Management of Cardiogenic Shock due to Thyrotoxicosis: A Systematic Literature Review

Abstract

Background: A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing further left ventricular dysfunction and cardiogenic shock. This manuscript aims to review the literature on cardiogenic shock associated with thyrotoxicosis and present management recommendations on this rare condition. Method: A literature search was performed in December of 2018, using the PubMed medical search engine. A systematic search was carried out using the keywords Thyroid Storm AND Cardiogenic Shock and Thyrotoxicosis AND Shock. Management: A) Decrease of thyroid hormone levels using therapeutic plasma exchange B) LV Unloading and ventilation by Impella and Extracorporeal Mechanical Ventilation (ECMO). Conclusion: Patients presenting with thyroid storm-induced shock may not be suitable candidates for traditional management with β-adrenergic blockers (β-blockers). Use of β-blockers could exasperate their condition. Through extensive literature review on this rare condition, the most effective management was found to be therapeutic plasma exchange in order to decrease thyroid hormone levels, which have direct toxic effect on the heart. Furthermore, the use of ECMO and Impella are advised to reduce pressure on the heart and ensure the patient’s organs are well oxygenated and perfused while the left ventricle is recovering.

Thyrotoxicosis-Induced Cardiomyopathy Complicated by Refractory Cardiogenic Shock Rescued by Extracorporeal Membrane Oxygenation

“…This is a consequence of expanded plasma volume and a hyperdynamic circulatory state in the absence of left ventricular dysfunction. Less than 1% of these patients are found to develop dilated cardiomyopathy with evidence of severely impaired left ventricular systolic function consistent with TCM, as seen in echocardiographic findings of this patient [ 1 , 2 ].…”

“…However, if clinical manifestations are highly suspected, regardless of BWPS, treatments should be initiated as soon as possible to reduce mortality [ 5 ]. If the clinical status fails to improve despite appropriate medical treatment, therapeutic plasmapheresis (TPE) is considered to be the most effective management to decrease circulation of the thyroid hormone in patients with thyroid storm [ 2 ]. TPE effectively exchanges serum proteins, which is the binding agent for approximately 99% of thyroid hormones.…”

“…Presentations may include palpitations, exertional dyspnea, and edema. Approximately 1% of thyrotoxic patients develop thyrotoxicosis-induced cardiomyopathy, a rare but life-threatening type of dilated cardiomyopathy causing severely impaired left ventricular function and resulting in overt cardiogenic shock [ 1 , 2 ]. Early diagnosis is crucial since the patient is critically ill and urgently needs support measures in the intensive care unit.…”

“…Early diagnosis is crucial since the patient is critically ill and urgently needs support measures in the intensive care unit. The use of mechanical circulatory support may be required in patients with refractory shock to prevent organ failure and reduce short-term mortality [ 2 ]. However, the abnormal cardiac structure and function are potentially reversible after achievement of euthyroid state [ 1 ].…”

Thyroid Storm Patients With Elevated Brain Natriuretic Peptide Levels and Associated Left Ventricular Dilatation May Require Percutaneous Mechanical Support

“…In addition to specific antithyroid therapy, supportive therapy in an ICU and recognition and treatment of any precipitating factors are essential. Although beta-blockers are used as a first-line treatment for TS, there are reports of patients with TS who developed cardiogenic shock after administration of beta-blockers ( 3 , 4 ). Temporary percutaneous mechanical circulatory support (p-MCS) is useful to stabilize hemodynamics, especially in TS patients who are hemodynamically compromised ( 5 ).…”