
==== Front
Ann Noninvasive Electrocardiol
Ann Noninvasive Electrocardiol
10.1111/(ISSN)1542-474X
ANEC
Annals of Noninvasive Electrocardiology
1082-720X
1542-474X
John Wiley and Sons Inc. Hoboken

10.1111/anec.13133
ANEC13133
ANEC-24-4943.R1
Original Article
Original Article
Establishment of a prediction model of pulmonary artery hypertension in patients with hyperthyroidism
Yan et al.
Yan Tianhui MD 1
Ma Qiang MD 1
Li Xin MD 1
Shen Qing MD 2
Liu Xiuxiu MD 3
Zhang Xia MD https://orcid.org/0009-0001-9895-5459
1 yjsusd@163.com

1 Department of Ultrasound Medicine The First Affiliated Hospital of Wannan Medical College Wuhu City Anhui Province China
2 Department of Ultrasound Medicine Fuyang City Women and Children Hospital Fuyang City Anhui Province China
3 Department of Ultrasound Medicine Fuyang City People's Hospital Fuyang City Anhui Province China
* Correspondence
Xia Zhang, Department of Ultrasound Medicine, Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Wuhu City, Anhui Province 241000, China.
Email: yjsusd@163.com

12 9 2024
9 2024
29 5 10.1111/anec.v29.5 e1313316 4 2024
17 1 2024
03 6 2024
© 2024 The Author(s). Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

Objective

This study aims to assess the tricuspid annular plane systolic excursion (TAPSE)/PASP ratio as a potential indicator for predicting the probability of developing pulmonary arterial hypertension (PAH) in hyperthyroidism patients. A nomogram model will be developed based on our findings, as well as the receiver operating characteristic (ROC) curve.

Methods

The study involved 166 hyperthyroid patients treated at Yijishan Hospital, and the period covered August 2021 to August 2022. Patients were divided into two groups according to pulmonary artery systolic pressure ≥35 mmHg. Univariate and multivariate logistic analyses were performed on the two groups' demographic and laboratory data to identify potential diagnostic markers. These parameters were evaluated using ROC curves to determine their precision in forecasting PAH. The findings were validated by plotting a calibration curve based on a line chart model.

Results

In the study, eventually, 80 patients were enrolled: 30 in the PAH group and 50 in the No PAH group. Multipleistic regression analysis predicted the occurrence risk of developing PAH. When paired with other conventional echocardiographic parameters (such as TAPSE, MPI, and SV) and serological markers (such as FT3 and FT4), the developed model demonstrated outstanding predictive performance with an area under the ROC curve of 0.985, a Youden index of 0.971, a sensitivity of 100%, and a specificity of 97.1%.

Conclusions

The nomogram model constructed by combining the TAPSE/PASP ratio with FT3 and FT4 serum markers, as well as conventional ultrasound parameters SV and MPI in hyperthyroidism patients, demonstrates robust discriminatory ability and consistency.

We tried to establish a model to predict the risk of pulmonary artery hypertension in patients with hyperthyroidism and help clinicians to manage patients. Finally, we successfully constructed a nomogram composed of tricuspid annular plane systolic excursion (TAPSE), myocardial performance index, SV, FT3, FT4, and TAPSE/PASP. After the verification of differentiation, calibration, and decision curve analysis (DCA), this model can significantly improve the prediction accuracy of PAH risk in patients with hyperthyroidism and has good clinical application value.

nomogram
nomogram model
prediction effectiveness
pulmonary artery hypertension
right‐ventricle‐pulmonary artery coupling
Young and Middle‐aged Scientific Research Fund of Wannan Medical CollegeWK202215 Anhui Province Public Welfare Technology Application Research Linkage Program2020MS3‐5 source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:12.09.2024
Yan, T. , Ma, Q. , Li, X. , Shen, Q. , Liu, X. , & Zhang, X. (2024). Establishment of a prediction model of pulmonary artery hypertension in patients with hyperthyroidism. Annals of Noninvasive Electrocardiology, 29 , e13133. 10.1111/anec.13133
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pmc1 INTRODUCTION

