Risk factors for QTc-prolongation: systematic review of the evidence

Dietary inflammatory index (DII) and sleep quality, duration, and timing: A systematic review

Sleep has strong inflammatory underpinnings and diet is one of the primary determinants of systemic inflammation. A systematic literature review was conducted to synthesize current research associating dietary inflammatory potential, as measured by the dietary inflammatory index (DII®) or the energy-adjusted DII (E-DII™) and sleep quality and duration. The National Library of Medicine (Medline), Web of Science, and PsycInfo databases were searched through March 2023. Studies must have used the DII/E-DII as the independent variable and sleep outcomes as dependent variables. Study characteristics, based on STROBE guidelines, were scored based on the presence of the recommendation. Out of the initial 14 studies identified, a total of 12 studies were included for data synthesis. In all 12 studies, more anti-inflammatory diets (i.e., low DII/E-DII scores) were associated with better sleep in at least one sleep domain (most often sleep efficiency and wake-after-sleep-onset). Among those studies with more rigorous diet and sleep measurements, such as dietary recalls and actigraphy, associations between DII/E-DII and sleep outcomes were stronger and more consistent compared to studies using primarily subjective assessments. More rigorous measurement of diet and sleep, especially those relating to sleep stage structure, should be considered in future studies with prospective designs.

An Updated Safety Review of the Relationship Between Atypical Antipsychotic Drugs, the QTc Interval and Torsades de Pointe As: Implications for Clinical Use

INTRODUCTION

The rising prevalence of psychiatric disorders has resulted in a significant increase in the use of antipsychotic medications. These agents may prolong the corrected QT interval (QTc), running the risk of precipitating ventricular arrhythmias, notably Torsades de Pointes (TdP). Current recommendations vary regarding the optimal approach to safe prescribing practices and QTc surveillance for antipsychotics. This review summarizes the current literature addressing these clinical concerns.

AREAS COVERED

The physiologic basis of the QTc interval, mechanisms underlying its susceptibility to pharmacological influence, specific risks associated with atypical antipsychotic agents, and recommendations for safe prescription practices. We performed a literature review using Pubmed and Embase databases, searching for 'antipsychotics' and 'torsades de pointes.'

EXPERT OPINION

Finding a safe and universally accepted protocol for prescribing antipsychotics remains a persistent challenge in medicine. Predictive models that integrate clinical history with demographic and ECG characteristics can help estimate an individual's susceptibility to therapy-associated risks, including QTc prolongation. Agents such as ziprasidone and iloperidone are significantly more likely to prolong the QTc interval compared to others such as brexpiprazole, cariprazine, olanzapine, and clozapine. A personalized approach using low-risk medications when clinically feasible, and at the lowest efficacious dose, offers a promising path toward safer antipsychotic prescribing.

Impact of preoperative QTc interval prolongation on short-term postoperative outcomes: A retrospective study

STUDY OBJECTIVE

Although a prolonged heart rate-corrected QT interval (QTcI) is associated with an increased risk of mortality in the general population, its prognostic value in surgical patients remains unclear. We aimed to examine whether preoperative QTcI prolongation predicts short-term postoperative outcomes in elderly patients undergoing noncardiac surgery.

DESIGN

The study was a retrospective analysis using the TriNetX network database.

SETTING

Operating room.

INTERVENTION

Assessment and categorization of preoperative QTcI.

PATIENTS

Data of patients aged ≥65 years who underwent non-cardiac surgery between 2010 and 2023 were analyzed.

MEASUREMENTS

Patients were categorized into four groups based on preoperative QTcI: long (500-600 ms), borderline (460-500 ms), high-normal (420-460 ms) and control (370-420 ms) groups. The groups were compared using a propensity score-matched analysis. The primary outcome was the all-cause 90-day mortality risk. The secondary outcomes included 90-day risks of postoperative new-onset atrial fibrillation (Af), ventricular arrhythmias (VAs), emergency visits, hospital readmissions, and pneumonia.

RESULTS

In total, data on 519,929 patients were collected in this study. Pairwise comparisons showed that all QTcI prolongation groups demonstrated a heightened incidence of postoperative mortality, arrhythmias, and other complications compared to the control group. Patients with a long QTcI had a 3-fold higher risk of mortality (hazard ratio [HR] = 3.124, p < 0.001), Af (HR = 3.059, p < 0.001), and VAs (HR = 3.617, p < 0.001) than controls. The risks of emergency visits (HR = 1.287, p < 0.001), hospital readmissions (HR = 1.591, p < 0.001), and pneumonia (HR = 1.672, p < 0.001) were also higher in the long QTcI group than in the control group. A dose-dependent response was evident between QTcI and mortality as well as arrhythmia risk.

CONCLUSION

Preoperative QTcI screening effectively risk-stratifies elderly surgical patients, with a QTcI≥500 ms being strongly predictive of short-term postoperative mortality and other complications. Incorporating QTcI assessment into the preoperative evaluation may guide perioperative monitoring and management.

A Calculated Risk: Evaluation of QTc Drug-Drug Interaction (DDI) Clinical Decision Support (CDS) Alerts and Performance of the Tisdale Risk Score Calculator

INTRODUCTION

A risk factor for a potentially fatal ventricular arrhythmia Torsade de Pointes is a prolongation in the heart rate-corrected QT interval (QTc) ≥ 500 milliseconds (ms) or an increase of ≥ 60 ms from a patient's baseline value, which can cause sudden cardiac death. The Tisdale risk score calculator uses clinical variables to predict which hospitalized patients are at the highest risk for QTc prolongation.

OBJECTIVE

To determine the rate of overridden QTc drug-drug interaction (DDI)-related clinical decision support (CDS) alerts per patient admission and the prevalence by Tisdale risk score category of these overridden alerts. Secondary outcome was to determine the rate of drug-induced QTc prolongation (diQTP) associated with overrides.

METHODS

Our organization's enterprise data warehouse was used to retrospectively access QTc DDI alerts presented for patients aged ≥ 18 years who were admitted to Brigham and Women's Hospital during 2022. The QTc DDI CDS alerts were included if shown to a physician, fellow, resident, physician assistant, or nurse practitioner when entering the order in inpatient areas for patients with a length of stay of at least 2 days. Variables collected for the Tisdale calculator included age, sex, whether patient was on a loop diuretic, potassium level, admission QTc value, admitting diagnosis of acute myocardial infarction, sepsis, or heart failure, and number of QTc-prolonging drugs given to the patient.

RESULTS

A total of 2649 patients with 3033 patient admissions had 18,432 QTc DDI alerts presented that were overridden. An average of 3 unique QTc DDI alerts were presented per patient admission and the alerts were overridden an average of 6 times per patient admission. Overall, 6% of patient admissions were low risk (score ≤ 6), 64% moderate risk (score 7-10), and 30% high risk (score ≥ 11) of QTc prolongation. The most common QTc DDI alerts overridden resulting in an diQTP were quetiapine and propofol (11%) and amiodarone and haloperidol (7%). The diQTP occurred in 883 of patient admissions (29%) and was more frequent in those with higher risk score, with 46% of patient admissions with diQTP in high risk, 23% in moderate risk, and 8% in low risk.

CONCLUSION

Use of the Tisdale calculator to assess patient-specific risk of QT prolongation combined with CDS may improve overall alert quality and acceptance rate, which may decrease the diQTP rate.

Use of drugs for hypertension or heart failure and the risk of death in COVID-19: association with loop-diuretics

PURPOSE

To study the association between the use of drugs for hypertension or heart failure, particularly diuretics, and risk of death in COVID-19.

METHODS

We conducted a cohort study, based on record linked individual-based data from national registers, of all Swedish inhabitants 50 years and older (n = 3,909,321) at the start of the first SARS-CoV-2 wave in Sweden. The association between use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), thiazides, loop diuretics, aldosterone antagonists, beta blocking agents and calcium channel blockers at the index date 6 March 2020, and death in COVID-19 during 7 March to 31 July 2020, was analysed using Cox-proportional hazards regression, adjusted for a wide range of possible confounders.

RESULTS

Use of loop diuretics was associated with higher risk [adjusted hazard ratio (HR) 1.26; 95% confidence interval (95% CI) 1.17-1.35] and thiazides with reduced risk (0.78; 0.69-0.88) of death in COVID-19. In addition, lower risk was observed for ACEI and higher risk for beta-blocking agents, although both associations were weak. For ARB, aldosterone antagonists and calcium channel blockers no significant associations were found.

