Critical Cases - New Onset Afib with High Output Heart Failure!
- 49 yo F pHx asthma presents ED with worsening DOE for the last month acutely worsening today
- No prior hospitalizations or intubations for asthma exacerbation
- Positive for dyspnea, palpitation
- Positive for abdominal distention, which she attributes to constipation
- Moderate intermittent asthma on albuterol PRN
BP 166/103 HR 173 T 98.8 RR 26 Pox 81% on RA (improved to 97% on 2L NC)
- Pt awake and alert, conversant
- HEENT: B/l exophthalmos
- Pulm: Decreased air movement b/l, rales at bases, no wheezing
- Heart: tachycardia, irregularly regular rhythm, no murmurs
- Abd: distended, but no tenderness to palpation
- Extremities: 2+ pitting edema extending from dorsal feet to proximal shins b/l
ECG Interpretation: Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes, Rate 174bpm, QTc 507ms
Pulm: No B lines present. Bilateral moderate sized pleural effusions.
CardiacVisibly reduced ejection fraction Normal RV:LV ratio.
Abbreviated DDx for new onset afib: ”PIRATES”
- Atrial myxoma
- Diltiazem 15mg bolus given with improvement of rate from 260s to 150s
- Furosemide 40mg IV given
- Cardiology consult
- Patient was weaned from 2 NC to RA
- hsTrp <6; proBNP elevated @6,000
- Thyroid profile concerning for new dx of hyperthyoidism leading to new onset afib with high output heart failure
- Thyroid ultrasound demonstrated enlarged heterogeneous hypervascular thyroid gland, consistent with thyroiditis
- thyrotropin receptor antibodies and thyroid stimulating immunoglobulin resulted at 10.03 (normal < = 2.00) and 379 (normal <140), respectively.
Check out this excellent summary of high output heart failure from the University of Michigan here
- B blockers should be the mainstay of rate control in patients with afib and thyrotoxicosis (to achieve HR control & decrease peripheral conversion of T4 to T3)
- PTU or methimazole (PTU preferred as it also decreases peripheral conversion of T4 to T3)
- In suspected thyroid storm, iodine can be administered >1 hour after PTU/methimazole administration (prevents iodine from being used as a substrate for new hormone synthesis). Check out this awesome summary of the management of thyroid storm here