Benefit and Preference of Propranolol Over Metoprolol in Thyrotoxicosis-Induced Atrial Fibrillation: A Case Report and Review of Literature

Abstract

Atrial fibrillation is a common manifestation seen in patients with hyperthyroidism and thyroid storm. The presence of excess thyroid hormone (TH) alters adrenergic receptors in the heart and blood vessels, thereby causing an increase in sympathetic function and atrial fibrillation as a sequela of this excess circulating hormone. Excess thyroid hormone (T3) shortens the action potential of cardiomyocytes in the pulmonary vein, which facilitates the generation of reentrant circuits causing atrial fibrillation. Thyroid hormone can regulate cardiac beta-adrenergic receptor expression leading to enhanced catecholamine sensitivity of betaadrenergic coupled cardiac response. We present a case of a 64-year-old female with a history of hypertension (HTN), nonobstructive coronary artery disease (CAD), congestive heart failure (CHF) [ejection fraction (EF) 35-40%], chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTO2), obstructive sleep apnea (OSA)/hypoventilation syndrome, atrial flutter/atrial fibrillation with a loop recorder on rivaroxaban, and obesity who presented to the emergency department (ED) with gastroenteritis symptoms precipitating difficulty breathing and atrial fibrillation with a rapid ventricular response (HR 140-150) requiring ICU admission for rate and rhythm control. During the course of hospitalization, she was treated with an amiodarone infusion, which induced thyrotoxicosis and increased the ectopic electrical activity in the atrium, worsening atrial fibrillation. On day 3, amiodarone was stopped, and IV esmolol and metoprolol tartrate PO were continued with no resolution of atrial fibrillation. The patient was transitioned to propranolol, which achieved adequate heart rate control prior to discharge. The aim of our review is to highlight that propranolol should be used over metoprolol in patients with hyperthyroidism-induced atrial fibrillation due to the effect of propranolol on blocking the activity of T4 conversion to active T3 and, as such, blocking its effect on cardiac myocytes, terminating reentrant atrial excitation.

Clinical nomogram prediction model to assess the risk of prolonged ICU length of stay in patients with diabetic ketoacidosis: a retrospective analysis based on the MIMIC-IV database

“…In line with our findings, patients with DKA with high OASIS scores had longer Changes in the level of consciousness are important clinical symptoms and criteria for evaluating disease severity in patients with DKA. Cerebral oedema can occur in patients with DKA due to the combined effects of various factors, such as severe water loss, circulatory disorders, increased osmotic pressure, and cerebral cell hypoxia, causing central nervous system dysfunction and varying degrees of impaired consciousness [14,15]. Fluid resuscitation is the initial step in relieving circulatory disturbances in patients with DKA.…”

Data Analysis and Systematic Scoping Review on the Pathogenesis and Modalities of Treatment of Thyroid Storm Complicated with Myocardial Involvement and Shock

“…There are two types of AIT; type 1 generally occurs in patients with clinical thyroid disease [174]. According to our review, [43,93,103,174,212,229] six cases were described with AIT, including both types 1 and 2. Ozcan et al presented a patient who was administered amiodarone infusion to control AF; however, the ventricular rate was not controlled, and arrhythmia worsened even after discontinuation of amiodarone and ICD insertion.…”

The Comparative Assessment of Wellens’ Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review

“…One study affirmed multivessel critical stenosis: 100% stenosis in the proximal RCA and LCX, 90% stenosis in the middle LAD, and 95% stenosis in distal LAD [25]. The overall findings claimed that although Wellens' syndrome has high prevalence with LAD stenosis, it is often noted to have multivessel disease, with the involvement of the coronary arteries not limited to the LAD but also involves RCA or LCX or both.…”