CONCLUSION

In this nationwide cohort of nearly 4 million persons 50 years and older, the use of loop diuretics was associated with increased risk of death in COVID-19 during the first SARS-CoV-2 wave in Sweden. This contrasted to the decreased risk observed for thiazides. As treatment with loop diuretics is common, particularly in the elderly, the group most affected by severe COVID-19, this finding merit further investigation.

Association Between Disturbed Serum Phosphorus Levels and QT Interval Prolongation

Introduction

QT interval prolongation is a risk factor for fatal arrhythmias and other cardiovascular complications. QT interval prolongation in patients on hemodialysis (HD) is not well understood. Hypocalcemia is a suspected, but poorly verified etiology in these patients, and the association between serum phosphorus levels and QT interval prolongation is unknown. We sought to determine the prevalence of QT interval prolongation in patients on HD and to verify the association between predialysis serum calcium (Ca) and phosphate (P) levels and QT interval prolongation.

Methods

A cross-sectional study was conducted on adult patients on maintenance HD who were enrolled in the Japanese Society for Dialysis Therapy and Renal Data Registry 2019. After assessing patient characteristics, linear regression analysis was performed with predialysis serum Ca and P levels as exposures and a rate-corrected QT (QTc) interval as the outcome.

Results

A total of 204,530 patients were analyzed with a mean QTc of 451.2 (standard deviation, 36.9) ms. After multivariable analysis, estimated change in QTc (coefficients; 95% confidence interval) per 1 mg/dl increase in serum Ca and P was -2.02 (-3.00 to -1.04) and 5.50 (3.92-7.09), respectively. In the restricted cubic spline curve, estimated change in QTc increased with lower values of serum Ca. The correlation between serum P and QTc showed a U-shaped curve.

Conclusion

Decreased serum Ca levels and decreased and increased serum P levels may be associated with QT interval prolongation in patients on maintenance HD.

Hydroxychloroquine and the associated risk of arrhythmias

Hydroxychloroquine (HCQ), which was initially used as an antimalarial drug, is now being used to treat other illnesses, especially rheumatic autoimmune disorders  such as systemic lupus erythematosus, primary Sjögren's syndrome, and rheumatoid arthritis, because it is safe, effective, and cost efficient. This drug has shown high efficacy and has become the first-line treatment for many of these diseases. Although HCQ has many therapeutic effects, it has unfortunately shown some complications, especially with its long-term use. One of these side effects is arrhythmia through prolongation of the QT interval. This narrative literature review focuses on the effects of HCQ on the QT interval in patients with rheumatologic diseases who have been prescribed this drug. In particular, we will focus on the increased risk of arrhythmia when HCQ is administered with other drugs, such as azithromycin and many others, along with drug-drug interactions. In addition, we investigated the safety of this drug in pregnant women.

Age of onset for increased dose-adjusted serum concentrations of antidepressants and association with sex and genotype: An observational study of 34,777 individuals

PURPOSE

The aim of this study was to examine the age of onset for increased dose-adjusted serum concentrations (C/D ratio) of common antidepressant drugs and to explore the potential association with sex and CYP2C19/CYP2D6 genotype.

METHODS

Serum concentrations and prescribed daily doses for citalopram, escitalopram, sertraline, venlafaxine and mirtazapine, and CYP genotypes, were obtained from a therapeutic drug monitoring (TDM) service. Segmented linear regression analysis was used to examine the relationship between age and antidepressant log C/D ratio in (i) all individuals, (ii) men and women, and (iii) CYP2D6/CYP2C19 normal metabolizers (NMs) and CYP2D6/CYP2C19 intermediate or poor metabolizers (IMs/PMs).

RESULTS

A total of 34,777 individuals were included in the study; CYP genotype was available for 21.3%. An increase in C/D ratio started at 44‒55 years of age. Thereafter, the increase progressed more rapidly for citalopram and escitalopram than for venlafaxine and mirtazapine. A doubled C/D ratio was estimated to occur at 79 (citalopram), 81 (escitalopram), 86 (venlafaxine), and 90 years (mirtazapine). For sertraline, only modest changes in C/D ratio were observed. For escitalopram and venlafaxine, the observed increase in C/D ratio started earlier in women than in men. The results regarding CYP genotype were inconclusive.

CONCLUSION

The age-related increase in C/D ratio starts in middle-aged adults and progresses up to more than twofold higher C/D ratio in the oldest old. Sertraline seems to be less prone to age-related changes in C/D ratio than the other antidepressants.

Phosphate Restriction Prevents Metabolic Acidosis and Curbs Rise in FGF23 and Mortality in Murine Folic Acid-Induced AKI

SIGNIFICANCE STATEMENT

Patients with AKI suffer a staggering mortality rate of approximately 30%. Fibroblast growth factor 23 (FGF23) and phosphate (P i ) rise rapidly after the onset of AKI and have both been independently associated with ensuing morbidity and mortality. This study demonstrates that dietary P i restriction markedly diminished the early rise in plasma FGF23 and prevented the rise in plasma P i , parathyroid hormone, and calcitriol in mice with folic acid-induced AKI (FA-AKI). Furthermore, the study provides evidence for P i -sensitive osseous Fgf23 mRNA expression and reveals that P i restriction mitigated calciprotein particles (CPPs) formation, inflammation, acidosis, cardiac electrical disturbances, and mortality in mice with FA-AKI. These findings suggest that P i restriction may have a prophylactic potential in patients at risk for AKI.

BACKGROUND

In AKI, plasma FGF23 and P i rise rapidly and are independently associated with disease severity and outcome.

METHODS

The effects of normal (NP) and low (LP) dietary P i were investigated in mice with FA-AKI after 3, 24, and 48 hours and 14 days.

RESULTS

After 24 hours of AKI, the LP diet curbed the rise in plasma FGF23 and prevented that of parathyroid hormone and calcitriol as well as of osseous but not splenic or thymic Fgf23 mRNA expression. The absence of Pth prevented the rise in calcitriol and reduced the elevation of FGF23 in FA-AKI with the NP diet. Furthermore, the LP diet attenuated the rise in renal and plasma IL-6 and mitigated the decline in renal α -Klotho. After 48 hours, the LP diet further dampened renal IL-6 expression and resulted in lower urinary neutrophil gelatinase-associated lipocalin. In addition, the LP diet prevented the increased formation of CPPs. Fourteen days after AKI induction, the LP diet group maintained less elevated plasma FGF23 levels and had greater survival than the NP diet group. This was associated with prevention of metabolic acidosis, hypocalcemia, hyperkalemia, and cardiac electrical disturbances.

CONCLUSIONS

This study reveals P i -sensitive FGF23 expression in the bone but not in the thymus or spleen in FA-AKI and demonstrates that P i restriction mitigates CPP formation, inflammation, acidosis, and mortality in this model. These results suggest that dietary P i restriction could have prophylactic potential in patients at risk for AKI.

Escitalopram-induced QTc prolongation and its relationship with KCNQ1, KCNE1, and KCNH2 gene polymorphisms

BACKGROUND

Escitalopram can cause prolongation of the QT interval on the electrocardiogram (ECG). However, only some patients get pathological QTc prolongation in clinic. We investigated the influence of KCNQ1, KCNE1, and KCNH2 gene polymorphisms along with clinical factors on escitalopram-induced QTc prolongation.

METHODS

A total of 713 patients prescribed escitalopram were identified and had at least one ECG recording in this retrospective study. 472 patients with two or more ECG data were divided into QTc prolongation (n = 119) and non-prolongation (n = 353) groups depending on the threshold change in QTc of 30 ms above baseline value (∆QTc ≥ 30 ms). 45 patients in the QTc prolongation group and 90 patients in the QTc non-prolongation group were genotyped for 43 single nucleotide polymorphisms (SNPs) of KCNQ1, KCNE1, and KCNH2 genes.

RESULTS

Patients with QTc prolongation (∆QTc ≥ 30 ms) got higher escitalopram dose (10.3 mg) than patients without QTc prolongation (9.4 mg), although no significant relationship was found between QTc interval and escitalopram dose in the linear mixed model. Patients who were older/coronary disease/hypertension or carried with KCNE1 rs1805127 C allele, KCNE1 rs4817668 C allele, KCNH2 rs3807372 AG/GG genotype were significantly at risk for QTc prolongation (∆QTc ≥ 30 ms). Concomitant antipsychotic treatment was associated with a longer QTc interval.

LIMITATIONS

A relatively small sample size and lack of the blood concentration of escitalopram restricted the accurate relationship between escitalopram dose and QTc interval.

CONCLUSION

Our study revealed that KCNQ1, KCNE1, and KCNH2 gene polymorphisms along with clinical factors provide a complementary effect in escitalopram-induced QTc prolongation.

