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An Unusual Case Of Recurrent Atrial Fibrillation. Mark Linzer MD Section of GIM Scholars GIM Conference 4-16-08. Financial Disclosure. No support for this talk. Learning Objectives. To learn an uncommon cause of recurrent atrial fibrillation More objectives after the case report.

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An Unusual Case Of Recurrent Atrial Fibrillation

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An unusual case of recurrent atrial fibrillation

An Unusual Case Of Recurrent Atrial Fibrillation

Mark Linzer MD

Section of GIM Scholars

GIM Conference 4-16-08


Financial disclosure

Financial Disclosure

  • No support for this talk


Learning objectives

Learning Objectives

  • To learn an uncommon cause of recurrent atrial fibrillation

  • More objectives after the case report


Case report

Case Report

  • Robust 73 yo man with mild HBP, lipid d/o

  • Develops episodic afib 2003, ETT neg. Echo dilated LA, EF 60%; TSH 2

  • Started on amiodarone and coumadin

  • Chest pain in 2005; LAD stent

  • Did well until 2007; usual HR 50-60


2007 abnormal liver function tests

2007: Abnormal Liver Function Tests

  • 7/07 ALT 160, AST 80; amio discontinued.

  • 10/07 frequent afib, SOB, anxiety.

  • PMH: CAD, BPH, GERD, lipids, OA

  • Meds: ASA, lipitor, doxazosin, lisinopril, metoprolol, PPI, warfarin

  • PE: BP 130/70, pulse 60-80, o/w neg


Next steps don t turn page

Next steps? (Don’t turn page)


Objectives

Objectives:

  • Know two types of amiodarone-induced thyrotoxocosis (AIT)

  • Know how to attempt to distinguish them

  • Know the treatments


Work up

Work Up

  • TSH 0, FT4 high; LFTs near nl; amio zero

  • Paged Endocrine, bumped beta blockers

  • Scan arranged for Txgiving wkend

  • Uptake 1% (very low)

  • Dx: amiodarone induced thyroiditis (likely)

  • Rx: high doses steroids, beta blockers


Amio induced thyrotoxicosis ait

Amio-induced thyrotoxicosis (AIT)

  • Prevalence 3% (2-3 yrs after Rx onset)

  • Type 1: exacerbation of latent Graves

  • Type 2: drug-induced thyroiditis (majority)

  • Some patients have mixed picture

  • Amio half life 100 days

  • Note amio and hyperthyroidism can increase sensitivity to warfarin*

    • Kurnik et al. Medicine. 2004;83:107-113.


Amio and iodine

Amio and iodine

  • Very high iodine content (20x usual)*

  • Can cause hypo or hyperthyroidism

  • Has beta blocking properties and decreases T4 to T3 conversion:

    • can mask hyperthyroidism

    • stopping amio may make sx worse.

    • *UpToDate, Ross DS. Amio and thyroid dysfunction. 2008.


Type 1 vs type 2 ait

Type 1 vs. Type 2 AIT

  • Type 1: Exacerbation latent Graves: usually with MNG; due to excess Iodine. Can (but may not) have high scan uptake

  • Type 2: Destructive thyroiditis, amio toxicity follicular cells, excess release T4. Scan uptake low.

  • Remember: patients must not be pregnant if scanned


Ways to distinguish

Ways to distinguish

  • Thyroid scan: low uptake Type 2 (thyroiditis); can be low Type 1 (amio competes with tracer)

  • Other methods*:

    • Color flow doppler: 80% sensitive Type 1 due to increased vascularity

    • Goiter (type 1)

    • IL-6 elevated in Type 2

    • Amio duration longer (>2 yrs) in Type 2

    • Response to prednisone implies Type 2

  • *Basaria S, Cooper DC. Amiodarone and the thyroid. Am J Med. 2005;118:706-14


An unusual case of recurrent atrial fibrillation

Basaria S, Cooper DC. Amiodarone and the thyroid. Am J Med. 2005;118:706-14.


Treatment

Treatment

  • “AIT… complex Dx and Rx challenge*.”

  • Type 1: antithyroid meds, beta blockers

  • Type 2: prednisone 40 mg x 1-3 months, slow taper

  • Mixed or uncertain: antithyroid meds and steroids

  • Other Rx: surgery, plasmapharesis

    • *Rajeswaran. Swiss Med Wkly 2003;133:579-85


Clinical course for my patient

Clinical course for my patient

  • Prednisone 40 mg daily x 2 wks; tapered

  • Free T4 fell, TSH 0 (can lag).

  • Relapsed, with free T4 rising. Refer Endo.

  • Re-Rx with prednisone, longer taper.

  • After 4 weeks, TSH 1, Free T4 normal. BMD osteopenia

  • Next time: Color flow doppler; IL-6, longer prednisone Rx, early Endo.


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