Cardiovascular Collapse Secondary to Beta-Blocker Administration in a Setting of Coexisting Thyroid Storm and Atrial Fibrillation: A Case Report

Abstract

A thyroid storm is a rare endocrinological emergency caused by severe hyperthyroidism. Reducing circulating levels of free T3 in blood and beta-adrenergic inhibition are the basis of medical treatment for thyroid storms. Propranolol, due to its additional effect of preventing the peripheral conversion of dormant T4 to active form T3, is the chosen drug for blockade in hyperthyroidism and thyroid storm. We describe a rare clinical case of cardiovascular collapse following propranolol administration in a setting of thyroid storm. The patient presented with symptoms of dyspnea and palpitations and had an ejection fraction of 10%. He was started on a calcium channel blocker (diltiazem). Further investigations revealed that the patient also had a thyroid storm and was immediately shifted to methimazole and propranolol. However, following the administration of a beta-blocker, the patient developed circulatory failure as a result of cardiac arrest, necessitating the use of vasopressors and inotropes. This implores the need for further investigations and treatment regimens for cardiovascular conditions, especially atrial fibrillation arising in thyrotoxicosis, as there are no solid treatment guides in the literature to the best of our knowledge.

Thyrotoxicosis-Induced Cardiogenic Shock: Acute Management Using a Multidisciplinary Approach

“…Although the traditional treatment of thyrotoxicosis includes non-selective beta-blockers, their use may be destructive in a patient with severely reduced stroke volume due to their negative inotropic, and chronotropic effects, especially in situations where controlling the heart rate is fundamental to maintaining cardiac output as in the case of our patient [4]. This is in line with the existing literature, with a total of 11 cases of beta-blockerinduced cardiogenic shock in thyroid crisis reported shortly after the administration of a non-cardioselective beta-blocker, commonly propranolol [5][6].…”

Acute decompensated heart failure in the setting of cavotricuspid isthmus-dependent atrial flutter and thyroid storm

“…Due to ongoing cardiomyopathy with signs of heart failure along with atrial flutter based on recent evidence esmolol drip is probably the safest beta-blocker to use in the acute setting due to its very short half-life (9 minutes) avoiding unexpected cardiovascular collapse with longer halflife beta blocker like propranolol (3-4 hours) and allowing quick hemodynamic adjustments at bedside. 4 In addition, evidence supports that a singleprocedure ablation success rate exceeds 90% for typical and atypical atrial flutter and is associated with decreased hospitalizations, improvement of the LVEF, emergency department visits, development of subsequent atrial flutter, and improved quality of life. 5 The early ablation and multidisciplinary approach were the cornerstones in our case.…”

Esmolol Is Not the Solution: Thyroid Storm With Atrial Fibrillation

“…There have been multiple reported cases of patients with thyroid storm who have collapsed and suffered a cardiac arrest shortly after starting propranolol [13][14][15]. Pong et al [12], Dalan and Leow [14], and Modarresi et al [16] clearly recommend starting esmolol for such cases due to the fact that it has a short life and is easily titratable.…”