Developing a Model for Quantifying QTc-Prolongation Risk to Enhance Medication Safety Assessment: A Retrospective Analysis

There are currently no established methods to predict quantitatively whether the start of a drug with the potential to prolong the QTc interval poses patients at risk for relevant QTc prolongation. Therefore, this retrospective study aimed to pave the way for the development of models for estimating QTc prolongation in patients newly exposed to medications with QTc-prolonging potential. Data of patients with a documented QTc prolongation after initiation of a QTc-prolonging drug were extracted from hospital charts. Using a standard model-building approach, general linear mixed models were identified as the best models for predicting both the extent of QTc prolongation and its absolute value after the start of a QTc-time-prolonging drug. The cohort consisted of 107 adults with a mean age of 64.2 years. Patients were taking an average of 2.4 drugs associated with QTc prolongation, with amiodarone, propofol, pipamperone, ondansetron, and mirtazapine being the most frequently involved. There was a significant but weak correlation between measured and predicted absolute QTc values under medication (r2 = 0.262, p < 0.05), as well as for QTc prolongation (r2 = 0.238, p < 0.05). As the developed models are based on a relatively small number of subjects, further research is necessary to ensure their applicability and reliability in real-world scenarios. Overall, this research contributes to the understanding of QTc prolongation and its association with medications, providing insight into the development of predictive models. With improvements, these models could potentially aid healthcare professionals in assessing the risk of QTc prolongation before adding a new drug and in making informed decisions in clinical settings.

The Impact of Chronic Disease on the Corrected QT (QTc) Value in Women in a British Columbia First Nations Population

BACKGROUND

Indigenous women have higher rates of chronic disease than Indigenous men and non-Indigenous women. Long QT syndrome (LQTS) can be inherited or acquired; the latter may occur with chronic disease. A prolonged corrected QT value (QTc) is an independent risk factor for ventricular arrhythmias and sudden death, but few studies have quantified the impact of chronic disease on the QTc. We assessed the association between chronic disease and QTc prolongation in a population of First Nations women previously ascertained to study a high rate of inherited LQTS due to a unique genetic (founder) variant in their community.

METHODS

This substudy focusing on women expands on the original research where patients with clinical features of LQTS and their relatives were assessed for genetic variants discovered to affect the QTc. Medical records were retrospectively reviewed and chronic diseases documented. Using multivariate linear regression, adjusting for the effect of genetic variants, age, and QTc-prolonging medications, we evaluated the association between chronic disease and the QTc.

RESULTS

In total, 275 women were included. After adjustments, a prolonged QTc was associated with coronary artery disease (26.5 ms, 95% confidence interval [CI] 9.0-44.1 ms; P = 0.003), conduction system disease (26.8 ms, 95% CI 2.2-51.4 ms; P = 0.033), rheumatoid arthritis (28.9 ms, 95% CI 12.7-45.1 ms; P = 0.001), and type 2 diabetes mellitus (17.9 ms, 95% CI 3.6-32.3 ms; P = 0.015).

CONCLUSIONS

This quantification of the association between chronic disease and QTc prolongation in an Indigenous cohort provides insight into the nongenetic determinants of QTc prolongation. Corroboration in other populations will provide evidence for generalisability of these results.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms

BACKGROUND

Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk.

METHODS

Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias.

RESULTS

Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed.

CONCLUSIONS

Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias.

AIMS

This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Electrocardiographic measurements in children with pre-dialysis chronic kidney disease and undergoing kidney replacement therapy

Cardiovascular diseases are the main causes of morbidity in children with chronic kidney disease (CKD). Electrocardiography (ECG) can provide important information about cardiac functions and parameters associated with sudden cardiac death. This study aims to evaluate the potentially dangerous changes in CKD and kidney replacement therapies by ECG and to determine the value of ECG in predicting cardiovascular outcome compared with echocardiography. 101 patients with CKD were divided into subgroups according to treatment modalities as pre-dialysis CKD, hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation (KTx). Differences in anthropometric measurements, laboratory results, blood pressures, ECG monitoring were compared within groups as well as with 40 healthy controls. Available echocardiographic findings were noted. In the patients, HD group had highest frequency of hypertension. ECG revealed prolonged QTc as more frequent (16.8% vs 0%, p = 0.006) and higher QTcD (56.7 ± 6.5 vs 39.9 ± 5.1 ms, p = 0.001) in the patients compared to controls, especially in dialysis patients, whereas lowest values were in KTx subgroup. Left ventricular (LV) hypertrophy (LVH) was more frequent (47.1%) in HD compared to other CKD subgroups in ECG (p = 0.052). Echocardiography also showed LV mass index as highest in HD and lowest in KTx (121.4 ± 55.7 vs 63.7 ± 18.3 g/m2, p = 0.000), with numerically highest LVH in HD (58.3%, p = 0.063).  Conclusion: ECG can be used to detect cardiovascular problems in patients with CKD, especially in HD. As ECG results were in line with echocardiography, patients with ECG abnormalities suggestive of LVH should be referred for echocardiographic assessment. What is Known: • Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmias and sudden cardiac death are major causes of morbidity and mortality in chronic kidney disease. • Electrocardiography has significant advantages in demonstrating cardiac functions in children because it is readily available, non-invasive and often non-experts can interpret the results. What is New: • The heart rate is higher, QTc is longer and QTcD is higher in dialysis patients and the prolonged QTc is more frequent in patients with underlying glomerular diseases. • Left ventricular hypertrophy is more common in HD patients and those with hypertension, hypercalcemia, anemia or glomerular etiology. The cardiovascular risky conditions are less frequent in the patients with kidney transplantation.

Cardiometabolic sex differences in adults born small for gestational age

Aim

This study aimed to assess the cardiometabolic sex similarities and differences in adults born small for gestational age.

Methods

This study was an ambispective cohort study from a birth registry in Barcelona, Spain, including 523 adult participants (20-40 years-old) subdivided as born small for gestational age (SGA, if birth weight <10th centile) or adequate fetal growth for gestational age (AGA). Cardiometabolic health was assessed by echocardiography, electrocardiogram, blood pressure measurement, vascular ultrasound, anthropometric measurements, and serum glycemia and lipid profile. Stratified analyses by sex were performed by estimation of adjusted absolute difference (AAD) using inverse probability weighting.

Results

Compared with AGA, the stratified analyses by sex showed a more pronounced reduction in ejection fraction [AAD: female -1.73 (95% CI -3.2 to -0.28) vs. male -1.33 (-3.19 to 0.52)] and increment in heart rate [female 3.04 (0.29-5.8) vs. male 2.25 (-0.82 to 5.31)] in SGA females compared with SGA males. In contrast, a more pronounced reduction in PR interval [female -1.36 (-6.15 to 3.42) vs. male -6.61 (-11.67 to -1.54)] and an increase in systolic blood pressure [female 0.06 (-2.7 to 2.81) vs. male 2.71 (-0.48 to 5.9)] and central-to-peripheral fat ratio [female 0.05 (-0.03 to 0.12) vs. male 0.40 (0.17-0.62)] were mainly observed in SGA male compared with SGA female.

Conclusions

Sex differences were observed in the effect of SGA on cardiometabolic endpoints with female being more prone to cardiac dysfunction and male to electrocardiographic, vascular, and metabolic changes. Future research including sex-stratification data is warranted.

Electrocardiographic Markers of Arrhythmogenic Risk in Synthetic Cannabinoids Users

Background: Synthetic cannabinoids (SCs) users appeared to have heightened risk for cardiac arrhythmias; however, current line of research is insufficient in terms of demonstrating both conventional and novel electrocardiographic arrhythmia risk indicators in this population. Objective(s): We aimed to investigate P-wave dispersion (Pwd), corrected QT interval (QTc), QTc dispersion (QTcd), Tpeak-Tend (Tp-e), Tp-e/QT ratio, corrected JT interval (JTc), and JTc dispersion (JTcd), which are shown among the risk factors for emergence of an arrhythmia, among SCs users, suggestive of possible adverse effects of SCs on the cardiac rhythm. Methods: Forty-one male SCs user patients who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorder criteria and 41 healthy male controls included in the study. Substance-related characteristics were recorded. Electrocardiography recordings under standardized procedure of all participants were performed and arrhythmia risk markers were calculated from electrocardiograms (ECGs). Results: Age and heart rate per minute did not significantly differ between the groups. SCs user group had significantly higher Pwd, QTc, QTcd, Tp-e, Tp-e/QTc ratio, JTc, and JTcd values compared with controls. Among risk markers, only Pwd was significantly correlated with duration of SCs use. Conclusions: Alterations in ECG-derived markers of arrhythmia, which are acquired through an easy and cheap method, should be evaluated for the prediction and prevention of severe cardiac conditions in patients with SCs use.

