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Primary hypothyroid patients usually feel best, and/or obtain the best symptom or physiological test scores on T4 and/or T4/T3 regimens that produce a low or suppressed TSH (Cooke, Escobar-Morreale, Appelhof)

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Massive smooth muscle cell apoptosis occurs and is replaced by collagen fibers, whereas myofibroblast activation and proliferation enter an exhausted phase, leading to a significant decline in -SMA synthesis capacity