Atrial fibrillation is associated with poor clinical trajectory of COVID-19

Abstract Background Atrial fibrillation (AF) has been described as a common cardiovascular manifestation in patients suffering from coronavirus disease 2019 (COVID-19) and is discussed to be a potential risk factor for a poor clinical course. AF is also already known to be associated with increased risk for all cause death. Purpose In the present study we sought to investigate the impact of AF on the clinical trajectory of patients suffering from COVID-19. Methods We included all patients hospitalized due to COVID-19 in 2020 in our Hospital. A poor clinical trajectory was defined as transfer to intensive care unit (ICU), intermediate care unit (IMC) or death from any cause. Initial ECGs were analyzed in consensus by two experienced readers. First, we compared patients with poor clinical trajectory vs. good clinical course. Secondly, the study population was categorized into two groups with or without AF on admission. A subgroup analysis was performed to differentiate between new onset AF and patients with known history of AF. To compensate for confounders (age, BMI, known cardiomyopathy (CMP), known coronary artery disease (CAD), chronic airway disease, renal insufficiency, diabetes, arterial hypertension and sex), a full clinically validated multiple logistic regression model with poor clinical trajectory as dependent target variable was performed. Results From our enrolled 666 patients in 2020 (58% male, average age: 66 (IQR:58–80)) 223 patients (33.5%) experienced a poor clinical course. 179 (27%) patients were transferred to IMC/ICU and 86 (13%) patients died. All in all, patients with poor clinical trajectory were more frequently male (70% vs. 52%; P<0.001), older (71±14 vs. 64±20; P<0.001) and had significantly more co-morbidities such as CAD, CMP, hypertension and diabetes in comparison to patients with a good clinical course. 96 (14.4%) had AF on admission. Among these 37.5% had new-onset AF, which showed similar baseline characteristics as patients without AF. Indeed, patients with COVID-19 and new onset AF were more likely to die (25% vs 12%; P=0.038), or be in need for ICU/IMC (25% vs. 62%; P<0.001) and therefore experienced a poor clinical trajectory more frequently (75% vs. 31%; P<0.001) with a confounder adjusted OR of 5.89. In the subgroup analysis of all patients with AF on admission. Patients with new onset of AF had significantly more underlying CMP, Diabetes and chronic airways disease. While mortality was not higher in patients with new onset of AF, IMC/ICU transfers (62% vs 24%; P<0.001) and as a result poor clinical trajectory (75% vs 40%; P=0.001) was significantly increased in comparison to patients with known AF. Conclusion In patients suffering from COVID-19, new onset of AF on admission was associated with a poor clinical course and higher in-hospital mortality. FUNDunding Acknowledgement Type of funding sources: None.

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Impact of smoking cessation after the new diagnosis of atrial fibrillation on the risk of stroke: a nationwide cohort study

European Heart Journal ◽

10.1093/ehjci/ehaa946.0396 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S.R Lee ◽

E.K Choi ◽

J.H Jung ◽

K.D Han ◽

S Oh ◽

...

Keyword(s):

Atrial Fibrillation ◽

Smoking Cessation ◽

Hazard Ratio ◽

Total Study Population ◽

Increased Risk ◽

Before And After ◽

The Impact ◽

Never Smoker ◽

New Onset

Abstract Background There are limited data about the impact of modifying behavior such as smoking cessation after atrial fibrillation (AF) diagnosis on the clinical outcome. Purpose To evaluate the association between smoking cessation after newly diagnosed AF and the risk of stroke. Methods Among subjects with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (i) never smoker; (ii) new smoker after AF diagnosis; (iii) quit-smoker after AF diagnosis; and (iv) persistent smoker. The primary outcome was incident stroke during follow-up. Results A total of 97,869 patients were included (mean age 61±12, men 62%, and mean CHA2DS2-VASc 2.3±1.5). During a median of 3 years of follow-up, stroke occurred in 3,121 patients (1.0 per 100 person-years). Never smoker, new smoker, quit-smoker, and persistent smoker was 79%, 2%, 7%, and 12% of the total study population, respectively. After multivariable adjustment, new smoker and persistent smoker were associated with an increased risk of stroke compared to never smoker (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.48–2.28 for new smoker; HR 1.66, 95% CI 1.48–1.86 for persistent smoker) (Figure). Quit-smoker who stopped smoking after AF diagnosis also showed a higher risk of stroke than never smoker (HR 1.19, 95% CI 1.03–1.38). The quit-smoker group showed a lower compared to those who continued smoking after AF diagnosis (HR 0.720, 95% CI 0.608–0.851). Conclusion Smoking cessation after AF diagnosis showed a lower risk of stroke compared to patients smoking persistently. Lifestyle change as smoking cessation after diagnosis of AF could modify the risk of stroke in patients with new-onset AF. Hazard ratio of smoking status for AF Funding Acknowledgement Type of funding source: None