Methadone Maintenance and QT-Interval: Prevalence and Risk Factors-Is It Effective to Switch Therapy to Levomethadone?

Methadone is a chiral synthetic opioid primarily used to treat heroin and prescription-opioid addiction: the (R)-enantiomer (Levomethadone) activates the µ-opioid receptor more potently than the (S)-enantiomer, which is a more potent blocker of the hERG potassium channels, resulting in QTc prolongation. The purpose of this retrospective study was to assess the effect of methadone on the QTc interval and to investigate the benefits of Levomethadone. The electrocardiograms of 165 patients taking methadone at various dosages and for different periods of time were examined: the QTc value was manually measured and then adjusted using Bazett's formula. Data analysis revealed a linear association between the dosage of methadone and QTc length; no correlation was found between the QTc value and gender, age, or duration of therapy. In total, 14% of the sample (23 patients) showed a prolongation of the QTc interval (>470 ms in males and >480 ms in females); 10 of the 23 patients with QTc elongation underwent a change of therapy from Methadone to Levomethadone-in 90% of these patients, a normalization in the QTc length was established. This study confirmed the role of methadone, specifically its dosage, in QTc prolongation and the efficiency of Levomethadone as an adequate therapeutic substitute in these circumstances. This study validates the importance of careful electrocardiographic monitoring in methadone-treated patients.

Screening for Rare Coding Variants That Associate With the QTc Interval in Iceland

Background Long-QT syndrome (LQTS) is a cardiac repolarization abnormality that can lead to sudden cardiac death. The most common causes are rare coding variants in the genes KCNQ1, KCNH2, and SCN5A. The data on LQTS epidemiology are limited, and information on expressivity and penetrance of pathogenic variants is sparse. Methods and Results We screened for rare coding variants associated with the corrected QT (QTc) interval in Iceland. We explored the frequency of the identified variants, their penetrance, and their association with severe events. Twelve variants were associated with the QTc interval. Five in KCNQ1, 3 in KCNH2, 2 in cardiomyopathy genes MYBPC3 and PKP2, and 2 in genes where coding variants have not been associated with the QTc interval, ISOC1 and MYOM2. The combined carrier frequency of the 8 variants in the previously known LQTS genes was 530 per 100 000 individuals (1:190). p.Tyr315Cys and p.Leu273Phe in KCNQ1 were associated with having a mean QTc interval longer than 500 ms (P=4.2×10^-7; odds ratio [OR], 38.6; P=8.4×10^-10, OR, 26.5; respectively), and p.Leu273Phe was associated with sudden cardiac death (P=0.0034; OR, 2.99). p.Val215Met in KCNQ1 was carried by 1 in 280 Icelanders, had a smaller effect on the QTc interval (P=1.8×10^-44; effect, 22.8 ms), and did not associate with severe clinical events. Conclusions The carrier frequency of associating variants in LQTS genes was higher than previous estimates of the prevalence of LQTS. The variants have variable effects on the QTc interval, and carriers of p.Tyr315Cys and p.Leu273Phe have a more severe disease than carriers of p.Val215Met. These data could lead to improved identification, risk stratification, and a more precise clinical approach to those with QTc prolongation.

Increased Dispersion of Ventricular Repolarization as an Arrhythmic Risk Marker in Drug-free Patients With Major Depressive Disorder: A Preliminary Comparative Study

OBJECTIVE

Drug-free patients with major depressive disorder (MDD) are understudied in terms of increased risk for arrhythmias. In this study, we compared changes in corrected QT interval (QTc), QTc dispersion (QTcd), Tpeak-Tend (Tp-e), Tp-e/QT ratio, corrected JT interval (JTc), and JTc dispersion (JTcd), which are considered to be among the risk factors for the emergence of ventricular arrhythmias in patients with MDD.

METHODS

The study involved 50 patients with MDD who had been free of psychotropic medications for at least 1 month and 52 age-matched and sex-matched healthy controls. Illness-related characteristics, including duration of illness and Beck Depression Inventory scores, were recorded. Electrocardiography recordings made under a standardized procedure were performed for all participants, and arrhythmia risk markers were calculated from the electrocardiograms.

RESULTS

The patient group had significantly higher QTcd, JTc, and JTcd values compared with the controls. Among electrocardiogram markers, only Tp-e/QTc was significantly and inversely correlated with the duration of illness, while none of the markers was associated with Beck Depression Inventory scores.

CONCLUSIONS

Alterations in electrocardiogram-derived markers of ventricular arrhythmia, which can be obtained easily and inexpensively, can be evaluated for the prediction and prevention of severe cardiac conditions in patients with MDD and considered in selecting the safest antidepressant options available.

Association between pre-operative prolonged corrected QT interval and all-cause mortality after non-cardiac surgery

BACKGROUND

Prolonged corrected QT interval (QTc) has been linked to risk of arrhythmias and mortality in the general population. Pre-operative electrocardiography is often obtained for patient-and procedural cardiovascular risk assessment. The aim of this study was to investigate the association of pre-operative QTc and all-cause mortality in a non-cardiac surgical cohort.

METHODS

A retrospective study of all patients over 18 years undergoing non-cardiac surgery at Landspitali-the National University Hospital in Iceland between 2 January 2005 to 31 December 2015, with follow-up through 20 May 2016. Patients were separated into five categories according to their pre-operative QTc interval ≤ 379, 380-439 (reference group), 440-479, 480-519 and ≥520 ms. Primary outcome was long-term mortality and secondary outcome was 30-day mortality.

RESULTS

A total of 10,209 surgeries for 10,209 individuals were included. The median follow-up for mortality was 2691 days (interquartile range [IQR] 1620-3705 days). Patients with longer QTc interval had a higher comorbidity burden, were more likely to undergo emergency surgery and were often prescribed cardiac medications. After adjustment for confounding variables, the hazard ratio (HR) for long-term mortality compared with reference (QTc 380-439 ms) was 0.85 [CI: 0.66-1.09] for QTc ≤379, 1.08 [CI: 0.99-1.17] for QTc 440-479 ms, 1.26 [CI: 1.10-1.43] for QTc between 480 and 519 ms and 0.97 [CI: 0.78-1.21] for QTc ≥520 ms. When compared with reference, only patients with QTc interval between 480 and 519 ms had higher odds ratio for 30-day mortality as odds ratio for other groups were following; 1.12 [CI: 0.18-3.8] for ≤379 ms, 1.03 [CI: 0.70-1.51] for QTc 440-479 ms, 1.64 [CI: 1.02-2.60] for QTc 480-519 ms and 0.98 [0.44-2.06] for QTc ≥520 ms.

CONCLUSION

Pre-operative QTc between 480 and 519 ms is associated with both higher long-term and 30-day mortality after non-cardiac surgery. The results suggest that this could reflect an underlying cardiovascular risk.

Review article: diagnosis, pathophysiology and management of atrial fibrillation in cirrhosis and portal hypertension

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding.

AIMS

To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective.

METHODS

An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored.

RESULTS

The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred.

CONCLUSIONS

Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.

Development in Prescriptions of Contraindicated and Potentially Harmful QT Interval-Prolonging Drugs in a Large Geriatric Inpatient Cohort From 2011 to 2021

Regulatory authorities put major emphasis on QT (interval)-prolonging properties of new molecular entities. Product information/Summaries of Product Characteristics (SmPCs) of multiple drugs contain warnings or contraindications regarding QT prolongation, e.g., on coadministration of QT-prolonging drugs (QT drugs). To characterize the development of the QT drug burden, we performed a trend analysis of prescriptions and co-prescriptions of QT drugs in a large geriatric inpatient cohort. The German SmPCs (status of 2014 and of 2021) and the year-wise listings in the CredibleMeds^® database from 2011 to 2021 were used as sources. There were 402,631 geriatric cases included. The group of QT drugs according to SmPCs in 2014, which must not be combined with other QT drugs, was less frequently involved in contraindicated co-prescriptions in 2021 compared with 2015 (3.0% (2.5-3.7%) of cases with at least one of those drugs in 2021 vs. 4.0% (3.5-4.5%) in 2015), with citalopram, escitalopram, and amiodarone involved in nearly 90% of the co-prescriptions. The number of CredibleMeds-QT-drugs per patient increased from 0.4 (SD=1.1) in 2011 to 1.8 (SD=3.9) in 2021. The percentage of contraindicated co-prescriptions of drugs with known risk for torsade de pointes according to CredibleMeds^® listings at the beginning of the respective years increased from 1.7% in 2011 to 6.1% in 2021. Considering the regularly updated CredibleMeds^® QT drugs list, the contraindicated co-prescriptions of QT drugs markedly increased in the last decade. If prescribers considered only the few most frequently (co-) prescribed QT drugs, then most of the medication errors regarding QT drugs could be prevented.

