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  • Review Article
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Hypothyroidism, atherosclerosis and cardiovascular risk prevention

Nature Reviews Endocrinology (2025)Cite this article

Abstract

Hypothyroidism, which is characterized by reduced thyroid hormone production, affects approximately 5% of the general population. Although primarily associated with metabolic and endocrine alterations, hypothyroidism has also been associated with an increased risk for cardiovascular disease (CVD), mainly due to accelerated atherosclerosis. Although the association between overt hypothyroidism and CVD is well established, that between subclinical or mild hypothyroidism and CVD remains questionable. CVD is among the most common non-communicable diseases and is the leading cause of death globally. The present narrative Review delves into the intricate relationship between hypothyroidism and cardiovascular risk factors. It explores the biochemical and molecular mechanisms underlying the heightened susceptibility of the hypothyroid state to CVD, while also seeking to identify potential avenues for improving management and designing preventive strategies via examination of both conventional and new risk factors. Furthermore, the Review scrutinizes the reported role of thyroid hormones in modulating cardiac structure and function, to shed light on their influence on the development and progression of CVD. Risk evaluation and personalized treatment approaches for individuals with hypothyroidism are also discussed.

Key points

  • Hypothyroidism is a common disease linked to atherosclerosis and cardiovascular disease (CVD).

  • Untreated hypothyroidism can increase several risk factors for CVD and should be categorized as a non-communicable disease (NCD), along with conditions such as diabetes mellitus and obesity.

  • In the context of the World Health Organization’s strategic framework for the prevention of NCDs, hypothyroidism can be regarded as a mediator of major NCDs, including arterial hypertension and dyslipidaemia. Preventing different degrees of hypothyroidism could help reduce the risk of NCDs.

  • The measurement of levels of thyroid-stimulating hormone (TSH) has become the accepted first-line diagnostic tool for thyroid disorders. It is crucial to maintain appropriate TSH levels when treating overt or subclinical hypothyroidism, especially when conditions such as arterial hypertension, dyslipidaemia or other NCDs are present.

  • Future studies should utilize omics technologies to investigate the effects of thyroid hormone treatment on CVD development and possibly mitigation, as well as define appropriate biomarkers for monitoring proper diagnostic and treatment outcomes.

  • Studies should be designed to assess the efficacy of thyromimetics for patients with hypothyroidism, low T3 levels and pre-existing CVD who have experienced a myocardial infarction.

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Fig. 1: Complications of hypothyroidism that can contribute to the development of atherosclerosis.
Fig. 2: The metabolism of cholesterol and the mechanism of reverse cholesterol transport.
Fig. 3: Τhe important interactive regulation of cholesterol metabolism by thyroid hormone.

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Acknowledgements

U.F.-R. is supported by an unrestricted grant from the Kirsten and Freddy Johansen’s Fund.

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Authors and Affiliations

  1. Evgenidion Hospital Unit of Endocrinology, Diabetes, and Metabolism, Thyroid Section, National and Kapodistrian University of Athens, Athens, Greece

    Leonidas H. Duntas

  2. Department of Nephrology and Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Ulla Feldt-Rasmussen

  3. Institute of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark

    Ulla Feldt-Rasmussen

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  1. Leonidas H. Duntas
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Nature Reviews Endocrinology thanks Alessandro Delitala, Zoran Gluvic and Alessandro Pingitore for their contribution to the peer review of this work.

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We searched the PubMed and Cochrane databases for articles in English from 1 January 2005 to 30 June 2025. We selected many eligible articles primarily published in relevant journals, comprehensive reviews, and several older important studies with high citation scores. The search terms were ‘hypothyroidism’ and ‘atherosclerosis’, ‘dyslipidemia’, ‘hypertension’, ‘endothelial dysfunction’, ‘homocysteinemia’, ‘c-reactive protein’ and ‘air pollution’.

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WHO noncommunicable diseases factsheet: https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/ncd-mortality

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Duntas, L.H., Feldt-Rasmussen, U. Hypothyroidism, atherosclerosis and cardiovascular risk prevention. Nat Rev Endocrinol (2025). https://doi.org/10.1038/s41574-025-01202-z

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