Hyperthyroidism (referred to as “thyrotoxicosis”) is approximately 1.2% (Kim et al., 2020). The prevalence of pulmonary arterial hypertension (PAH) ranges from 65% in individuals with hyperthyroidism suffering from thyrotoxicosis (Song et al., 2021). An individual patient suffers from right heart failure and, in severe cases, dies due to increased pulmonary artery pressure (Spiekerkoetter et al., 2019). During progressive pressure increases in the pulmonary vascular system, pulmonary vascular resistance and right ventricular remodeling increase. In this way, the coupling between the right ventricle and pulmonary artery is maintained. An enlarged right ventricular chamber, uncoupling, and impaired right ventricular contractility occur once the heart is decompensated (Ancona et al., 2021; Andersen & Knosgaard, 2020; Monaco, 2003). Patients with PAH have a poor prognosis based on their right ventricular structure (Badagliacca et al., 2021; Kamimura et al., 2018; Weatherald et al., 2018) and function (Fischer et al., 2018; Sunbul et al., 2014). Guazzi first proposed using tricuspid annular plane systolic excursion (TAPSE)/PASP ratios to assess right ventricular‐pulmonary artery coupling in 2017 as an ultrasound surrogate (Guazzi et al., 2017). Different diseases can now be diagnosed using it as a prognostic indicator. Despite this, its value is unknown for predicting the risk of PAH occurrence. Thus, this study aims to investigate whether the TAPSE/PASP ratio can determine the risk of PAH in patients with thyrotoxicosis. Additionally, the study aims to develop a thyrotoxicosis risk assessment model based on a reliable nomogram.

2 MATERIALS AND METHODS

2.1 Study population

From August 2021 to August 2022, 166 patients with hyperthyroidism sought medical treatment at Wannan Medical College's first affiliated hospital (Figure 1). The inclusion criteria were as follows: (1) thyroid stimulating hormone (TSH) <0.5 mIU/L; (2) increased concentration of free thyroxine (FT4); (3) increased concentration of free triiodothyronine (FT3); (4) left ventricular ejection fraction >50%; (5) the presence of tricuspid regurgitation allows for the estimation of pulmonary artery pressure; (6) complete thyroid function‐related serological results; (7) signed informed consent, with criteria (2) or (3) met.

FIGURE 1 Study selection flowchart.

Exclusion criteria for this study: (1) patients without appropriate tricuspid regurgitation; (2) patients with secondary hyperthyroidism; (3) patients with a history of severe cardiovascular disease or valvular heart disease; (4) patients with other conditions that may lead to pulmonary hypertension, such as pulmonary embolism, chronic lung disease, and connective tissue diseases; (5) patients with poor visualization of the right ventricular endocardium; (6) Patients who have been pregnant within the past year or have a smoking habit, and patients with hypercholesterolemia; (7) patients who have received radioactive iodine treatment in the past.

The investigation adhered to the principles outlined in the Declaration of Helsinki (Br Med J 1964; ii: 177) and received approval from our hospital's Medical Ethics Committee. One hundred sixty‐six patients participated in this study. Among them, 26 patients had poor image quality, 8 had concomitant connective tissue diseases, 10 had undergone radioactive iodine treatment, 8 had missing serological results, 19 had a pregnancy history within the past year, and 15 had a smoking habit. Following the exclusion of these patients, 80 patients were included in the analysis. Among them, 30 patients with pulmonary artery systolic pressure (PASP) ≥35 mmHg were classified as having PAH, while the remaining 50 were classified as not having PAH. Patient general and laboratory data were collected, including age, gender, heart rate, blood pressure, duration of illness, and free triiodothyronine (FT3) and free thyroxine (FT4).