Determinants of severe QTc prolongation in a real-world gerontopsychiatric setting

Introduction

QT_c prolongation carries the risk of ventricular tachyarrhythmia (Torsades de Pointes) and sudden cardiac death. Psychotropic drugs can affect ventricular repolarization and thus prolong the QT_c interval. The present study sought to investigate the risk factors (pharmacological and non-pharmacological) of severe QT_c prolongation in gerontopsychiatric patients.

Methods

Electrocardiograms of patients on a gerontopsychiatric ward were screened for QT_c prolongation. Medication lists were examined utilizing the AzCERT classification. Potential drug interactions were identified with the electronic drug interaction program mediQ.

Results

The overall prevalence of QT_c prolongation was 13.6%, with 1.9% displaying severe QT_c prolongation (≥ 500 ms). No statistically significant differences between patients with moderate and severe QT_c prolongation were identified; however, patients with severe QT_c prolongation tended to take more drugs (p = 0.063). 92.7% of patients with QT_c prolongation took at least one AzCERT-listed drug, most frequently risperidone and pantoprazole. Risperidone and pantoprazole, along with pipamperone, were also most frequently involved in potential drug interactions. All patients displayed additional risk factors for QT_c prolongation, particularly cardiac diseases.

Conclusion

In addition to the use of potentially QT_c-prolonging drugs, other risk factors, especially cardiac diseases, appear to be relevant for the development of QT_c prolongation in gerontopsychiatric patients. Pantoprazole was frequently involved in potential drug interactions and should generally not be used for more than 8 weeks in geriatric populations. As clinical consequences of QT_c prolongation were rare, potentially QT_c-prolonging drugs should not be used overcautiously; their therapeutic benefit should be considered as well. It is paramount to perform diligent benefit-risk analyses prior to the initiation of potentially QT_c-prolonging drugs and to closely monitor their clinical (side) effects.

Prolonged QT Interval in Cirrhosis: Twisting Time?

Approximately 30% to 70% of patients with cirrhosis have QT interval prolongation. In patients without cirrhosis, QT prolongation is associated with an increased risk of ventricular arrhythmias, such as torsade de pointes (TdP). In cirrhotic patients, there is likely a significant association between the corrected QT (QTc) interval and the severity of liver disease, and possibly with increased mortality. We present a stepwise overview of the pathophysiology and management of acquired long QT syndrome in cirrhosis. The QT interval is mainly determined by ventricular repolarization. To compare the QT interval in time it should be corrected for heart rate (QTc), preferably by the Fridericia method. A QTc interval >450 ms in males and >470 ms in females is considered prolonged. The pathophysiological mechanism remains incompletely understood, but may include metabolic, autonomic or hormonal imbalances, cirrhotic heart failure and/or genetic predisposition. Additional external risk factors for QTc prolongation include medication (IKr blockade and altered cytochrome P450 activity), bradycardia, electrolyte abnormalities, underlying cardiomyopathy and acute illness. In patients with cirrhosis, multiple hits and cardiac-hepatic interactions are often required to sufficiently erode the repolarization reserve before long QT syndrome and TdP can occur. While some risk factors are unavoidable, overall risk can be mitigated by electrocardiogram monitoring and avoiding drug interactions and electrolyte and acidbase disturbances. In cirrhotic patients with prolonged QTc interval, a joint effort by cardiologists and hepatologists may be useful and significantly improve the clinical course and outcome.

QTc interval diurnal variations in patients treated with psychotropic medications: implications for the evaluation of drug induced QTc changes

Psychotropic drugs such as antipsychotics may prolong the QTc interval, increasing the risk of torsades de pointes (TdP) and sudden cardiac death. To assess QTc prolongation by psychotropic drugs, an electrocardiogram (EKG) is usually recorded before and after starting treatment. Circadian variations in the QTc interval have been described but have not been adequately studied in patients taking psychotropic drugs. In psychiatric clinical practice, EKGs before and after treatment initiation are often compared, without considering the time of day at which the two EKGs are recorded. To determine whether there is a circadian change in the QTc interval in patients treated with psychotropic drugs, we evaluated the EKGs of a group of patients treated with psychotropic drugs (85% on antipsychotics) and the EKGs of a group of patients that were not treated with medications. In each group, we compared the EKGs recorded before 11:00 am with those recorded after 5:00 pm. The QTc value was significantly longer in the group treated with psychotropic drugs than in the group without drugs at both morning and evening evaluations (p ≤ 0.001). In each group, a statistically significant difference was found between the EKGs recorded before 11:00 a.m. and the EKGs recorded after 5:00 p.m. In patients treated with medications, the mean QTc in the morning was 453.3 ± 25.4 while the mean QTc in the afternoon was 428.4 ± 24.7 (p < 0.0001). In patients who were not receiving any medication, the morning mean QTc was 422.4 ± 22.6 while the mean afternoon QTc was 409.4 ± 19.6 (p = 0.002). These results suggest that a circadian variation in QTc is observed both in patients taking psychotropic drugs and in patients not taking medication. We conclude that any comparison of EKGs to test the effect on QTc of a medication, should be referred to EKGs recorded at the same time of day.

The Role of Hypomagnesemia in Cardiac Arrhythmias: A Clinical Perspective

The importance of magnesium (Mg2+), a micronutrient implicated in maintaining and establishing a normal heart rhythm, is still controversial. It is known that magnesium is the cofactor of 600 and the activator of another 200 enzymatic reactions in the human organism. Hypomagnesemia can be linked to many factors, causing disturbances in energy metabolism, ion channel exchanges, action potential alteration and myocardial cell instability, all mostly leading to ventricular arrhythmia. This review article focuses on identifying evidence-based implications of Mg2+ in cardiac arrhythmias. The main identified benefits of magnesemia correction are linked to controlling ventricular response in atrial fibrillation, decreasing the recurrence of ventricular ectopies and stopping episodes of the particular form of ventricular arrhythmia called torsade de pointes. Magnesium has also been described to have beneficial effects on the incidence of polymorphic ventricular tachycardia and supraventricular tachycardia. The implication of hypomagnesemia in the genesis of atrial fibrillation is well established; however, even if magnesium supplementation for rhythm control, cardioversion facility or cardioversion success/recurrence of AF after cardiac surgery and rate control during AF showed some benefit, it remains controversial. Although small randomised clinical trials showed a reduction in mortality when magnesium was administered to patients with acute myocardial infarction, the large randomised clinical trials failed to show any benefit of the administration of intravenous magnesium over placebo.

Sleep disturbance exacerbates the cardiac conduction abnormalities induced by persistent heavy ambient fine particulate matter pollution: A multi-center cross-sectional study

Fine particulate matter (PM_2.5) exposure and sleep disturbance have been significantly associated with adverse cardiovascular outcomes, however, the combined effects of these two factors are still unclear. We conducted a multi-center cross-sectional study from November 2018 to May 2019 in the Beijing-Tianjin-Hebei region in China to investigate the potential modifying effects of sleep disturbance on associations between cardiac conduction abnormalities and PM_2.5 exposure, as well as the combined effects of sleep disturbance and heavy pollution episodes, which were defined based on the PM_2.5 mass concentration (≥75 μg/m³, falling in the 75th/90th percentile) and duration (1 day and ≥2 days). The sleep quality and sleep duration of all participants were evaluated using the Pittsburgh Sleep Quality Index. Standard 12-lead electrocardiogram (ECG) test was performed to measure the heart rate (HR), QRS duration (time taken for ventricular depolarization), HR corrected QT interval (time for ventricular depolarization and repolarization) and PR interval (time for atrioventricular conduction). Multivariable linear regression models were performed to evaluate the associations of PM_2.5 and heavy pollution events on ECG parameters and the joint effects with sleep disturbance. We found PM_2.5 exposure was independently associated with prolonged QRS and QTc intervals. Association between PM_2.5 and the QTc interval was significantly stronger in participants with poor sleep quality. For each 10-μg/m³ increase in PM_2.5 concentration, the QTc interval in the participants with poor sleep quality increased by 0.41 % (95 % confidence interval: 0.19, 0.64). In addition, heavy PM_2.5 pollution episodes, especially extremely heavy pollution of long duration, were found to have synergistic effects with sleep disturbance on ECG parameters. Our findings provide evidence that PM_2.5 exposure, especially heavy pollution episodes, may increase abnormal cardiac conduction and have a synergistic effect with sleep disturbance. Improving sleep hygiene is crucial to protect the heart health of the general population.

