Association of Childhood Growth Hormone Treatment With Long-term Cardiovascular Morbidity

Importance Concerns about the cardiovascular safety of recombinant human growth hormone (rhGH) treatment in childhood have recently been raised; however, long-term studies are limited. Objective To investigate the long-term risk of overall and severe cardiovascular events in patients previously treated with rhGH in childhood and whether there is an association with treatment duration or dose. Design, Setting, and Participants This nationwide population-based cohort study included patients treated with rhGH during childhood from January 1, 1985, to December 31, 2010, in Sweden, with follow-up through December 31, 2014. Included patients were treated with rhGH owing to isolated growth hormone deficiency (GHD), small for gestational age (SGA), and idiopathic short stature (ISS). For each patient, 15 age-, sex-, and region-based matched control individuals were randomly selected from the general population as a comparison group. Data on cardiovascular outcomes and covariates including gestational age, birth weight, birth length, socioeconomic status, and height were obtained through linkage with several health care and population-based registers. Data were analyzed from January 1, 1985, to December 31, 2014. Exposures Treatment with rhGH during childhood and adolescence (aged 0-18 years). Main Outcomes and Measures The primary outcome was the first cardiovascular event recorded after the start of follow-up, and the secondary outcome was the first severe cardiovascular event. Results A total of 53 444 individuals (3408 patients and 50 036 controls; 67.7% men; mean [SD] age at study end, 25.1 [8.2] years) were followed up for as long as 25 years (median follow-up, 14.9 [range, 0-25] years; total, 795 125 person-years). Among 1809 recorded cardiovascular events, the crude incidence rates were 25.6 events per 10 000 person-years for patients and 22.6 events per 10 000 person-years for controls. The adjusted hazard ratio (HR) for all cardiovascular events was higher in patients compared with controls (HR, 1.69; 95% CI, 1.30-2.19), especially for women (HR, 2.05; 95% CI, 1.31-3.20) compared with men (HR, 1.55; 95% CI, 1.12-2.13). All subgroups had increased HRs (SGA, 1.97 [95% CI, 1.28-3.04]; GHD, 1.66 [95% CI, 1.21-2.26]; and ISS, 1.55 [95% CI, 1.01-2.37]). Longer duration of rhGH treatment (HR, 2.08; 95% CI, 1.35-3.20) and total cumulative dose (HR, 2.05; 95% CI, 1.18-3.55) were associated with higher risk for overall cardiovascular disease. The adjusted HR for severe cardiovascular disease was 2.27 (95% CI, 1.01-5.12). Conclusions and Relevance In this cohort study, treatment with rhGH during childhood due to GHD, SGA, or ISS was associated with increased risks of cardiovascular events in early adulthood, particularly in women; however, conclusions of causality are still limited and the absolute risk remains low. Question Is childhood growth hormone treatment associated with an increased long-term risk of cardiovascular morbidity? Findings In this nationwide population-based cohort study of 3408 patients treated with growth hormone in childhood and followed up for 25 years, risk of cardiovascular events later in life was increased compared with 50 036 age-, sex-, and region-matched control individuals adjusted for possible confounders. Longer duration of treatment and higher cumulative dose further increased this risk. Meaning These findings suggest that childhood growth hormone treatment is associated with an increased risk of cardiovascular events in early adulthood, although conclusions of causality are limited and the absolute risks are low. This cohort study investigates the long-term risk of overall and severe cardiovascular events in patients previously treated with recombinant human growth hormone in childhood and assesses whether these events are associated with treatment duration or dose.

Automated summary

A nationwide cohort study in Sweden found that patients treated with rhGH during childhood had an increased risk of cardiovascular events in early adulthood, especially in women. However, conclusions regarding causality are limited and the absolute risk remains low. Longer duration of treatment and higher cumulative dose further increased the risk of cardiovascular events.