2.2 Conventional echocardiographic data

A Philips EPIQ CVx color Doppler ultrasound diagnostic instrument was used to obtain all ultrasound images, with the X5‐1 phased array probe operating between 1.0 and 5.0 MHz. During image acquisition, participants were instructed to lie on their left side, breathe calmly, and hold their breath. “Guidelines for Ultrasonic Cardiography Examination and Measurement in Chinese Adults” (The Echocardiography Group, Ultrasonic Medicine Branch, Chinese Medical Association, 2016) were followed for all parameter measurements. Dynamic images of the right ventricular apical four‐chamber were continuously captured for four cardiac cycles, using the PAHilips 3D AutoRV software to obtain measurements of right ventricular end‐diastolic volume (RVEDV), right ventricular end‐diastolic volume index (RVEDVI), right ventricular end‐systolic volume (RVESV), right ventricular end‐systolic volume index (RVESVI), right ventricular stroke volume, right ventricular fractional area change (RVFAC), TAPSE, tricuspid annular plane systolic velocity (s'), and right ventricular myocardial performance index (MPI). The Auto Strain RV analysis obtained the GLS‐FW and GLS‐GLS for the right ventricular free wall. To estimate right atrial pressure, the collapsibility index of the inferior vena cava was determined in the subcostal view below the xiphoid process. Using “Guidelines for Adult Right Heart Echocardiography Evaluation” published by the American Society of Echocardiography (Rudski et al., 2010), the estimated right atrial pressure is 5 mmHg when the inferior vena cava diameter is 21 mm, and the collapsibility index is >50%. In cases where the inferior vena cava diameter exceeds 21 mm, and the collapsibility index is 50%, the estimated right atrial pressure is 15 mmHg; in cases where the above conditions are not met, the estimated right atrial pressure is 8 mmHg. Based on these measurements, the TAPSE/PASP ratio and pulmonary artery systolic pressure were calculated. The above data were measured three times, and the average values were used.

2.3 Statistical analysis

R software and SPSS 26.0 were applied to data analysis. GraphPad Prism 9 and Medcalc were utilized. A continuous variable is the mean × standard deviation (x ± s). By using the K‐S test, the data were assessed for normality. LSD‐t tests assessed customarily distributed data with equal variances. A t‐test comparing two groups was performed based on independent sample data. The Welch test compares data with unequal variances. Using n (%), chi‐square tests were conducted to compare counts between multiple groups. According to Chinese experts (Xianhong, 2023), when the scatter‐tracking echocardiography measured the longitudinal strain of the myocardium to be less than −18.2, it was considered an indication of impaired right ventricular systolic function. A list of predictors of PAH was developed based on one‐way analysis of varince results and relevant literature. For each factor, a regression equation and joint probability were calculated. Multiple logistic regression analyses were conducted to determine independent predictors and create an optimal model. We plotted receiver operating characteristic (ROC) curves for individual and combined indicators to assess their predictive capabilities. Based on this evaluation, sensitivity, specificity, threshold, and area under the curve (AUC) were calculated. Internal validation was performed on the model after construction as a nomogram. The variance inflation factor (VIF) was used in the multicollinearity analysis, with five indicating its presence. Statistical significance was determined by a p‐value of .05.

3 RESULTS

3.1 General baseline data results and analysis

We included 80 hyperthyroid patients in this study. Table 1 summarizes patients' baseline characteristics. There were no statistically significant differences between the two groups regarding age, gender, BMI, systolic and diastolic blood pressures, and duration of illness. This was based on the PASP ≥35 mmHg classification criteria. There was a statistically significant difference in heart rate between the PAH and No PAH groups (p = .313). All subjects' conventional echocardiographic data were obtained and compared (Table 2, Figure 2). A marked increase in RVD1, RVD2, RVD3, RVEDV, RVEDVI, RVESV, and RVESVI was observed in the PAH group compared to the No PAH group.

TABLE 1 Comparison of general clinical data characteristics between PAH group and no PAH group.

	PAH (n = 30)	No PAH (n = 50)	p value	
Age, years	38.6 ± 9.36	39.38 ± 11.27	NS	
Female, n (%)	22 (73.3%)	36 (72%)	NS	
Body mass index, kg/m2	21.86 ± 3.74	22.5 ± 4.04	NS	
Systolic pressure (mmHg)	134.67 ± 14.95	132.64 ± 12.17	NS	
Diastolic blood pressure (mmHg)	77.33 ± 9.72	80.8 ± 8.6	NS	
Heart rate (beats per minute)	101.43 ± 17.3	94.72 ± 14.99	<.05	
Disease duration, years	4.31 ± 6.06	3.19 ± 4.74	NS	
Note: The results for continuous variables are represented by the mean ± standard deviation (SD). The categorical variables are in the form of numbers (percentages).

Abbreviations: FT3, free triiodothyronine; FT4, free thyroxine; NS, no significant.

TABLE 2 Comparison of echocardiographic data features between PAH group and No PAH group.