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Acute Dental Periapical Abscess and New-Onset Atrial Fibrillation: A Nationwide, Population-Based Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10132927 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2927

Author(s):

Amaar Obaid Hassan ◽

Gregory Y. H. Lip ◽

Arnaud Bisson ◽

Julien Herbert ◽

Alexandre Bodin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Multivariable Analysis ◽

National Database ◽

Increased Risk ◽

Periapical Abscess ◽

The Relationship ◽

Onset Atrial Fibrillation ◽

New Onset

There are limited data on the relationship of acute dental infections with hospitalisation and new-onset atrial fibrillation (AF). This study aimed to assess the relationship between acute periapical abscess and incident AF. This was a retrospective cohort study from a French national database of patients hospitalized in 2013 (3.4 million patients) with at least five years of follow up. In total, 3,056,291 adults (55.1% female) required hospital admission in French hospitals in 2013 while not having a history of AF. Of 4693 patients classified as having dental periapical abscess, 435 (9.27%) developed AF, compared to 326,241 (10.69%) without dental periapical abscess that developed AF over a mean follow-up of 4.8 ± 1.7 years. Multivariable analysis indicated that dental periapical abscess acted as an independent predictor for new onset AF (p < 0.01). The CHA2DS2VASc score in patients with acute dental periapical abscess had moderate predictive value for development of AF, with Area Under the Curve (AUC) 0.73 (95% CI, 0.71–0.76). An increased risk of new onset AF was identified for individuals hospitalized with dental periapical abscess. Careful follow up of patients with severe, acute dental periapical infections is needed for incident AF, as well as investigations of possible mechanisms linking these conditions.

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Nonalcoholic fatty liver disease and the risk of atrial fibrillation stratified by body mass index: a nationwide population-based study

Scientific Reports ◽

10.1038/s41598-021-83367-x ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

So-Ryoung Lee ◽

Kyung-Do Han ◽

Eue-Keun Choi ◽

Seil Oh ◽

Gregory Y. H. Lip

Keyword(s):

Atrial Fibrillation ◽

Body Mass Index ◽

Liver Disease ◽

Fatty Liver ◽

Nonalcoholic Fatty Liver Disease ◽

Body Mass ◽

Fatty Liver Disease ◽

Nonalcoholic Fatty Liver ◽

Increased Risk ◽

The Impact

AbstractWe evaluated the association between nonalcoholic fatty liver disease (NAFLD) and incident atrial fibrillation (AF) and analyzed the impact of NAFLD on AF risk in relation to body mass index (BMI). A total of 8,048,055 subjects without significant liver disease who were available fatty liver index (FLI) values were included. Subjects were categorized into 3 groups based on FLI: < 30, 30 to < 60, and ≥ 60. During a median 8-year of follow-up, 534,442 subjects were newly diagnosed as AF (8.27 per 1000 person-years). Higher FLI was associated with an increased risk of AF (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.046–1.060 in 30 ≤ FLI < 60, and HR 1.115, 95% CI 1.106–1.125 in FLI ≥ 60). In underweight subjects (BMI < 18.5 kg/m2), higher FLI raised the risk of AF (by 1.6-fold in 30 ≤ FLI < 60 and by twofold in FLI ≥ 60). In normal- and overweight subjects, higher FLI was associated with an increased risk of AF, but the HRs were attenuated. In obese subjects, higher FLI was not associated with higher risk of AF. NAFLD as assessed by FLI was independently associated with an increased risk of AF in nonobese subjects with BMI < 25 kg/m2. The impact of NAFLD on AF risk was accentuated in lean subjects with underweight.

