µU/ml) 2.28± 0.65 8.56± 1.76 <0.05* Free T4 (ng/dl) 1.24±0.87 1.14±0.45 0.07N S Free T3 (pg/dl) 3.25± 0.76 3.12±0.84 0.06 N S hs-CRP (mg/ml) 1.16 ±0.45 2.93 ±0.87 <0.05* Total Cholesterol (mg/dl) 135.87 ±51.24 176.65± 41.25 <0.05* HDL Cholesterol (mg/dl) 46.96 ±8.52 35.76± 7.2 <0.05* Triglycerides (mg/dl) 125.65 ±24.8 154.72 ±49.25 <0.05* *p-value<0.05 significant; SD: Standard deviation Table 2: Coefficient correlation analysis for the effect of age BMI, thyroid profiles and lipid profiles onhsCRP in SCH Variables F-Value p-value Age 0.94 0.67 N S BMI 0.67 0.77N S TSH 55.46 <0.05* Free T3 1.12 0.54N S FreeT4 1.34 0.48N S Total Cholesterol 0.72 0.76N S Triglycerides 1.43 0.45N S HDL Cholesterol 0.82 0.82N S *p<0.05 significant; NS-Non Significant displayed significant and positive association between hs- CRP and TSH (p< 0.005; F-value: 55.46). However, the other variables like age, BMI, free T3 and T4, lipid profiles had not shown any significant correlation with hs-CRP (p>0.05) Furthermore, Pearson coefficient analysis revealed the significant (p<0.05) association between TSH and hs-CRP with a Pearson coefficient of 1 for TSH and 0.876 for hs- CRP respectively. 4. Discussion Subclinical hypothyroidism (SCH) is clinical condition in which the thyroid functions have been altered. SCH is of high clinical important since it has a high prevalence which inturn may overture to cause hypothyroidism and associated CVD risks. Mounting studies indicate that High-sensitivity C-reactive protein (hs-CRP) is a reliable marker of primary proinflammatory conditions and effective CVD. 16,17 In the present study, there exists an elevated level of hs-CRP in SCH as that of normal subjects (euthyroid). The results of our study is in corroboration with other studies done by Similar results were observed in the studies done by Gupta et al. 18 and Vaya et al 19 in their study concluded that the hs-CRP is significantly elevated in SCH patients along with the other inflammatory markers like Interleukin-6 and ESR. Thus in our study, SCH cases has no earlier history of systemic inflammation and the elevation in hs-CRP is not due to prevailing inflammatory condition other than SCH. 20 It has been noted that TSH level >10 µU/ml has been significantly associated with higher cardiovascular risk. In our study, out of 50 SCH cases, 40 patients has the TSH value >10 µU/ml. Further added, in our study as per ADA, CDC and NACB criteria 14% of SCH cases were at high risk for the progression of CVD. Our results are in line with the study done by Vyakaranam et al. 21 where 23.3% of SCH cases were at high risk for CVD development. Mounting studies displayed contrasting results regarding the SCH and this association is still under obscure. 22,23 In this study, elevated levels of total cholesterol, triglycerides were observed in SCH cases as that of the control. Our observation is in consistent with the previous studies were SCH subjects displayed higher cholesterol and triglycerides level SCH patients in this study were also observed by various studies. 24,25 Further, decreased HDL cholesterol level was observed in SCH cases in the present study, which is in line with the previous reports. 26 In our study, coefficient correlation and Pearson coefficient analysis had confirmed a significant positive association between TSH and hsCRP in SCH. However, in our study other variables like age, BMI and lipid profiles were not significantly correlated with hs-CRP. Previous research done by Yu et al. 14 showed confirmed significant positive correlation between hs-CRP and TSH after adjusting for potential confounder. Panda et al. / Panacea Journal of Medical Sciences 2022;12(1):86–90 89 5. Conclusion On the basis of data evaluated in this study, it has been revealed that the SCH patients are associated with increased