	PAH (n = 30)	No PAH (n = 50)	p Value	
Analysis of right heart cavity diameter	
RA‐D1 (mm)	51.33 ± 5.32	47.97 ± 5.39	.008	
RA‐D2 (mm)	41.25 ± 4.27	38.73 ± 4.47	.015	
RA‐S (mm2)	16.44 ± 5.41	14.23 ± 4.43	.05	
RV‐D1 (mm)	37.33 ± 3.28	34.15 ± 4.44	.001	
RV‐D2 (mm)	29.64 ± 3.5	27.16 ± 4.89	.017	
RV‐D3 (mm)	68.72 ± 5.26	64.56 ± 6.22	.003	
RVEDV (mL)	115.51 ± 17.29	105.34 ± 14.56	.006	
RVEDVI (mL/m2)	73.8 ± 13.38	65.07 ± 10.94	.007	
RVESV (mL)	54.74 ± 11.82	50.92 ± 3.45	.035	
RVESVI (mL/m2)	35.01 ± 8.72	31.54 ± 4.17	.046	
Analysis of right heart‐related functional parameters	
FAC	0.44 ± 0.07	0.48 ± 0.07	.017	
TAPSE	21.62 ± 6.28	19.32 ± 5.31	.085	
MPI	47.77 ± 14.14	56.82 ± 17.84	.014	
s'	18.47 ± 2.61	16.31 ± 2.59	<.01	
TAPSE/PASP	0.83 ± 0.24	0.75 ± 0.23	.157	
PCWP (mmHg)	17.91 ± 3.86	13.47 ± 2.84	<.001	
GLS‐FW	17.24 ± 1.51	18.3 ± 1.74	.007	
GLS	19.23 ± 1.51	20.12 ± 1.7	.021	
Abbreviations: FAC, right ventricular area change rate; GLS, right ventricular longitudinal strain; GLS‐FW, right ventricular free wall longitudinal strain; MPI, right ventricular myocardial performance index; PCWP, pulmonary capillary wedge pressure; RA‐D1, right atrial long diameter; RA‐D2, right atrial minor axis; RA‐S, right atrial systolic area; RV‐D1, right ventricular basal internal diameter; RV‐D2, right ventricular mid‐segment diameter; RV‐D3, right ventricular long‐axis internal diameter; RVEDV, right ventricular end‐diastolic volume; RVEDVI, right ventricular end‐diastolic volume index; RVESV, right ventricular end‐systolic volume; RVESVI, right ventricular end‐systolic volume index; s', tissue Doppler imaging of mitral annulus systolic velocity; TAPSE, tricuspid annular systolic displacement.

FIGURE 2 (a) The process diagram of obtaining RVEDV, RVEDVI, RVESV, and RVESVI using RT‐3DE. (b) The process diagram of obtaining GLS‐FW and GLS using 2D‐STI.

3.2 Predictors of pulmonary artery hypertension

Figure 3 presents a forest plot demonstrating the predictive efficacy of various parameters in assessing PAH risk. It can be observed that the TAPSE/PASP ratio exhibits higher predictive accuracy than conventional right heart function indicators. Table 3 displays the results of both univariate and multi‐collinear analyses. The multicollinearity analysis indicates no multicollinearity among the parameters (VIF < 5). In contrast, the univariate analysis identifies TAPSE, MPI, TAPSE/PASP, SV, FT3, and FT4 as potential predictors for PAH. The optimal model is constructed through multiple regression analysis by incorporating MPI, SV, FT3, FT4, and TAPSE/PASP ratios, as shown in Table 4. Model comparison is conducted by examining each indicator's AUC, sensitivity, specificity, and Youden index, as shown in Table 5. It can be concluded that the TAPSE/PASP ratio is an influential predictive factor for PAH in hyperthyroid patients. Its capability can be enhanced by creating a model with other physiological indicators. The ROC curve analysis reveals an AUC of 0.985, with a sensitivity of 100% and a specificity of 97.1%. The Youden index is also calculated to be 0.971, as illustrated in Figure 4. Using the R Programming language software, a nomogram model is constructed to evaluate the risk of PAH. This is based on various parameters. Figure 5 shows this. Figure 6 shows the nomogram decision curve. The nomogram illustrates that as the FT3, FT4, and SV levels increase, the TAPSE/PASP ratio decreases, and the cumulative score rises. This indicates a higher risk of PAH in patients. The calibration curve of the nomogram model, as shown in Figure 7, demonstrates a C‐index of 0.985, indicating the nomogram model's high accuracy and clinical value.

