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Campinas A, Pereira Santos M, Sousa MJ, Gomes C, Torres S. Amiodarone-Induced Electrical Storm: A Nightmare in the Emergency Room. Cureus 2023; 15:e49494. [PMID: 38152805 PMCID: PMC10751592 DOI: 10.7759/cureus.49494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Drug-induced long QT syndrome (LQTS) is defined as prolonged corrected QT interval (QTc ≥460 ms) plus polymorphic ventricular arrhythmia fitting the description of torsades de pointes temporally associated with the administration of a drug or combination of drugs. Amiodarone therapy is a known uncommon cause of acquired QT interval prolongation that should not be underestimated. We present a case of an iatrogenic electrical storm with atrial fibrillation (AF) in which amiodarone was administered to attempt chemical cardioversion, resulting in an unnoticed prolongation of the QT interval, with subsequent repeated polymorphic ventricular tachycardia, managed with isoproterenol. Concomitant drugs and slight electrolyte disturbances potentiated this phenomenon. Given the widespread use of this drug in the emergency department, our case highlights a pertinent matter for all medical emergency practitioners. Additionally, it stresses the significance of potential precipitating factors, such as electrolyte imbalances, which are clinical conditions very frequent in the emergency context, along with the importance of recognizing drug interactions. Finally, this case also emphasizes the vital importance of closely monitoring the patient's receiving amiodarone.
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Affiliation(s)
- Andreia Campinas
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | | | - Maria João Sousa
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Catarina Gomes
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Severo Torres
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
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2
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Fernandes DDA, Camões GDF, Ferreira D, Queijo C, Fontes-Ribeiro C, Gonçalves L, Pina R, António N. Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study. World J Emerg Med 2023; 14:454-461. [PMID: 37969211 PMCID: PMC10632761 DOI: 10.5847/wjem.j.1920-8642.2023.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/21/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Long QT syndrome (LQTS) is a heterogeneous syndrome that may be congenital or, more frequently, acquired. The real-world prevalence of acquired LQTS (aLQTS) in the emergency department (ED) remains to be determined. The aim of this study was to determine prevalence of aLQTS and its impact on symptoms on ED admissions. METHODS Electrocardiograms (ECG) of 5,056 consecutively patients admitted in the ED of a tertiary hospital between January 28th and March 17th of 2020 were reviewed. All patients with aLQTS were included. Clinical data with a focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without corrected QT (QTc) interval greater than 500 ms (value that is considered severely increased). RESULTS A total of 383 ECGs with prolonged QTc were recognized, corresponding to a prevalence of aLQTS at admission of 7.82%. Patients with aLQTS were more commonly men (53.3%) with an age of (73.49±14.79) years old and QTc interval of (505.3±32.4) ms. Only 20.4% of these patients with aLQTS were symptomatic. No ventricular arrhythmias were recorded. Patients with QT interval greater than 500 ms were more frequently female (59.5%; P<0.001) and were more frequently on QT prolonging drugs (77.3%; P=0.025). Main contributing factor was intake of antibiotics (odds ratio [OR] 4.680) followed by female gender (OR 2.473) and intake of antipsychotics (OR 1.925). CONCLUSION aLQTS is particularly prevalent in the ED. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made to avoid, detect and treat aLQTS as early as possible.
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Affiliation(s)
- Diogo de Almeida Fernandes
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Guilherme de Freitas Camões
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Diana Ferreira
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Carolina Queijo
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Carlos Fontes-Ribeiro
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
| | - Lino Gonçalves
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
| | - Rui Pina
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
| | - Natália António
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
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3
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Schueller O, Lohmer L, Xue H, Darpo B, Patel J. A Phase 1 Thorough QT/QTc Study of Therapeutic and Supratherapeutic Doses of Belumosudil in Healthy Subjects. Clin Pharmacol Drug Dev 2022; 11:1221-1232. [PMID: 35881051 DOI: 10.1002/cpdd.1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/20/2022] [Indexed: 01/27/2023]
Abstract
Belumosudil is a selective Rho-associated, coiled-coil-containing protein kinase-2 inhibitor. In this crossover design thorough QT/QTc study, single therapeutic (200 mg) and supratherapeutic (1000 mg) oral doses of belumosudil, moxifloxacin (positive control), and placebo were administered to 34 subjects. Twelve-lead electrocardiograms and serial pharmacokinetic sampling were acquired. The effect of belumosudil on the placebo-corrected, change-from-baseline QTcF was small, and an effect exceeding 10 ms could be excluded across all time points with both doses. Using concentration-QTc analysis, an effect on ΔΔQTcF >10 ms can be excluded up to belumosudil concentrations of ≈12 080 ng/mL, more than 2-fold above mean Cmax after the supratherapeutic dose. There was no clinically relevant effect on heart rate or cardiac conduction (ie, the PR and QRS intervals) for belumosudil. No differences in safety were noted between belumosudil and placebo treatment. Assay sensitivity was demonstrated by moxifloxacin's effect on the QTc interval. In conclusion, belumosudil at therapeutic and supratherapeutic doses did not have a clinically meaningful effect on electrocardiogram parameters.