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Impact of established cardiovascular disease on 10-year death after coronary revascularization for complex coronary artery disease

Clinical Research in Cardiology ◽

10.1007/s00392-021-01922-y ◽

2021 ◽

Author(s):

Rutao Wang ◽

Scot Garg ◽

Chao Gao ◽

Hideyuki Kawashima ◽

Masafumi Ono ◽

...

Keyword(s):

Cardiovascular Disease ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Coronary Revascularization ◽

Long Term Outcomes ◽

Vital Status ◽

Increased Risk ◽

Artery Disease ◽

The Impact

Abstract Aims To investigate the impact of established cardiovascular disease (CVD) on 10-year all-cause death following coronary revascularization in patients with complex coronary artery disease (CAD). Methods The SYNTAXES study assessed vital status out to 10 years of patients with complex CAD enrolled in the SYNTAX trial. The relative efficacy of PCI versus CABG in terms of 10-year all-cause death was assessed according to co-existing CVD. Results Established CVD status was recorded in 1771 (98.3%) patients, of whom 827 (46.7%) had established CVD. Compared to those without CVD, patients with CVD had a significantly higher risk of 10-year all-cause death (31.4% vs. 21.7%; adjusted HR: 1.40; 95% CI 1.08–1.80, p = 0.010). In patients with CVD, PCI had a non-significant numerically higher risk of 10-year all-cause death compared with CABG (35.9% vs. 27.2%; adjusted HR: 1.14; 95% CI 0.83–1.58, p = 0.412). The relative treatment effects of PCI versus CABG on 10-year all-cause death in patients with complex CAD were similar irrespective of the presence of CVD (p-interaction = 0.986). Only those patients with CVD in ≥ 2 territories had a higher risk of 10-year all-cause death (adjusted HR: 2.99, 95% CI 2.11–4.23, p < 0.001) compared to those without CVD. Conclusions The presence of CVD involving more than one territory was associated with a significantly increased risk of 10-year all-cause death, which was non-significantly higher in complex CAD patients treated with PCI compared with CABG. Acceptable long-term outcomes were observed, suggesting that patients with established CVD should not be precluded from undergoing invasive angiography or revascularization. Trial registration SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050. Graphic abstract

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New onset of atrial fibrillation in cardiogenic shock

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.009 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

H Santos ◽

T Vieira ◽

J Fernandes ◽

AR Ferreira ◽

M Rios ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiogenic Shock ◽

Linear Regression Analysis ◽

Clinical Signs ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Coronary Syndrome ◽

The Impact ◽

New Onset

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The development of cardiogenic shock (CS) is associated with worse prognosis, and can produce several hemodynamic manifestations. Then, is not surprised the manifestation of new-onset atrial fibrillation (AF) in these patients. Purpose Evaluate the impact of cardiovascular previous history, clinical signs and diagnosis procedures at admission as predictors of new-onset of AF in CS. Methods Single-centre retrospective study, engaging patients hospitalized for CS between 1/01/2014-30/10/2018. 222 patients with CS are included, 40 of them presented new onset of AF. Chi-square test, T-student test and Mann-Whitney U test were used to compare categorical and continuous variables. Multiple linear regression analysis was performed to evaluate predictors of new-onset AF in CS patients. Results CS patients without AF had a mean age of 61.08 ± 13.77 years old, on the other hand new-onset of AF patients in the setting of CS had a mean age of 67.02 ± 14.21 years old (p = 0.016). Nevertheless, no differences between the two groups was detected regarding the sex cardiovascular history (namely arterial hypertension, diabetes, dyslipidemia, obesity, smoker status, alcohol intake, previous acute coronary syndrome, history of angina, previous cardiomyopathy), neoplasia history, cardiac arrest during the CS, clinical signs at admission (like heart rate, blood pressure, respiratory rate), blood results (hemoglobin, leukocytes, troponin, creatinine, C-Reactive protein), left ventricular ejection fraction and the culprit lesion. New-onset of AF in CS patient had not impact in mortality rates. Multiple logistic regression reveals that only age was a predictor of new onset of AF in CS patients (odds ratio 1.032, confident interval 1.004-1.060, p = 0.024). Conclusions Age was the best predictor of new-onset AF in CS patients. The presence of this arrhythmia can have a hemodynamic impact, however, seems not influenced the final outcome.