Serious arrhythmia in initiators of citalopram, escitalopram, and other selective serotonin reuptake inhibitors: A population-based cohort study in older adults

The selective serotonin reuptake inhibitors (SSRIs) citalopram and escitalopram are associated with QT prolongation, which increases the risk of serious arrhythmia. Consequently, regulatory agencies issued safety warnings in 2011. This study aimed to investigate the risk of serious arrhythmia following initiation of citalopram or escitalopram compared to other SSRIs and the risk in the periods before and after the warnings were issued. We conducted a series of nationwide cohort studies emulating a target trial using Danish healthcare register data from January 1, 2002, to December 31, 2016. We included patients (aged ≥65 years) who filled an SSRI prescription with a 1-year washout period before the index date. The outcome was an event of serious arrhythmia. Individuals were followed for a maximum of 6 months using an intention-to-treat approach. Log-binomial regression analyses were performed, estimating risk ratios (RRs) and 95% confidence intervals (CIs) adjusting for age and sex, comorbidities, and comedications with propensity scores. Dose-response effects were not investigated because dosage instructions were not available. We included 167,366 (146,014 individuals), 40,113 (37,069 individuals), and 50,281 (44,754 individuals) person-trials of citalopram, escitalopram, and other SSRIs, respectively. In total, there were 228 events of serious arrhythmia. No difference in risk was observed in the entire study period for either citalopram (0.87 [0.62-1.22]) or escitalopram (0.85 [0.53-1.40]). We identified lower point estimates after the safety warning, RR 0.54 (95% CI 0.31-0.93) for citalopram and 0.58 (0.20-1.63) for escitalopram. Initiation of citalopram and escitalopram was not associated with an increased risk of serious arrhythmia. However, lower point estimates were observed after the safety warning.

Magic truffle intoxication: A case report

Unusual forms of hallucinogenic mushrooms are emerging, which may delay diagnosis and compromise optimal management. Here, we discuss clinical and biological findings in a case of “magic mushroom” intoxication in a 20-year-old man who was brought to hospital emergency department in a state of euphoria, disorientation, intense visual hallucinations, episodic amnesia and agitation requiring physical restraint. The patient’s family brought intact specimens of the consumed product, without any health professional being able to identify it. Toxicological screening detected psilocin in urine and in the unknown mushrooms, allowing guiding the mushroom identification towards the Psilocybes genus. Ten hours post-ingestion, the patient was discharged asymptomatic. We believe that recognition of the unusual form of hallucinogenic mushroom presented here by emergency physicians might contribute to better diagnosis and subsequent optimal management, especially since hallucinogenic substances are not routinely tested in toxicological analyses.

Influence of NOS1AP Risk Variants on the Corrected QT (QTc) Interval in the Pharmacotherapy of Schizophrenia

INTRODUCTION

The variants of the gene for nitric oxide synthase 1 adaptor protein (NOS1AP) are associated with schizophrenia and cardiovascular deficits involving corrected QT (QTc) interval prolongation. Here, we investigated a possible pharmacogenetic effect of antipsychotic treatment on QTc length in interaction with two NOS1AP variants (rs12143842 and rs10494366) whose minor alleles are associated with increased QTc interval length.

METHODS

We conducted a retrospective analysis of electrocardiographic (ECG) and genotype data of 239 patients diagnosed with schizophrenia. We converted antipsychotics dosage to chlorpromazine equivalents and defined daily doses. We analysed the effects of the minor (i. e. rs12143842-CT/TT and rs10494366-GT/GG) and major (i. e. rs12143842-CC and rs10494366-TT) allele genotypes to QTc interval for female and male participants separately.

RESULTS

As expected, rs12143842 and rs10494366 exhibit strong linkage disequilibrium. Both polymorphisms had no direct effect on antipsychotic use or QTc interval. However, there was a continuous increase in QTc interval with increasing antipsychotic dosage in males. For both variants, positive correlation of QTc length with antipsychotic dosage was found in homozygous male carriers of the major alleles (i. e. rs12143842-CC and rs10494366-TT), but not in minor allele carriers. There was no significant interaction between antipsychotic dosage and QTc interval for either genotype in female patients.

CONCLUSIONS

In this study, a significant interaction was found between both NOS1AP variants, rs12143842 and rs10494366, and antipsychotic treatment on the QTc interval in a sex-dependent manner. Our findings might be relevant for adequate antipsychotic treatment in rs12143842 and rs10494366 major allele carriers.

QTc Prolongation with the Use of Hydroxychloroquine and Concomitant Arrhythmogenic Medications: A Retrospective Study Using Electronic Health Records Data

Introduction

Hydroxychloroquine can induce QT/QTc interval prolongation for some patients; however, little is known about its interactions with other QT-prolonging drugs.

Objective

The purpose of this retrospective electronic health records study was to evaluate changes in the QTc interval in patients taking hydroxychloroquine with or without concomitant QT-prolonging medications.

Methods

De-identified health records were obtained from the Cerner Health Facts^® database. Variables of interest included demographics, diagnoses, clinical procedures, laboratory tests, and medications. Patients were categorized into six cohorts based on exposure to hydroxychloroquine, methotrexate, or sulfasalazine alone, or the combination of any those drugs with any concomitant drug known to prolong the QT interval. Tisdale QTc risk score was calculated for each patient cohort. Two-sample paired t-tests were used to test differences between the mean before and after QTc measurements within each group and ANOVA was used to test for significant differences across the cohort means.

Results

A statistically significant increase in QTc interval from the last measurement prior to concomitant exposure of 18.0 ms (95% CI 3.5–32.5; p < 0.05) was found in the hydroxychloroquine monotherapy cohort. QTc changes varied considerably across cohorts, with standard deviations ranging from 40.9 (hydroxychloroquine monotherapy) to 57.8 (hydroxychloroquine + sulfasalazine). There was no difference in QTc measurements among cohorts. The hydroxychloroquine + QTc-prolonging agent cohort had the highest average Tisdale Risk Score compared with those without concomitant exposure (p < 0.05).

Conclusion

Our analysis of retrospective electronic health records found hydroxychloroquine to be associated with a moderate increase in the QTc interval compared with sulfasalazine or methotrexate. However, the QTc was not significantly increased with concomitant exposure to other drugs known to increase QTc interval.

Hydroxyzine Initiation Following Drug Safety Advisories on Cardiac Arrhythmias in the UK and Canada: A Longitudinal Cohort Study

Introduction

Regulatory advisories on hydroxyzine and risk of QT prolongation and Torsade de pointes (TdP) were issued in the UK in April 2015 and Canada in June 2016. We hypothesized patients with risk factors for QT prolongation and TdP, compared with those without risk factors, would be less likely to initiate hydroxyzine in the UK and in British Columbia (BC), Canada, following advisories.

Methods

We conducted a longitudinal study with repeated measures, and evaluated hydroxyzine initiation in a UK cohort and a concurrent BC control cohort (April 2013–March 2016) as well as in a BC advisory cohort (June 2014–May 2017).

Results

This study included 247,665 patients in the UK cohort, 297,147 patients in the BC control cohort, and 303,653 patients in the BC advisory cohort. Over a 12-month post-advisory period, hydroxyzine initiation decreased by 21% in the UK (rate ratio 0.79, 95% confidence interval 0.66–0.96) relative to the expected level of initiation based on the pre-advisory trend. Hydroxyzine initiation did not change in the BC control cohort or following the Canadian advisory in the BC advisory cohort. The decrease in hydroxyzine initiation in the UK in the 12 months after the advisories was not significantly different for patients with risk factors compared with those without risk factors.

Conclusion

Hydroxyzine initiation decreased in the UK, but not in BC, in the 12 months following safety advisories. The decrease in hydroxyzine initiation in the UK was not significantly different for patients with versus without risk factors for QT prolongation and TdP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-022-01175-2.

Electrocardiogram Monitoring Practices for Hospitalized Adults Receiving Antipsychotics: A Retrospective Cohort Study

OBJECTIVE

Antipsychotics are frequently used for managing both acute and chronic neuropsychiatric disorders. While antipsychotics are known to be associated with increased mortality due to cardiac arrhythmia, there is a lack of consensus on the timing and frequency of electrocardiogram (ECG) monitoring.  The goal of this study was to examine current ECG monitoring practices for adults receiving antipsychotics, specifically during hospital admission.

METHODS

The study involved a multisite retrospective chart review of adults admitted across 8 hospitals between January 2010 and December 2015 who received antipsychotics during hospitalization. The primary outcome was the presence of an ECG after receiving an antipsychotic.