FIGURE 3 Forest plot of binary logic analysis results for Best model.

TABLE 3 Univariate analysis of the risk of pulmonary artery hypertension in patients with hyperthyroidism.

Variables	Univariate analysis	Multiple collinearity diagnosis	
OR (95% CI)	p‐Value	Tolerance	VIF	
TAPSE/PASP	0.002 (0.000–0.034)	<.001	0.754	1.326	
FT3	1.231 (1.127–1.344)	<.001	0.797	1.255	
FT4	1.163 (1.083–1.250)	<.001	0.726	1.378	
SV	1.090 (1.047–1.134)	<.001	0.796	1.256	
TAPSE	1.316 (1.149–1.507)	<.001	0.642	1.556	
MPI	1.103 (1.052–1.156)	<.001	0.695	1.439	
Abbreviations: FT3, free triiodothyronine; FT4, free thyroxine; MPI, right ventricular myocardial performance index; PASP, pulmonary artery systolic pressure; SV, stroke volume; TAPSE, tricuspid annular plane systolic excursion.

TABLE 4 Multivariate analysis of the risk of pulmonary artery hypertension in patients with hyperthyroidism.

	OR (95% CI)	p‐Value	
TAPSE/PASP	0.000 (0.000–0.182)	.021	
FT3	1.435 (1.092–1.887)	.01	
FT4	1.155 (1.009–1.322)	.036	
SV	1.143 (1.002–1.305)	.046	
TAPSE	0.875 (0.638–1.201)	.409	
MPI	1.134 (1.016–1.266)	.024	

TABLE 5 Each parameter receiver operator characteristic curve for predicting pulmonary artery hypertension.

Variables	SV	FT3	FT4	TAPSE/PASP	MPI	Best model	
AUC	0.804	0.817	0.892	0.824	0.787	0.985	
95% CI	0.700–0.884	0.715–0.895	0.803–0.950	0.723–0.900	0.681–0.871	0.928–0.999	
Sensitivity (%)	69.6	89.13	93.5	86.9	67.4	100	
Specificity (%)	79.4	79.41	76.5	70.6	88.2	97.1	
Youden index J	0.490	0.685	0.700	0.58	0.556	0.971	
p‐Value	<.0001	<.0001	<.0001	<.0001	.008	<.0001	

FIGURE 4 Receiver operating characteristic (ROC) analysis results for each parameter. The Best model was constructed by combining MPI, SV, FT3, FT4, and TAPSE/PASP.

FIGURE 5 Nomogram prediction model of MPI, SV, FT3, FT4, and TAPSE/PASP on predicting the risk of right ventricular dysfunction in patients with hyperthyroidism.

FIGURE 6 DCA calibration curve for nomogram of Best model.

FIGURE 7 Nomogram's calibration curve.

4 DISCUSSION

4.1 Pulmonary artery hypertension predicts prognosis in hyperthyroid patients

Hyperthyroidism (thyrotoxicosis) is a common endocrine disorder, with a prevalence second only to diabetes and osteoporosis in the population (Hughes & Eastman, 2021). Hyperthyroidism has also gradually become an important cause of pulmonary hypertension (PAH). The World Symposium on Pulmonary Hypertension (WSPH) 2018 categorized hyperthyroidism as a trigger “related to certain unidentified mechanisms of pulmonary hypertension associated with specific risk factors.” The exact reasons for PAH occurrence in patients with hyperthyroidism are not fully understood. Possible mechanisms include immune‐mediated pulmonary vascular proliferation, pulmonary vascular endothelial injury, and metabolic abnormalities of substances that regulate pulmonary vascular relaxation. Under the combined action of thyroid hormones and pulmonary blood volume, the metabolism of pulmonary vasodilators (NO and prostacyclin) and inhibitors of pulmonary vasoconstriction (endothelin‐1, serotonin, and thromboxane) is accelerated (Marvisi et al., 2006). These increase pulmonary blood volume, resulting in tremendous shear stress on pulmonary vessel cells. This stimulates the proliferation of smooth muscle cells in the pulmonary vascular wall (Naeije et al., 2022; Trapp et al., 2012). Deactivating caveolin‐1 in the endothelium reduces intracellular Ca2+ influx, contributing to endothelial dysfunction, activating mechanosensitive channels in vascular smooth muscle cells, stimulating cytoplasmic calcium levels, and causing pulmonary vasoconstriction (Wang et al., 2022). In the early stages of increased pulmonary circulation pressure, the right ventricle adapts to the increased afterload caused by myocardial hypertrophy. It enhances its contractile capacity. However, if the afterload exceeds the adaptive capacity of the right ventricle, it can contribute to a decrease in right ventricular filling pressure. This can lead to dilation. Diastolic right ventricle dysfunction can lead to right ventricular failure due to this dilation. The latest guidelines from the European Society of Cardiology (ESC) and European Respiratory Society (ERS) in 2022 also emphasize the importance of right heart function in diagnosing and treating pulmonary hypertension (Humbert et al., 2023). These guidelines emphasize that right heart function is crucial to determining PAH symptoms and prognosis. It has been shown that TAPSE and tricuspid regurgitation flow are hemodynamic indicators of right ventricular dysfunction. Patients with PAH can use these indicators to stratify their mortality risk and risk stratification (Mercurio et al., 2022). Hemodynamic indicators can guide clinical treatment decisions in real‐time. Consequently, timely identification and treatment of patients at high risk of PAH and stratified treatment accordingly can improve patient outcomes.

