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cardio.acute-hf.thyrotoxicosis.v1

Acute HF — thyrotoxicosis-induced (high-output)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.acute-hf.core.v1 — thyrotoxicosis-induced high-output HF specialization. Hyperthyroidism → high-output state + tachycardia (often AFib) + direct myocardial effects. Etiologies: Graves (~70%), toxic nodular goiter, toxic adenoma, thyroiditis (transient), iodine-induced (amiodarone, contrast — Jod-Basedow), exogenous, thyroid storm (Burch-Wartofsky ≥45 = life-threatening). Treatment: BB FIRST (propranolol 40 mg PO q4-6h — also reduces T4→T3); thionamide (methimazole 20-30 mg/d outside pregnancy first-tri; PTU 100 mg q8h in first-tri or storm); Lugol 5 drops q8h ≥1h AFTER thionamide in storm; hydrocortisone 100 mg IV q8h in storm; cholestyramine 4 g QID in storm. Definitive: RAI or thyroidectomy when euthyroid. AVOID aspirin (worsens free T4), iodinated contrast in iodine-induced, aggressive cooling (worsens hemodynamics), haloperidol in storm. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (thyrotoxicosis specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • lab_abnormality
    TSH <0.01 + elevated free T4 or T3 + HF symptoms (dyspnea, edema, orthopnea) → thyrotoxic HF pathway
    suppressed_tsh_with_elevated_free_t4_or_t3_and_hf
  • symptom
    New AFib with rapid ventricular response + features of thyrotoxicosis (heat intolerance, weight loss, tremor, lid lag, exophthalmos) — check TSH urgently
    new_afib_with_features_of_thyrotoxicosis
  • history
    Recent amiodarone exposure or iodinated contrast within 6-8 weeks + new thyrotoxicosis + HF — Jod-Basedow / amiodarone-induced thyrotoxicosis
    amiodarone_or_iodinated_contrast_with_new_thyrotoxicosis_and_hf
  • symptom
    Burch-Wartofsky ≥45 (fever, AMS, GI, severe tachycardia, HF) → thyroid storm — life-threatening decompensation
    thyroid_storm_features

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients have apathetic thyrotoxicosis (subtle presentation) + higher AFib + HF risk; pregnancy alters drug choice (PTU first trimester, methimazole 2nd-3rd)
  • tsh_free_t4_free_t3required
    lab • used at INITIAL_WORKUP
    TSH <0.01 + elevated free T4 and/or T3 confirms thyrotoxicosis; T3 toxicosis if T4 normal but T3 elevated (~5%); subclinical if FT4/T3 normal but TSH suppressed (less HF risk)
  • thyroid_disease_history_and_etiology_cluesrequired
    history • used at CONTEXT
    Prior Graves diagnosis, neck irradiation, recent pregnancy/delivery, amiodarone, contrast exposure, exogenous hormone; etiology guides definitive therapy choice
  • ecg_for_afib_or_other_arrhythmiarequired
    imaging • used at INITIAL_WORKUP
    AFib in 10-25% of thyrotoxicosis (50%+ in elderly); RVR drives high-output HF decompensation; rule out other arrhythmias (atrial flutter, MAT)
  • echo_with_ef_and_chamber_dimensionsrequired
    imaging • used at INITIAL_WORKUP
    High CO state with normal/elevated EF + dilated atria (often biatrial); LV dysfunction with chronic untreated thyrotoxicosis; rule out underlying valvular disease
  • temperature_hr_bp_for_burch_wartofskyrequired
    vital • used at RED_FLAGS
    Burch-Wartofsky Point Scale: temperature, CNS, GI, HR, HF → ≥45 = thyroid storm; 25-44 = impending; <25 = unlikely; drives ICU + storm protocol
  • liver_function_testsrequired
    lab • used at CONTEXT
    Baseline LFTs essential before PTU (hepatotoxicity risk including fulminant hepatic failure) + methimazole (cholestasis); also elevated in thyroid storm itself
  • cbc_with_differentialrequired
    lab • used at CONTEXT
    Baseline before thionamide (agranulocytosis ~0.3%); pregnancy test in reproductive-age women
  • creatininerequired
    lab • used at CONTEXT
    eGFR for drug dosing; cardiorenal physiology if HF + AKI; baseline for I-131 contraindication assessment
  • precipitating_event_screenrequired
    history • used at CONTEXT
    Storm precipitants: surgery, infection, parturition, withdrawal of antithyroid drugs, iodine load (contrast), thyroid manipulation, DKA, MI, trauma — must identify + treat to resolve storm

12-phase flow (10)

