Pause Dependent Torsade de Pointes caused by amiodarone administration complicated by thyroid heart disease

31 years old female admitted

to ER with chief complaint syncope since 4 days ago. She just had undergone P1A0L1 spontaneous parturition 2 months ago, and in breast feeding period. She feels fatigue, palpitation and over-sweating since she delivered her baby. No history of congenital heart disease, hypertension in pregnancy, and this is the first time she got detected an arrhytmia.

Early VS :

Compos mentis, BP 90/50,HR 101x/min,RR 28x/min,Temp 36,0 C.

No detectable murmur, irregular pulses, no rhonchi, no wheezing. No enlargement of spleen and liver, with normal peristaltic sounds. No lower extremity edema.

ECG : VES bigemini running to Ventricular tachyarrhytmia.

Lab : Trombocyte=145.000;Ht=41%;

Random blood sugar=101mg/dl; Calcium=8.4mg/dl;

Na=141meq/l;K=2.8meq/l;Cl=104meq/l.

patient has administered Amiodarone 150

mg pushed;

continue with maintenance Kendaron drip 600mg

(start 2.1cc/hours) and suggested to check plasma

magnesium and thyroid function.

40 mins after admission, patient had undergone monomorphic VT followed by general tonic clonic seizure and GP decided to give cardioversion.

Neurology consultation suggested to prepare diazepam intravenous 10 mg pushed slowly. Neurologist recommendation to control metabolic deterioration and manage the tachyarrhytmia.

After 200 joules shock for 2 times, ECG changed back to VES bigemini multifocal but with worsening pattern of ECG that tend to show running VT.

After 5 hours treatment, patient developed to many forms of tachyarrhytmia :monomorphic VT-polymorphic, VT(Torsade de Pointes)-T wave alternans.

Result for plasm magnesium=1.9meq/l and

thyroid function:TSH=4.5 mcg/ml;

FT4=35 mg/dl;T3=2.8 mmol/l &T4=165 mg/dl.

In this scenario, General Practitioner had misdiagnosed patient without considering thyroid involvement in patient's arrhytmia. So, as a general guidelines for Ventricular tachyarrhytmia, GP gave amiodarone as drug of choice for this patient. Au contraire, Amiodarone worsening the patient's condition.

After Amiodarone's restriction, and 2 gr intravenous magnesium drip, patient start reducing her refractory Torsade de Pointes along the fits and back to the early ECG pattern when she came to the hospital.

Next question is, what are drugs that should she has for her arrhytmia.