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Prevalence, Epidemiological Characteristics, and Pharmacotherapy of Coronary Artery Disease among Patients with Atrial Fibrillation: Data from Jo-Fib Study

Medicina ◽

10.3390/medicina57060605 ◽

2021 ◽

Vol 57 (6) ◽

pp. 605

Author(s):

Hanna K. Al-Makhamreh ◽

Mohammed Q. Al-Sabbagh ◽

Ala’ E. Shaban ◽

Abdelrahman F. Obiedat ◽

Ayman J. Hammoudeh

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Antiplatelet Agents ◽

Retrospective Case ◽

Increased Risk ◽

Artery Disease ◽

Epidemiological Characteristics ◽

Cad Risk

Background and Objectives: Patients with AF are at increased risk for Coronary Artery Disease (CAD) owing to their shared etiologies and risk factors. This study aimed to assess the prevalence, cardiovascular risk factors, and used medications of CAD in AF patients. Materials and Methods: This retrospective, case-control study utilized data from the Jordanian Atrial Fibrillation (Jo-Fib) registry. Investigators collected clinical features, history of co-existing comorbidities, CHA2DS2-VASc, and HAS BLED scores for all AF patients aged >18 visiting 19 hospitals and 30 outpatient cardiology clinics. A multivariable binary logistic regression was used to asses for factors associated with higher odds of having CAD. Results: Out of 2000 patients with AF, 227 (11.35%) had CAD. Compared to the rest of the sample, those with CAD had significantly higher prevalence of hypertension (82.38%; p < 0.01), hypercholesterolemia (66.52%, p < 0.01), diabetes (56.83%, p < 0.01), and smoking (18.06%, p = 0.04). Patients with AF and CAD had higher use of anticoagulants/antiplatelet agents combination (p < 0.01) compared to the rest of the sample. Females had lower CAD risk than males (OR = 0.35, 95% CI: 0.24–0.50). AF Patients with dyslipidemia (OR = 2.5, 95% CI: 1.8–3.4), smoking (OR = 1.7, 95% CI: 1.1–2.6), higher CHA2DS2-VASc score (OR = 1.5, 95% CI: 1.4–1.7), and asymptomatic AF (OR = 1.9, 95% CI: 1.3–2.6) had higher risk for CAD. Conclusions: Owing to the increased prevalence of CAD in patients with AF, better control of cardiac risk factors is recommended for this special group. Future studies should investigate such interesting relationships to stratify CAD risk in AF patients. We believe that this study adds valuable information regarding the prevalence, epidemiological characteristics, and pharmacotherapy of CAD in patients with AF.

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Abstract P208: Functional Status, Rehospitalization, and Mortality Outcomes Among Acute Myocardial Infarction Patients with Prior and New-Onset Atrial Fibrillation

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_2.ap208 ◽

2011 ◽

Vol 4 (suppl_2) ◽

Author(s):

Kyle P Hornsby ◽

Kensey Gosch ◽

Amy L Miller ◽

Jonathan P Piccini ◽

Renato D Lopes ◽

...

Keyword(s):

