(288) Arrhythmia Treatment for Thyroid Storm Leading to Cardiopulmonary Arrest

Introduction: Thyroid storm is a severe presentation life threatening endocrine emergency from uncontrolled thyrotoxicosis with severe clinical manifestations. The most common complication is atrial fibrillation with rapid ventricular response (Afib with RVR). In rare instances, cardiac instability related to Afib with RVR can lead to cardiogenic shock. This is a rare case of thyroid storm with Afib with RVR that progressed to cardiogenic shock.

Description: 43-year-old male presented to urgent care with cough, shortness of breath, bloating, and diarrhea. He was found to be in AFib with RVR. Work up revealed hyperthyroidism with concerned for early thyroid storm. Admitted to ICU for treatment including Cardizem drip and propranolol. Hospitalization complicated by pulseless electrical activity cardiac arrest with return of spontaneous circulation (ROSC). An echocardiogram demonstrated new left heart failure with reduced ejection fraction 20-25% with diffuse hypokinesis and right heart failure. He was supported by vasopressors and inotropic medication. Over the course of hospitalization, his left heart function recovered to nearly normal and was able to be discharged.

Discussion: Thyroid storm is a rare, life-threatening endocrine emergency with an incidence of 0.57 to 0.76 per 100,000 and mortality rate of 10-30% if not promptly treated. Afib occurs at a rate of 30% in patients with thyroid storm. Thyroid storm can progress to cardiogenic shock in 0.5-3% of cases, with mortality approaching 30%. Standard therapies for thyroid storm include anti-thyroid medication, steroids, iodine, and beta-blockers (BBs). Afib with RVR treatment options include BBs, calcium channel blockers (CCBs), antiarrhythmic, and cardiac glycosides. When considering therapy for Afib with RVR in the setting of cardiogenic shock, risks and benefits should be considered when combining more than one class of drugs. This case describes a patient with newly diagnosed thyroid storm presenting with AFib with RVR, with cardiogenic shock. Combination of BB and CCB used in treatment lead to cardiopulmonary arrest with ROSC. In the end, the patient was able to make a full recovery.