TSH, hs-CRP levels and dyslipidemia. Further, coefficient correlation showed significant association between TSH and hs-CRP. Thus the elevated hsCRP levels in SCH showcases the CVS risk and useful for the potential early diagnosis and treatment. Further, large cohort studies are highly warranted to elucidate the hs-CRP involvement in SCH. Apart from hs-CRP it is highly vital to find out role of various inflammatory mediators status in SCH. 6. Acknowledgment None. 7. Conflict of Interest None. 8. Funding of Sources No financial support was received for the work within this manuscript References 1. Fatourechi V. Subclinical hypothyroidism: an update for primary care physicians. Mayo Clin Proc. 2009;84(1):65–71. doi:10.1016/S0025- 6196(11)60809-4. 2. Iervasi G, Molinaro S, Landi P, Taddei MC, Galli E, Mariani F. Association between increased mortality and mild thyroid dysfunction in cardiac patients. Arch Intern Med. 2007;167:1526–1558. 3. Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab. 2011;15(2):S78–81. doi:10.4103/2230-8210.83329. 4. Biondi B, Galderisi M, Pagano L, Sidiropulos M, Pulcrano M, D’Errico A, et al. Endothelial-mediated coronary flow reserve in patients with mild thyroid hormone deficiency. Eur J Endocrinol. 2009;161(2):323–9. doi:10.1530/EJE-09-0196. 5. Jiskra J, Limanova Z, Antosova M. Thyroid diseases, dyslipidemia and cardiovascular risk. Vnitr Lek. 2007;53(4):382–5. 6. Rodondi N, Elzen WD, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304(12):1365–74. doi:10.1001/jama.2010.1361. 7. Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of CRP and LDL cholesterol in prediction of first cardiovascular event. N Engl J Med. 2002;347(20):1557–65. doi:10.1056/NEJMoa021993. 8. Ridker PM, Cook N. Clinical usefulness of very high and very low levels of C-reactive protein across the full range of Framingham risk scores. Circulation. 2004;109(16):1955–9. doi:10.1161/01.CIR.0000125690.80303.A8. 9. Cushman M, Arnold AM, Psaty BM, Manolio TA, Kuller LH, Burke GL, et al. C reactive protein and the 10-year incidence of coronary heart disease in older men and women: the Cardiovascular Health Study. Circulation. 2005;112(1):25–31. doi:10.1161/CIRCULATIONAHA.104.504159. 10. Park R, Detrano R, Xiang M, Fu P, Ibrahim Y, Labree L, et al. Combined use of computed tomography coronary calcium scores and C-reactive protein levels in predicting cardiovascular events in nondiabetic individuals. Circulation. 2002;106(16):2073–7. doi:10.1161/01.cir.0000033819.29662.09. 11. Pasceri V, Willseron JT, Yeh ET. Direct proinflammatory effect of CRP on human endothelial cells. Circulation. 2002;102(18):2165–8. doi:10.1161/01.cir.102.18.2165. 12. Roy S, Banerjee U, Dasgupta A. Interrelationship of the proinflammatory marker HSCRP with dyslipidemic changes: a comparative study between subclinical and overt hypothyroidism. J Evol Med Dent Sci. 2016;5(16):806–12. doi:10.14260/jemds/2016/186. 13. Syamsunder AN, Pal P, Kamalanathan CS, Parija SC, Pal GK, Jayakrishnan G, et al. Dyslipidemia and low-grade inflammation are associated with sympathovagal imbalance and cardiovascular risks in subclinical and overt hypothyroidism. Int J Clin Exp Physiol. 2014;1(1):26–33. doi:10.4103/2348-8093.129726. 14. Yu YT, Ho CT, Li CI, Davidson LE, Liu CS, Li TC, et al. Subclinical hypothyroidism is associated with elevated high-sensitive C-reactive protein among adult Taiwanese. Endocrine. 2013;44(3):716–22. doi:10.1007/s12020-013-9915-0. 15. Mahto M, Chakraborthy B, Gowda SH, Kaur H, Vishnoi G, Lali P, et al. Are hsCRP levels and LDL/HDL ratio better and early markers to unmask onset of dyslipidemia and inflammation in asymptomatic subclinical hypothyroidism? Indian J Clin Biochem. 