Diltiazem-Induced Reversible Cardiogenic Shock in Thyroid Storm

Early recognition of underlying thyroid disease in patients presenting with new-onset tachyarrhythmia is central to management, as usual rate-control strategies can result in significant mortality and morbidity. Hyperthyroidism-induced cardiomyopathy complicated by cardiogenic shock is a life-threatening condition. Thyroid storm can lead to irreversible cardiovascular collapse and death if proper treatment is not initiated as soon as possible. In this case, we report a 44-year-old female who presented to the emergency department (ED) with the chief complaints of anxiety and palpitations. Her past medical history was significant for anxiety, but she was otherwise healthy. An electrocardiogram (ECG) in the ED demonstrated atrial fibrillation (A. fib) with rapid ventricular response (RVR) felt to be secondary to thyroid storm based on the Burch-Wartofsky point scale (BWPS), which is a quantitative diagnostic tool that uses clinical manifestation in diagnosing thyroid storm. The patient was initially managed with a continuous infusion of diltiazem to achieve rate control with a goal heart rate <115 beats per minute (bpm). Shortly after initiating the infusion, the patient developed signs and symptoms consistent with cardiogenic shock. Bedside echocardiogram revealed an estimated ejection fraction (EF) <10% with concomitant pulmonary edema. Repeat echocardiogram within 72 hours after stopping diltiazem and starting appropriate treatment for thyroid storm showed improvement of EF to 35%.