4.2 TAPSE/PASP ratio: an important predictor of PAH

Right ventricular function plays a pivotal role in determining the severity and prognosis of various diseases. It has been common practice to evaluate the right ventricle and pulmonary artery separately, overlooking their interconnected physiological relationship. The holistic relationship between right ventricular function and respiratory circulation has recently been highlighted in studies. We propose a comprehensive assessment approach based on the right ventricular‐pulmonary artery coupling. Due to its contraction, the afterload adjusts to the afterload, resulting in right ventricular‐pulmonary artery coupling. Previous studies (Tello et al., 2019) show that the TAPSE/PASP ratio is the only echocardiographic index independently correlated with right ventricular‐pulmonary artery coupling. The TAPSE/PASP ratio typically maintains a dynamic balance between 1.5 mm/mmHg and 2 mm/mmHg. TAPSE/PASP ratios below 0.31 mm/mmHg indicate decoupling once the right ventricle fails to adapt to increasing afterload. In patients with heart failure due to preserved ejection fraction, connective tissue diseases, severe aortic stenosis, and critical illness, the TAPSE/PASP ratio has been used as a prognostic indicator. The coupling status between the right ventricle and pulmonary artery also determines PAH patients' prognosis (Logantha et al., 1879; Tello et al., 2018). Consequently, clinicians must continuously assess the real‐time coupling status between the right ventricle and pulmonary artery in patients with PAH. Right heart catheterization is typically used to determine the right ventricular pressure‐volume loop as the “gold standard” for evaluating ventricular‐arterial coupling. In primary hospitals, however, this method is invasive and requires high proficiency from the operator. Primary hospitals without advanced auxiliary equipment face an urgent clinical challenge in accurately assessing the right ventricular‐pulmonary circulation coupling state. In addition, they must monitor patients' ventricular‐arterial coupling status in real time. According to the Adult Right Heart Echocardiography Assessment Guidelines published in 2010 (Rudski et al., 2010), traditional conventional ultrasound parameters such as MPI and TAPSE are recommended for evaluating right ventricular systolic function. Each parameter has advantages and disadvantages. A right atrial pressure increase or atrial fibrillation can affect MPI accuracy. It measures systolic and diastole. TAPSE assesses primarily the rate at which the right ventricle shortens longitudinally (Kamimura et al., 2018). Nonetheless, certain scholars have observed that patients undergoing cardiac surgery show alterations in their right ventricular systolic function. These alterations include an increase in transverse shortening and a decrease in longitudinal shortening. Systolic function, however, remains normal. As a result, TAPSE may also be less accurate for patients with right ventricles that predominantly exhibit nonlongitudinal motion (Weatherald et al., 2018). Logistic regression analysis prediction in hyperthyroid patients is the TAPSE/PASP ratio. Obtaining the TAPSE/PASP ratio without image quality accurately reflects the right ventricle's overall function. However, it only reflects the longitudinal motion of the free wall segment of the right ventricle (He et al., 2023). A TAPSE/PASP ratio was combined with conventional right ventricular systolic function measures, including TAPSE, MPI, and clinical serum markers FT3 and FT4, to construct a model and select the most appropriate one. It was found that the predictive accuracy of the combined model was significantly improved (AUC = 0.985, sensitivity of 100%, specificity of 97.1%), which was significantly higher than the diagnostic value of a single indicator. Hence, we assert that the TAPSE/PASP ratio, an alternative to invasive ultrasound for assessing right ventricular‐pulmonary artery coupling, demonstrated significant predictive capability in determining the likelihood of developing PAH in patients with hyperthyroidism. As a result, we found that the TAPSE/PASP ratio was lower in hyperthyroidism patients with coexisting PAH than in those without PAH. This indicates a decline in the coupling between right ventricular systolic function and afterload. It is suggested that those with concomitant PAH may have a poor hyperthyroidism prognosis. Myocardial fibrosis and changes in the geometric shape of the right ventricular cavity may result from the increased volume load (Dissabandara et al., 2023), leading to impaired right ventricular systolic function and a decoupling of the right ventricular artery from the pulmonary artery. As a result, interventions to reduce right ventricular pressure and volume load may benefit patients with hyperthyroidism and PAH. This may restore right ventricular systolic function, improve right ventricular‐pulmonary artery coupling, and improve patient outcomes. Pregnant women within 1 year of this study were excluded from this study. According to relevant literature, pregnancy‐induced hyperthyroidism is likely to develop between 0.1 and 0.4% of the time during the first 10 weeks of pregnancy (Aranyosi et al., 2020). As a result, human chorionic gonadotropin increases rapidly during pregnancy. Structurally, TSH, which, to some extent, activates TSH receptors, leads to a temporary increase in FT4 and hyperthyroidism (Nazarpour et al., 2022). Furthermore, hyperthyroidism, smoking, and hypercholesterolemia have also been linked to Graves' disease as its primary cause (Bartalena et al., 2021). These conditions were also excluded to exclude patients with these conditions from this study. Even though the parameters are independent, mutual influence is still possible. A nomogram was constructed based on relative risk. In this case, the forecast risk capacity index has been corrected to 0.985, which indicates high adaptability. Clinically effective prediction model results were obtained using DCA curves. All indicators within the model are easily obtainable and highly operational. This provides a solid theoretical basis for timely identification and early intervention of high‐risk patients in primary hospitals with limited medical conditions.