Myocardial Infarction ◽

Atrial Fibrillation ◽

Acute Myocardial Infarction ◽

Health Status ◽

Functional Status ◽

Physical Function ◽

Adverse Outcomes ◽

Increased Risk ◽

New Onset

Background: Little data are available regarding differences in prognosis and health status between new-onset and prior atrial fibrillation (AF) among patients with acute myocardial infarction (AMI). Methods: The TRIUMPH study enrolled 4340 AMI patients who received longitudinal follow-up including SF-12 health status assessments through 1 year post-AMI. We compared 1-year mortality, rehospitalization, and functional status according to AF type (none, prior, new) after adjusting for differences in baseline characteristics. Results: A total of 212 AMI patients (4.9%) had prior AF and 254 (5.9%) had new-onset AF. Compared with no AF, new AF was associated with older age, male sex, first MI, worse baseline physical function, home atrioventricular nodal blocker use, and worse ventricular function (c-index 0.77). Rates of 1-year mortality were 6.2%, 14.5%, and 13.0%, and 1-year rehospitalization rates were 29.1%, 44.2%, and 36.8% for no, prior, and new AF, respectively. After multivariable adjustment, neither prior nor new AF was associated with increased 1-year mortality, and only prior AF was associated with increased risk of 1-year rehospitalization (Figure). After adjusting for baseline SF-12 physical function scores, patients with prior AF had lower 1-year scores than those with no AF (40.6 vs. 43.7, p <0.003), whereas patients with new AF had similar scores (42.9 vs. 43.7, p=0.36). Conclusion: New-onset AF during AMI is associated with a number of comorbidities but, unlike prior AF, is not associated with adverse outcomes. These results raise the question of whether AF is itself a cause of or simply a marker of comorbidities leading to downstream adverse outcomes after AMI.

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Should the Presence or Extent of Coronary Artery Disease be Quantified in the CHA2DS2-VASc Score in Atrial Fibrillation? A Report from the Western Denmark Heart Registry

Thrombosis and Haemostasis ◽

10.1055/s-0038-1675401 ◽

2018 ◽

Vol 118 (12) ◽

pp. 2162-2170 ◽

Cited By ~ 11

Author(s):

Kamilla Steensig ◽

Kevin Olesen ◽

Troels Thim ◽

Jens Nielsen ◽

Svend Jensen ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Artery Disease ◽

Risk Factor ◽

Coronary Artery ◽

Coronary Angiography ◽

Ischaemic Stroke ◽

Independent Risk Factor ◽

Oral Anticoagulants ◽

Increased Risk ◽

Artery Disease

Background Patients with atrial fibrillation (AF) have an increased risk of ischaemic stroke. The risk can be predicted by the CHA2DS2-VASc score, in which the vascular component refers to previous myocardial infarction, peripheral artery disease and aortic plaque, whereas coronary artery disease (CAD) is not included. Objectives This article explores whether CAD per se or extent provides independent prognostic information of future stroke among patients with AF. Materials and Methods Consecutive patients with AF and coronary angiography performed between 2004 and 2012 were included. The endpoint was a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. The risk of ischaemic events was estimated according to the presence and extent of CAD. Incidence rate ratios (IRR) were calculated in reference to patients without CAD and adjusted for parameters included in the CHA2DS2-VASc score and treatment with anti-platelet agents and/or oral anticoagulants. Results Of 96,430 patients undergoing coronary angiography, 12,690 had AF. Among patients with AF, 7,533 (59.4%) had CAD. Mean follow-up was 3 years. While presence of CAD was an independent risk factor for the composite endpoint (adjusted IRR, 1.25; 1.06–1.47), extent of CAD defined as 1-, 2-, 3- or diffuse vessel disease did not add additional independent risk information. Conclusion Presence, but not extent, of CAD was an independent risk factor of the composite thromboembolic endpoint beyond the components already included in the CHA2DS2-VASc score. Consequently, we suggest that significant angiographically proven CAD should be included in the vascular disease criterion in the CHA2DS2-VASc score.

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Women with atrial fibrillation in the Middle East: utilization of oral anticoagulant agents in a population with bad baseline clinical profiles and risk scores

European Heart Journal ◽

10.1093/eurheartj/ehab724.2773 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

A Hammoudeh ◽

R Ibdah ◽

S Rawashdeh ◽

A Ababneh ◽

A Al-Kasasbeh ◽

...

Keyword(s):

