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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

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
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
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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