RESULTS

During the study period, there were 26,353 hospitalizations during which adults received antipsychotic medication; the average age of the patients was 61.4 years, 50.1% were female, and 64.8% were white. The average comorbidity score was 1.4 with a median length of stay of 8.3 days. Of the 26,353 patients who were hospitalized, 60.6% (n=15,977) of patients in the sample had an ECG during their hospitalization, and 41.2% (n=10,865) had the ECG following antipsychotic administration. Patients who received a follow-up ECG had a longer length of stay (median: 11.3 d) compared with those who did not receive a follow-up ECG (median: 7.0 d). Follow-up ECGs were more likely among patients who had a history of heart failure [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.06-1.30, P=0.002], who were receiving multiple antipsychotics (OR=1.3, 95% CI: 1.24-1.36, P<0.001) or other QT-prolonging medications (OR=1.09, 95% CI: 1.07-1.1, P<0.001), who were receiving risperidone (OR=1.12, 95% CI: 1.004-1.25, P=0.04), and who showed an increase in QTc duration (OR per 10 ms increase=1.02, 95% CI: 1.01-1.04, P=0.003). Follow-up ECGs were less likely to be administered to patients who were receiving antipsychotics before admission (OR=0.93, 95% CI: 0.87-0.997, P=0.04).

CONCLUSIONS

This study demonstrated that, in a large health system, ECG monitoring is not routinely practiced for hospitalized patients receiving antipsychotics. Further studies are needed to identify patients who would most benefit from ECG monitoring in the acute care setting.

Risk assessment tools for QT prolonging pharmacotherapy in older adults: a systematic review

Purpose

Many drugs are associated with the risk of QT prolongation and torsades de pointes (TdP), and different risk assessment tools (RATs) are developed to help clinicians to manage related risk. The aim of this systematic review was to summarize the evidence of different RATs for QT prolonging pharmacotherapy.

Methods

A systematic review was conducted using PubMed and Scopus databases. Studies concerning risk assessment tools for QT prolonging pharmacotherapy, including older adults, were included. Screening and selection of the studies, data extraction, and risk of bias assessment were undertaken.

Results

A total of 21 studies were included, involving different risk assessment tools. Most commonly used tools were risk scores (n = 9), computerized physician order entry systems (n = 3), and clinical decision support systems (n = 6). The tools were developed mainly for physicians and pharmacists. Risk scores included a high number of risk factors, both pharmacological and non-pharmacological, for QT prolongation and TdP. The inclusion of patients’ risk factors in computerized physician order entry and clinical decision support systems varied.

Conclusion

Most of the risk assessment tools for QT prolonging pharmacotherapy give a comprehensive overview of patient-specific risks of QT prolongation and TdP and reduce modifiable risk factors and actual events. The risk assessment tools could be better adapted to different health information systems to help in clinical decision-making. Further studies on clinical validation of risk assessment tools with randomized controlled trials are needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-022-03285-3.

Changes in QTc interval after hydroxychloroquine therapy in patients with COVID-19 infection: a large, retrospective, multicentre cohort study

OBJECTIVE

To evaluate the extent of hydroxychloroquine-induced corrected QT (QTc) prolongation and its relation to COVID-19 infection severity and incidence of polymorphic ventricular arrhythmias and sudden arrhythmic deaths.

DESIGN

A large-scale cohort study with retrospective analysis of baseline and on-therapy QT interval corrected using Bazett and Fridericia formulas.

SETTING

A multicentre study involving eight secondary and tertiary care hospitals of the Abu Dhabi Health Services Company (SEHA), United Arab Emirates.

PARTICIPANTS

2014 patients consecutively admitted with PCR-confirmed SARS-CoV-2 infection between 1 March 2020 and 1 June 2020.

INTERVENTIONS

Treatment with hydroxychloroquine alone or in combination with azithromycin for at least 24 hours and with a baseline ECG and at least one ECG after 24 hours of therapy.

MAIN OUTCOME MEASURES

Maximal QTc interval prolongation and its relationship to clinical severity, polymorphic ventricular tachycardia and sudden arrhythmic death while on treatment.

RESULTS

The baseline QTc_(Bazett) was 427.6±25.4 ms and the maximum QTc_(Bazett) during treatment was 439.2±30.4 ms (p<0.001). Severe QTc prolongation (QTc ≥500 ms) was observed in 1.7%-3.3% of patients (Fridericia and Bazett, respectively). There were no cases of polymorphic ventricular arrhythmia or hydroxychloroquine-related arrhythmic death. QTc prolongation was more pronounced in combination therapy compared with hydroxychloroquine alone (22.2 ms vs 11.0 ms, p<0.001) and in patients with higher COVID-19 clinical severity (asymptomatic: 428.4±25.4 ms, severe COVID-19 infection: 452.7±35.7 ms, p<0.001). The overall in-hospital mortality was 3.97% and deceased patients had longer on-therapy QTc_(Bazett) than survivors (459.8±21.4 ms vs 438.4±29.9 ms, p<0.001).

CONCLUSIONS

The incidence of severe QTc prolongation with hydroxychloroquine was low and not associated with ventricular arrhythmia. The safety concerns surrounding the use of hydroxychloroquine may have been overestimated; however, caution should be exercised when using hydroxychloroquine in patients with risk factors for QT prolongation.

Prevalence and risk factors of QTc prolongation in prostate cancer patients undergoing brachytherapy

QTc prolongation is linked to Torsade de Pointes, sudden cardiac death, and overall cardiovascular mortality. 754 prostate cancer patients undergoing brachytherapy were analyzed, prolonged QTc was defined as ≥450ms. A prolonged QTc was more frequent (10.1% vs 5.1%, p = 0.040) in patients with high-risk cancer than in low to intermediate risk patients. The absolute QTc-time was correlated with age (r = 0.125), neutrophil count (r = 0.130) and negatively correlated with the testosterone level (r=-0.205). Treating physicians should be aware of this and monitor the QTc during ADT to possibly decrease cardiac morbidity/mortality in these patients who are more likely to require ADT.

Psychological and Psychopharmacological Interventions in Psychocardiology

Patients with mental disorders have an increased risk to develop cardiovascular disease (CVD), and CVD are frequently comorbid with especially adjustment, anxiety and depressive disorders. Therefore, clinicians need to be aware of effective and safe psychological and pharmacological treatment strategies for patients with comorbid CVD and mental disorders. Cognitive behavioral therapy and third-wave of cognitive-behavioral therapy are effective for patients with CVD and mental disorders. Internet-based psychological treatments may also be considered. In more severe cases, psychopharmacological drugs are frequently used. Although generally well tolerated and efficacious, drug- and dose-dependent side effects require consideration. Among antidepressants, selective serotonin reuptake inhibitors, selective serotonin and noradrenalin reuptake inhibitors, and newer antidepressants, such as mirtazapine, bupropion, agomelatine, and vortioxetine, can be considered, while tricyclic antidepressants should be avoided due to their cardiac side effects. Mood stabilizers have been associated with arrhythmias, and some first- and second-generation antipsychotics can increase QTc and metabolic side effects, although substantial differences exist between drugs. Benzodiazepines are generally safe in patients with CVD when administered short-term, and may mitigate symptoms of acute coronary syndrome. Laboratory and ECG monitoring is always recommended in psychopharmacological drug-treated patients with CVD. Presence of a heart disease should not exclude patients from necessary interventions, but may require careful risk-benefit evaluations. Effectively and safely addressing mental disorders in patients with CVD helps to improve both conditions. Since CVD increase the risk for mental disorders and vice versa, care providers need to screen for these common comorbidities to comprehensively address the patients' needs.

[An implantable loop recorder after survived sudden cardiac death? : Uncommon case from daily practice]

A 58-year-old woman fainted on the ward a few days after an emergency appendectomy. Due to recurrent loss of consciousness, immediate resuscitation was started and a ventricular torsades de pointes tachycardia was documented. Further diagnostic procedures did not reveal any underlying cardiac disease or channelopathy and different potential causes were ruled out. For optimal diagnostic accuracy in a situation where a reversible/preventable cause might have been present, a loop recorder was implanted for continuous ECG monitoring of the patient.