  1. 1FRAME
    Thyrotoxicosis-induced high-output HF: TSH suppressed + elevated free T4/T3 + HF symptoms; AFib with RVR common precipitant; consider storm if Burch-Wartofsky ≥45; etiology drives definitive therapy
    inputs: tsh_free_t4_free_t3
    advance: thyrotoxic HF framed
  2. 2ENTRY
    Recognize thyrotoxic HF (suppressed TSH + elevated free T4/T3 + HF symptoms); calculate Burch-Wartofsky for storm; start BB if HR >120 (propranolol preferred — also reduces peripheral T4→T3); start thionamide; ICU if storm
    inputs: temperature_hr_bp_for_burch_wartofsky
    advance: BB + thionamide started
  3. 3CONTEXT
    Etiology screen (Graves vs toxic nodule vs thyroiditis vs iodine-induced vs exogenous), prior thyroid history, pregnancy status, baseline LFTs + CBC, comorbidities (CAD — caution BB if severe LV dysfunction)
    inputs: thyroid_disease_history_and_etiology_clues, liver_function_tests, cbc_with_differential, creatinine, precipitating_event_screen
    advance: context complete
  4. 4RED_FLAGS
    Thyroid storm (Burch-Wartofsky ≥45 — fever, AMS, GI symptoms, severe tachycardia, HF, jaundice); AFib with RVR + HF; severe HF symptoms (Killip III/IV); PTU-induced hepatotoxicity (LFTs >3x baseline); agranulocytosis (ANC <1000); iodine-induced storm
    inputs: temperature_hr_bp_for_burch_wartofsky
    actions: acute_pulm_edema
    advance: red flags screened
  5. 5INITIAL_WORKUP
    TSH + free T4 + free T3 + TSI/TRAb (Graves), CBC + LFTs + BMP + glucose, ECG (AFib screen), bedside echo (high CO + chamber size + EF), thyroid US (deferred if storm), pregnancy test, BNP/NT-proBNP (elevated in HF context, use trend)
    inputs: tsh_free_t4_free_t3, ecg_for_afib_or_other_arrhythmia, echo_with_ef_and_chamber_dimensions
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If suspected Graves → TRAb/TSI + thyroid US (diffuse uptake); if toxic nodular → US + RAIU (focal hot nodules); if thyroiditis → ESR/CRP (subacute), low/absent RAIU, painful neck (subacute) vs painless (postpartum); if amiodarone-induced → distinguish type 1 (excess iodine, treat with thionamide) from type 2 (destructive thyroiditis, treat with steroids); if exogenous → thyroglobulin LOW (vs elevated in endogenous)
    advance: etiology determined or pending stable evaluation
  7. 7TREATMENT
    BB FIRST (propranolol 40 mg PO q4-6h — also reduces T4→T3 conversion; or esmolol IV titrate in storm); thionamide (methimazole 20-30 mg/d outside pregnancy + first trimester; PTU 100 mg q8h in first-tri pregnancy or storm — PTU more rapidly blocks T4→T3); potassium iodide (Lugol 5 drops PO q8h) ≥1h AFTER thionamide in storm; hydrocortisone 100 mg IV q8h in storm; cholestyramine 4 g PO QID in storm to bind enterohepatic T4; standard HF supportive (loop diuretic for congestion, judicious use); rate control AFib (BB primary, digoxin add-on if needed); anticoagulation per CHA2DS2-VASc + thyrotoxicosis itself raises stroke risk; treat precipitant (infection, etc.); definitive therapy (RAI or thyroidectomy) when euthyroid
    inputs: liver_function_tests, cbc_with_differential
    actions: acute_pulm_edema
    advance: BB + thionamide + supportive HF therapy + storm bundle if applicable
  8. 8DISPOSITION
    ICU for storm (Burch-Wartofsky ≥45); telemetry floor for moderate thyrotoxic HF; outpatient endocrine + cardiology if mild + responding
    advance: unit assigned
  9. 9MONITORING
    Continuous telemetry + SpO2; serial BMP + LFT + CBC (q24-48h on thionamide); HR + BP + temperature q1-4h; daily Burch-Wartofsky in storm; weekly free T4 + T3 to track response (TSH lags weeks-months); UOP via foley if HF + diuresing; daily exam for thionamide adverse effects (rash, sore throat, jaundice)
    inputs: liver_function_tests, cbc_with_differential
    actions: panel.cardiac, panel.renal
    advance: monitoring active
  10. 10FOLLOWUP
    Endocrinology weekly/biweekly during titration; cardiology for HF management + AFib; definitive therapy planning (RAI vs thyroidectomy vs continued medical for Graves) at 12-18 mo if remission; LFT monitoring weekly × 4 then monthly on PTU; CBC at any infection/sore throat (agranulocytosis); BB withdrawal as euthyroidism achieved + HR normalizes
    advance: definitive therapy planned + euthyroid sustained