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

Abstract

Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients with thyroid disorders. The objective of this systematic scoping review was to better understand the pathophysiology of TS and its complications, in terms of myocardial affection, tachyarrhythmia, and cardiogenic shock. In addition, we explored the pharmacological, mechanical, and surgical treatments for TS. We also evaluated the outcomes of TS according to sex and cardiac involvement. Additionally, analytical analysis was performed on the selected data. A literature review of peer-reviewed journals was carried out thoroughly using medical terms, MeSH on PubMed, Google Scholar, and combinations such as thyrotoxicosis-induced cardiomyopathy, thyroid storm, cardiogenic shock, myocardial infarction, endocrine emergency, Burch–Wartofsky score, extracorporeal circulatory support, and thyroidectomy. A total of 231 papers were eligible (2 retrospective studies, 5 case series, and 224 case reports) with a total of 256 TS patients with cardiac involvement between April 2003 and August 2023. All age groups, sexes, patients with TS-induced cardiomyopathy, non-atherosclerotic myocardial infarction, tachyarrhythmia, heart failure, shock, and different forms of treatment were discussed. Non-English language articles, cases without cardiac involvement, and cases in which treatment modalities were not specified were excluded. Female sex was predominant, with 154 female and 102 male patients. Approximately 82% of patients received beta-blockers (BBs), 16.3% were placed on extracorporeal membrane oxygenation (ECMO) support, 16.3% received therapeutic plasma exchange (TPE), and 13.8% underwent continuous renal replacement therapy (CRRT), continuous venovenous hemofiltration (CVVHD), or dialysis. Overall, 18 females and 16 males died. BB-induced circulatory collapse, acute renal failure, CRRT, and ventricular fibrillation were significantly associated with mortality. Awareness of TS and not only thyrotoxicosis is vital for timely and appropriate treatment. The early diagnosis and management of TS in cardiac settings, including pharmacological, mechanical, and surgical modalities, can save high-risk patients. Sex matters in the presentation, treatment, and mortality of this population. However, further large-scale, and well-designed studies are required.

Thyrotoxic Cardiomyopathy Unveiled: Insights From a Compelling Case Report

“…In cases of poorly controlled thyroid function, dilated cardiomyopathy typically starts with left ventricular hypertrophy and high cardiac output. However, as the disease progresses, biventricular dilatation and congestive HF with reduced ejection fraction become more common, as documented in the literature [5,[7][8][9][10][11][12].…”

“…This can result in sinus tachycardia and AF due to the shortening of the refractory period of cardiomyocytes. Therefore, neglecting or underestimating these effects can take a heavy toll on the cardiovascular system over time, resulting in devastating cardiogenic shock and death [4,5,6].…”

“…Although TCM is a rare disease with an incidence of only 1% in patients with thyrotoxicosis, it is still a fatal type of dilated cardiomyopathy, and its prompt recognition is essential because it is a reversible cause of HF [6]. Recognizing TCM can be challenging due to the unexplained signs and symptoms of HF, making it a diagnosis of exclusion [5,6]. In cases of poorly controlled thyroid function, dilated cardiomyopathy typically starts with left ventricular hypertrophy and high cardiac output.…”

“…Among the numerous articles that have explored TCM in the literature [5,[7][8][9][10][11], this study, to the best of our knowledge, is one of the very few case reports of TCM presenting as heart failure with preserved ejection fraction (HFpEF) and only atrial involvement. Our findings provide a unique perspective that will advance the understanding of this rare condition and could lead to improved diagnosis and treatment for these patients.…”

“…Thus, it is imperative to maintain a high level of suspicion for thyroid disorders in patients with new-onset atrial fibrillation, heart failure, and tachycardia-induced cardiomyopathy. The most effective management strategy to control these patients' blood pressure and heart rate involves using anti-thyroid medications and treating any possible cardiovascular complications [5,6].…”