Atrial Fibrillation ◽

Middle East ◽

Risk Score ◽

Oral Anticoagulant ◽

Middle Eastern ◽

Risk Scores ◽

Funding Sources ◽

Middle Eastern Women ◽

Anticoagulant Agents ◽

Artery Disease

Abstract Background Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide and in the Middle East. Several studies have shown that women with AF are undertreated despite worse baseline clinical and risk profiles compared with men. It is largely unknown if this also applies to Middle Eastern AF patients. Purpose To evaluate baseline clinical features and utilization of guideline-recommended oral anticoagulant medications (OACs) in Middle Eastern women with AF. Methods The Jordan AF prospective multicenter study enrolled 2160 patients with AF, including 1164 (53.9%) women, in 20 hospital and outpatient clinics (May 2019 through January 2021). Results Nonvalvular AF was present in 1038 (91.0%) of women and 935 (94.6%) of men. Compared with men, women were older (mean age 69.2±11.5 years vs. 66.1±14.9 years, p<0.001), and had higher prevalence of hypertension (79.1% vs. 69.5%, p<0.001), diabetes (46.1% vs. 41.7%, p=0.04) and obesity (60.5% vs. 34.6%, p<0.001). Women, however, had lower prevalence of two comorbidities; heart failure (21.5% vs. 28.6, p=0.001) and coronary artery disease (7.7% vs. 15.4%, p<0.001) compared with men. Rate of utilization of oral anticoagulant agents (OACs) was higher in women than men with high and intermediate CHA2DS2 VASc scores (Table). Direct OACs were used in 64.0% of women and 63.3% of men with high risk score (p=NS). Multivariate analysis did not show sex to be an independent predictor of use of OACs. Conclusions Middle Eastern women with AF have worse baseline clinical and risk score profiles compared with men. In disagreement with other regional studies, the majority of these women received guideline-recommended OACs. FUNDunding Acknowledgement Type of funding sources: None.

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Call for Emergency Room Guidelines to Identify Hyperthyroid Patients Prior to Contrast Imaging

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1885 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A922-A923

Author(s):

Sandhya Bassin ◽

Louis F Amorosa

Keyword(s):

Atrial Fibrillation ◽

Emergency Room ◽

Definitive Treatment ◽

Graves Disease ◽

Contrast Imaging ◽

Iodinated Contrast ◽

Increased Risk ◽

History Of ◽

The Impact ◽

Hyperthyroid Patients

Abstract Background: Thyrotoxicosis can be mistaken for conditions such as atrial fibrillation and pulmonary embolism (PE) given the nonspecific symptoms of fatigue, palpitations, and dyspnea. Patients often undergo further imaging on presentation to the emergency room (ER), many of which use iodine for contrast. This can put patients at increased risk for iodine induced hyperthyroidism and delay definitive treatment in patients with Graves’ disease, the most common cause of hyperthyroidism. Clinical Case: A 53-year-old male with history of hyperthyroidism, atrial fibrillation, and prior PE presented with palpitations to the ER. He developed worsening dyspnea on exertion and palpitations over the last three days. He was unable to afford his medications, including methimazole, for the last nine months. In the ER he was in atrial fibrillation with rapid ventricular response. Due to concern for PE, he underwent a CTA with contrast, which was negative. His physical exam was notable for a diffusely enlarged goiter. His labs showed low TSH <0.01 (norm 0.35-5.50mIU/L) and high free T4 >7.77 (norm 0.9-1.8ng/dL). TSH stimulating antibodies were elevated at 1.9 (norm <1.3 TSI index), consistent with Graves’ hyperthyroidism. Endocrinology was then consulted for severe thyrotoxicosis, initially treating the patient with PTU and propranolol. The patient was transitioned to methimazole and continued propranolol on discharge. Since he was given contrast, plan was for repeat thyroid uptake scan and iodine ablation in 3 months. However, patient was not compliant with medications, resulting in readmission for thyrotoxicosis 3 months later. Conclusion: This case highlights the impact of increased use of contrast in imaging in hyperthyroid patients. Hyperthyroid patients are at an increased risk for emboli. However, iodine can cause contrast-induced hyperthyroidism and delay definitive treatment of Graves’ disease. As almost half of thyrotoxic patients receive iodinated contrast prior to an endocrine consultation, endocrinologists should work with emergency physicians to develop a set of guidelines to identify at risk populations for hyperthyroidism (1). We advocate for urgent thyroid testing in patients with new onset atrial fibrillation, a history of Graves’ disease, specific symptoms of Graves’, or those taking thyrotoxic-inducing medications. This will assist in determining if patients should receive a prophylactic dose of anti-thyroid medication prior to iodinated contrast imaging. These guidelines can help prevent contrast induced hyperthyroidism and disruptions in treatment of Graves’ while still imaging patients for other diagnoses on the differential. Reference: (1) Giacomini A, et al. Urgent thyroid-stimulating hormone testing in emergency medicine: A useful tool? J Emerg Med. 2015;49(4):481-487.

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