Psychotropics and COVID-19: An analysis of safety and prophylaxis

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

Primary Cardiac Lymphoma: Three Case Reports and a Review of the Literature

Primary cardiac lymphoma (PCL) is a rare entity that comprises only 1-2% of all cardiac tumors. Due to their scarcity and variable clinical presentation, early diagnosis is challenging. In this series, three cases of PCL from a single institution are described, which highlight the spectrum of presenting features and emphasize common principles. In the first case, a 73-year-old male who presented with dyspnea was found to have a 12.1 cm mass in the right ventricle. Biopsy via cardiac catheterization revealed diffuse large B cell lymphoma (DLBCL). He was treated with chemoimmunotherapy and survived for two months. The second case describes a 55-year-old female who presented with chest pain. Imaging revealed a 3.1 cm right atrial mass and bilateral pleural effusions, with cytology from the latter demonstrating DLBCL. She was lost to follow up after three cycles of chemoimmunotherapy. In the last case, an 80-year-old female presented with weakness. A 4.0 cm mass was discovered in the right atrium and the patient expired shortly after admission. Autopsy confirmed the diagnosis of DLBCL. These case summaries are followed by a review of the clinical presentation, diagnostic approach, and treatment outcomes of PCL.

Implementation of a Pharmacist Monitoring Process for Patients on QTc Prolonging Antibiotics: A Pilot Study

Purpose: The purpose of this pilot study was to implement a pharmacist monitoring process for 4 antimicrobials; azithromycin, ciprofloxacin, levofloxacin, and fluconazole. This pilot study was a patient safety initiative to screen patients and engage providers about therapies at risk for QT prolongation. Methodology: A concurrent chart review was performed at a single center from January 6, to February 22, 2020, of adult patients ≥ 18 years of age initiated on azithromycin, ciprofloxacin, levofloxacin, and fluconazole. Patient risk factors assessed: age, female sex, loop diuretic use, potassium ≤ 3.5 mEq/L, QTc ≥ 450 ms, acute myocardial infarction (MI) or heart failure, 1 or more QTc prolonging agents, and sepsis. The primary endpoint was successful implementation of the QTc monitoring process by pharmacists. Secondary endpoints were the interventions made by pharmacists. Results: From January 6, to February 22, 2020, there were a total of 412 orders for one of the target antimicrobials that resulted in 157 documented pharmacist reviews (38.1%). Of the 157 evaluations, 100 of these represented patients in our high risk group (84 moderate, 16 high risk). Successful implementation was observed through documentation of assessment on all patients with moderate or high risk scores in the 100 person cohort. Conclusion: The pilot study demonstrated a successful implementation of a QTc monitoring process by pharmacists since all patients had documented reviews. Further steps include investigating how to improve efficiency, as well as ways for continued success in monitoring.

Use of ECG monitoring for adult patients taking high-risk QT interval-prolonging drugs in clinical practice: a systematic review protocol

OBJECTIVE

The objective of this review is to determine the rates of electrocardiogram use in adult patients taking high-risk QT interval-prolonging drugs in clinical settings. This review will determine the extent of ECG monitoring being used to mitigate the risk of drug-induced QT prolongation.

INTRODUCTION

High-risk QT interval-prolonging drugs pose a well-established risk of cardiac arrhythmia, including torsades de pointes, among other serious long QT syndromes, which can be fatal. Detection and mitigation of QT prolongation involves use of electrocardiogram monitoring. This systematic review will present evidence for uptake of electrocardiogram monitoring in clinical practice to support the quality use of high-risk QT interval-prolonging drugs.

INCLUSION CRITERIA

Quantitative studies, published from 2004 that determine the rate of electrocardiogram monitoring before and during use of high-risk QT interval-prolonging drugs in adults 18 years or older, either in community or hospital settings, will be eligible for inclusion.

METHODS

CINAHL, Cochrane Library, Embase, and PubMed will be searched to identify published studies. EThOS, OpenGrey, and ProQuest Dissertations and Theses will be searched to identify unpublished studies. Conference abstracts will be excluded. There will be no restriction on country or language. Two reviewers will independently screen and select studies, assess methodological quality, and extract data. The JBI approach to systematic reviews of prevalence and incidence will be followed. Meta-analysis will be performed, if possible, and the Grading of Recommendations Assessment Development and Evaluation (GRADE) Summary of Findings presented.

Examining Side Effect Variability of Antipsychotic Treatment in Schizophrenia Spectrum Disorders: A Meta-analysis of Variance

Side effects of antipsychotic drugs play a key role in nonadherence of treatment in schizophrenia spectrum disorders (SSD). While clinical observations suggest that side effect variability between patients may be considerable, statistical evidence is required to confirm this. Here, we hypothesized to find larger side effect variability under treatment compared with control. We included double-blind, placebo-controlled, randomized controlled trials (RCTs) of adults with a diagnosis of SSD treated with 1 out of 14 antipsychotics. Standard deviations of the pre-post treatment differences of weight gain, prolactin levels, and corrected QT (QTc) times were extracted. The outcome measure was the variability ratio of treatment to control for individual antipsychotic drugs and the overall variability ratio of treatment to control across RCTs. Individual variability ratios were weighted by the inverse-variance method and entered into a random-effects model. We included N = 16 578 patients for weight gain, N = 16 633 patients for prolactin levels, and N = 10 384 patients for QTc time. Variability ratios (VR) were significantly increased for weight gain (VR = 1.08; 95% CI: 1.02-1.14; P = .004) and prolactin levels (VR = 1.38; 95% CI: 1.17-1.62; P < .001) but did not reach significance for QTc time (VR = 1.05; 95% CI: 0.98-1.12; P = 0.135). We found marked differences between individual antipsychotics and increased variability in side effects in patients under treatment with antipsychotics suggesting that subgroups of patients or individual patients may benefit from treatment allocation through stratified or personalized medicine.

Cardiac Safety of Clonidine and Quetiapine in Post-Cardiac Surgery Intensive Care Unit Patients

Background: Clonidine and quetiapine are frequently used medications in the cardiac surgery intensive care unit (ICU). Objective: The purpose of this study is to assess the impact of clonidine compared to quetiapine on cardiac safety outcomes in adult cardiac surgery ICU patients. Methods: This was a single-center, retrospective observational analysis at a tertiary care, academic medical center. Results: One hundred and sixty-one cardiac surgery patients who were administered clonidine or quetiapine during their ICU stay were included between June 2015 and May 2017. The major endpoint of this study was a cardiac safety composite of bradycardia, hypotension, and QTc prolongation. Minor endpoints included ICU and hospital length of stay, and in-hospital mortality. There were 115 patients included in the clonidine arm and 46 patients in the quetiapine arm. There was no difference between groups with regard to the major endpoint (30.43% vs 33.15%; P < .8). There was a shorter ICU and hospital length of stay in the clonidine arm compared to quetiapine P < .0001. All other endpoints were not statistically significant. Conclusion: Patients who received clonidine tended to have undergone less complex procedures, be younger, and have a lower APACHE II score than patients who received quetiapine. The incidence of composite cardiac safety outcomes was not different in clonidine compared to quetiapine in cardiac surgery ICU patients.

Evaluating the risk of QTc prolongation associated with hydroxychloroquine use with antidepressants in lupus patients with fibromyalgia

OBJECTIVE

Hydroxychloroquine (HCQ) is widely used in patients with systemic lupus erythematosus (SLE) due to its immunomodulatory properties. Antidepressants are commonly used in patients with fibromyalgia syndrome (FMS). Both HCQ and antidepressants are reported to cause QTc prolongation, which potentially increases the risk for a lethal ventricular arrhythmia that can result in sudden death. The objective of the study is to investigate the risk of QTc prolongation associated with HCQ use concomitantly with antidepressants in lupus patients with FMS.

METHODS

Outpatient 12-lead electrocardiograms (ECGs) were extracted from an electronic medical record and QTc intervals were calculated using the Bazett's formula. QTc intervals in 135 lupus patients treated with HCQ with or without antidepressants were analyzed.

RESULTS

We found taking HCQ was associated with mild QTc prolongation, and the prolongation was not affected by the length of time of HCQ use or the accumulated dose of HCQ. Concurrent use of HCQ and antidepressants had not further increased QTc intervals in this cohort. However, four patients on HCQ alone and three patients on HCQ and antidepressants were found QTc interval more than 500 milliseconds and most of these patients had underlying cardiological conditions.

CONCLUSIONS

It is important to evaluate lupus patient with ECG before and after starting HCQ, though our study suggests that while HCQ use did prolong the QTc in some, but the overall prolongation was subclinical, with or without antidepressants. ECG monitoring therefore is essential to identify new changes potentially related to drug use.

An old friend turned foe: Metformin-induced diarrhea with resultant symptomatic hypokalemia, hypomagnesemia, hypocalcemia, and hypophosphatemia

Metformin is known for gastrointestinal side effects, but has rarely been associated with diarrhea severe enough to cause symptomatic electrolyte abnormalities and hospitalization. This case illustrates such that occurred despite multiple outpatient encounters for diarrhea. Additionally, this case highlights the importance of a comprehensive medical reconciliation as part of a thorough medical evaluation.