Table 8.

Summary of drug treatment of thyrotoxic cardiac disease and management of associated hemodynamic changes and complications

Clinical condition	Excessive thyroid hormone	Tachycardia	Atrial fibrillation	Hypertension	Left ventricular hypertrophy	HFpEF	HFrEF	HFiEF
Drug treatment	Anti-thyroid drugs eg carbimazole and propylthiouracil	• Beta blockers-propranolol, atenolol and esmolol • CCB-diltiazem	• Beta blockers-propranolol, atenolol and esmolol • CCB • Digoxin • Amiodarone • Anticoagulants	• Beta blockers-propranolol and atenolol • CCB	• Beta blockers • CCB	• Beta blockers-propranolol and atenolol • CCB • Diuretics	• Diuretics • Digoxin • Beta blockers-metoprolol, carvedilol and busoprolol	• Beta blockers • CCB
Comments	Required in all cases of thyrotoxicosis. Pharmacokinetics and pharmacodynamics of drugs are altered in thyrotoxiocosis.	Propranolol 20–40 mg qds, od/iv; Diltiazem 60–120 mg qds, od	Esmolol is short acting. Amiodarone for refractory atrial fibrillation.	Propranolol also inhibits T4 to T3 conversion.	These drugs reverse ventricular re-modelling.	Atenolol is less likely than propranolol to cause bronchoconstriction.	Large doses of digoxin may be required. Optimize reduction of fluid retention before BB.	BB like carvedilol and nebivolol, as well as ACEI/ARB are contraindicated.

Abbreviations: HF_rEF, heart failure with reduced ejection fraction; HF_iEF, heart failure with increased ejection fraction; BB, beta blockers; ACEI, angiotensin receptor inhibitors; ARB, angiotensin receptor blockers; HF_pEF, heart failure with preserved ejection fraction.