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

Abstract

OBJECTIVES: To determine the characteristics of thyroid storm patients with acute decompensated heart failure who should be candidates for temporary percutaneous mechanical circulatory support in addition to beta-blocker treatment to prevent cardiogenic shock. DESIGN: A single-center, retrospective review of treatment details and data collected from electronic medical records. SETTING: Thyrotoxicosis complicated with acute decompensated heart failure. PATIENTS: Eight consecutive patients who were admitted to our hospital for acute decompensated heart failure with thyroid storm between December 2011 and August 2020 were retrospectively reviewed. Of the eight patients, four were treated with percutaneous mechanical circulatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Compared with thyroid storm patients who did not require percutaneous mechanical circulatory support, those who did had a significantly higher initial plasma brain natriuretic peptide level (1,231 [911–3,387] vs 447 pg/mL [243–653 pg/mL], respectively; p = 0.015), as well as a significantly larger left ventricular end-diastolic diameter (56 [54–63] vs 48 mm [38–48 mm], respectively; p = 0.029) and end-systolic diameter (50 [49–58] vs 28 mm [28–30 mm], respectively; p = 0.029) on echocardiogram. In terms of thyroid storm severity, the Burch-Wartofsky score was higher in patients with percutaneous mechanical circulatory support than in those without, although the difference was not significant. All patients survived this index admission. CONCLUSIONS: In thyroid storm patients, the presence of a high brain natriuretic peptide level, “left ventricular dilatation,” or both may necessitate hemodynamic assessment to determine the indication of percutaneous mechanical circulatory support before beta-blocker administration.

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

“…Precipitating factors: TS can be triggered by various factors; some may spark underlying thyroid dysfunction, and others exacerbate existing thyroid diseases, particularly Graves' disease [16]. These precipitating factors include noncompliance with ATD, surgery (thyroid and non-thyroid), trauma, acute illness with infection, childbirth, hydatidiform mole, acute stress, drugs, and excess iodine intake [2,16,99,107,136,144]. As 99% of thyroid hormones are in a bound form, stressors may decrease the hormone-binding capacity and thus abruptly increase the concentration of the free hormones, leading to TS (2191).…”

“…TS is a thyrotoxic status with at least one CNS manifestation plus one or more other symptoms, such as thermoregulatory dysfunction, cardiovascular findings in terms of tachycardia, atrial fibrillation, congestive heart failure, gastrointestinal and hepatic dysfunction, and precipitant history [15]. 'OR' A combination of at least three features among fever, GI/Hepatic, CHF, or tachycardia [16]. The Burch-Wartofsky point scale (BWS) is a quantitative diagnostic scoring system used to identify the presence of TS if the patient's score is > 45 points [15].…”