2012;27(3):284– 9. doi:10.1007/s12291-012-0206-y. 16. Goswami B, Tayal D, Tyagi S, Mallika V. Assessment of insulin resistance, dyslipidemia and inflammatory response in North Indian male patients with angiographically proven coronary artery disease. Minerva Cardioangiol. 2011;59(2):139–47. 17. Guruprasad S, Rajasekhar D, Subramanyam G, Rao PS, Vanajakshamma V, Latheef K, et al. High sensitivity C-reactive protein levels across spectrum and severity of coronary artery disease. J Clin Sci Res. 2012;1(3):126–30. 18. Gupta G, Sharma P, Kumar P, Itagappa M. Study on Subclinical Hypothyroidism and its Association with Various Inflammatory Markers. J Clin Diagn Res. 2015;9(11):4–6. doi:10.7860/JCDR/2015/14640.6806. 19. Vayá A, Giménez C, Sarnago A, Alba A, Rubio O, Hernández-Mijares A, et al. Subclinical hypothyroidism and cardiovascular risk. Clin Hemorheol Microcirc. 2014;58(1):1–7. doi:10.3233/CH-141871. 20. Ridker PM, Hennekens CH, Burning JE, Rifai N. C reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. New Engl J Med. 2000;342(12):836–43. doi:10.1056/NEJM200003233421202. 21. Vyakaranam S, Kondaveedu S, Nori S, Dandge S, Bhongir AV. Study of Serum High-sensitivity C-reactive Protein in Subclinical Hypothyroidism. Indian J Med Biochem. 2018;22(1):66–70. doi:10.5005/jp-journals-10054-0057. 22. Arikan S, Bahceci M, Tuzcu A, Celik F, Gokalp D. Postprandial hyperlipidemia in overt and subclinical hypothyroidism. Eur J Intern Med. 2012;23(6):141–5. doi:10.1016/j.ejim.2012.05.007. 23. Upadya BU, Suma MN, Srinath KM, Prashant A, Doddamani P, Sv S, et al. Effect of insulin resistance in assessing the clinical outcome of clinical and subclinical hypothyroid patients. J Clin Diagn Res. 2015;9(2):1–4. doi:10.7860/JCDR/2015/9754.5513. 24. Sridevi A, Vivekanand B, Giridhar G, Mythili A, Subrahmanyan KA. Insulin resistance and lipid alterations in subclinical hypothyroidism. Indian J Endocrinol Metab. 2012;16(2):345–6. doi:10.4103/2230- 8210.104085. 25. Kvetny J, Heldgaard PE, Bladbjerg EM, Gram J. Subclinical hypothyroidism is associated with a lowgrade inflammation, increased triglyceride levels and predicts cardiovascular disease in males below 50 years. Clin Endocrinol (Oxf). 2004;61(2):232–8. doi:10.1111/j.1365-2265.2004.02088.x. 26. Erdem TY, Ercan M, Ugurlu S, Balci H, Acbay O, Gundogdu S, et al. Plasma viscosity, an early cardiovascular risk factor in women with subclinical hypothyroidism. Clin Hemorheol Microcirc. 2008;38(4):219–25. http://dx.doi.org/10.1016/S0025-6196(11)60809-4 http://dx.doi.org/10.1016/S0025-6196(11)60809-4 http://dx.doi.org/10.4103/2230-8210.83329 http://dx.doi.org/10.1530/EJE-09-0196 http://dx.doi.org/10.1001/jama.2010.1361 http://dx.doi.org/10.1056/NEJMoa021993 http://dx.doi.org/10.1161/01.CIR.0000125690.80303.A8 http://dx.doi.org/10.1161/CIRCULATIONAHA.104.504159 http://dx.doi.org/10.1161/01.cir.0000033819.29662.09 http://dx.doi.org/10.1161/01.cir.102.18.2165 http://dx.doi.org/10.14260/jemds/2016/186 http://dx.doi.org/10.4103/2348-8093.129726 http://dx.doi.org/10.1007/s12020-013-9915-0 http://dx.doi.org/10.1007/s12291-012-0206-y http://dx.doi.org/10.7860/JCDR/2015/14640.6806 http://dx.doi.org/10.3233/CH-141871 http://dx.doi.org/10.1056/NEJM200003233421202 http://dx.doi.org/10.5005/jp-journals-10054-0057 http://dx.doi.org/10.1016/j.ejim.2012.05.007 http://dx.doi.org/10.7860/JCDR/2015/9754.5513 http://dx.doi.org/10.4103/2230-8210.104085 http://dx.doi.org/10.4103/2230-8210.104085 http://dx.doi.org/10.1111/j.1365-2265.2004.02088.x 90 Panda et al. / Panacea Journal of Medical Sciences 2022;12(1):86–90 Author biography Anuradha Panda, Senior Resident Deepak Kumar Dasmohapatra, Senior Resident Aditya Narayan Dash, Senior Resident Babita Ekka, Medical Officer Cite this article: Panda A, Dasmohapatra DK, Dash AN, Ekka B. Elevated high sensitivity c-reactive protein in patients with subclinical hypothyroidism: A case control study. Panacea J Med Sci 2022;12(1):86-90.