4.3 Study limitations

However, this study still has some limitations: (1) the samples are from a single center, and future research should attempt to conduct multi‐center sample studies; (2) the sample size is small, and further, stratified studies should be conducted among PAH patients while expanding the sample size; (3) the effectiveness of this model still needs to be validated in multi‐center, multi‐sample practice; (4) the TAPSE/PASP ratio is angle‐dependent, and RVLS/PASP (right ventricular longitudinal strain/pulmonary arterial systolic pressure) is a new noninvasive alternative for right ventricle‐pulmonary artery coupling, with its application value expected to be further explored in subsequent studies.

5 CONCLUSION

The nomogram model constructed by combining the TAPSE/PASP ratio with the serum markers FT3 and FT4, as well as the conventional ultrasound parameters SV and MPI, can effectively predict the risk of developing PAH in patients with hyperthyroidism. In general, the nomogram indicated high clinical value in judging the risk of pulmonary hypertension in patients with hyperthyroidism. It could provide guidance for clinicians to predict patient risk and manage patients in stratification according to different conditions.

AUTHOR CONTRIBUTIONS

Tianhui Yan, Qiang Ma conceived of the study; Xin Li, Qing Shen participated in its design and coordination, and Xiuxiu Liu, Xia Zhang helped to draft the manuscript. All authors read and approved the final manuscript.

FUNDING INFORMATION

This study received funding from the Anhui Province Public Welfare Technology Application Research Linkage Program (2020MS3‐5), Young and Middle‐aged Scientific Research Fund of Wannan Medical College (WK202215), which supported and facilitated the research. The organization does not have the authority to intervene in the publication of the manuscript as it did not participate in the data collection, compilation, and analysis, as well as the writing of relevant materials.

CONFLICT OF INTEREST STATEMENT

All of the authors had no any personal, financial, commercial, or academic conflicts of interest separately.

ETHICAL APPROVAL

This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Wannan Medical College's first affiliated hospital, and all subjects signed the informed consent.

DATA AVAILABILITY STATEMENT

All data generated or analyzed during this study are included in this published article.
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