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Affiliation(s)
| | | | | | | | - Jeegar Patel
- Kadmon Corporation, Inc., Cambridge, Massachusetts, USA
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Kahlon SS, Sikandar R, Tejovath S, Nair S, Hassan D, K Patel K, Peddemul A, Mostafa JA. Diagnosing Torsades De Pointes Based on Correlation to QT Interval: A Systematic Review. Cureus 2022; 14:e27833. [PMID: 36110477 PMCID: PMC9462954 DOI: 10.7759/cureus.27833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/09/2022] [Indexed: 02/05/2023] Open
Abstract
Torsades de Pointes (TdP) is a rare form of tachyarrhythmia which can potentially be fatal due to its tendency to degenerate into ventricular fibrillation. It is described as a polymorphic ventricular tachycardia characterized by twisting of the QRS complexes around the electrocardiogram (ECG) baseline in patients with a prolonged QT interval. Prolonged QT interval is known as long QT syndrome. Torsades de Poccurs most commonly in patients with an extended QT interval duration, and even though monitoring an ECG can assist in its prevention, there is no defined duration of a QT interval that can lead to an increased risk of Torsades de Pointes. So, it is hard to determine what QT interval constitutes enough risk for Torsades de Pointes to require intervention. The QT interval duration also depends on other factors, namely heart rate (HR) and other factors such as drugs, congenital diseases, and a combination of both. In this study, we considered various causes of QT prolongation but mainly focused on congenital diseases, drugs, or perioperative risk of QT prolongation and the correlation with the risk of impending TdP. By following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and researching studies on various databases, namely PubMed, Science Direct, Medline, and CiNii we were able to find various systematic reviews and articles showing the association between prolonged QT interval and its degeneration into TdP. This review encourages further research into this topic to understand the implications of QT prolongation and how it can help save the lives of patients with known long QT syndrome, or those on QT prolonging drugs with simple ECG monitoring and treatment for the respective cause.
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Affiliation(s)
- Simranjit S Kahlon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rabia Sikandar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sreedevi Tejovath
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shaalina Nair
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Danial Hassan
- Epidemiology and Public Health, Ministry of Public Health, Doha, QAT
- Cardiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Khushbu K Patel
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aishwarya Peddemul
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Bucklew E, Noory A, Okumus N, Radhakrishnan S, Mahabir S, Samra G, Dysert K, Cheema T, Ivanova V. Acute Cardiac Emergencies. Crit Care Nurs Q 2022; 45:200-217. [PMID: 35617087 DOI: 10.1097/cnq.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies.
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Affiliation(s)
- Eric Bucklew
- Cardiovascular Institute (Drs Bucklew, Noory, Okumus, Radhakrishnan, Mahabir, Samra, and Ivanova) and Division of Pulmonary Critical Care Medicine (Ms Dysert and Dr Cheema), Allegheny Health Network, Pittsburgh, Pennsylvania; and Drexel University College of Medicine, Pittsburgh, Pennsylvania (Dr Ivanova)
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Potnuri AG, Reddy KP, Suresh P, Husain GM, Kazmi MH, Harishankar N. Obesity Potentiates the Risk of Drug-Induced Long QT Syndrome - Preliminary Evidence from WNIN/Ob Spontaneously Obese Rat. Cardiovasc Toxicol 2021; 21:848-858. [PMID: 34302627 DOI: 10.1007/s12012-021-09675-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Drug-induced long QT syndrome (DI-LQTS) is fatal and known to have a higher incidence in women rather than in men. Multiple risk factors potentiate the incidence of DI-LQTS, but the actual contribution of obesity remains largely unexplored. Correspondingly, the present study is aimed to evaluate the susceptibility of DI-LQTS in WNIN/Ob rat in comparison with its lean counterpart using 3-lead electrocardiography. Four- and eight-month-old female WNIN/Ob and their lean controls were used for the experimentation. Non-invasive blood pressure measurement and total body electric conductivity (TOBEC) analysis were carried out. After the baseline evaluations, animals were anesthetized with Ketamine (50 mg/kg). Haloperidol (12.5 mg/kg single dose) was administered intraperitoneally and ECG was taken at 0, 10, 20, 30, 60 min, and 24 h time points. Myocardial lystes were used to assess the BNP, protein carbonylation, and hydroxyproline content. Adiposity, as assessed by TOBEC, is higher in obese rats with elevated mean arterial blood pressure. Baseline-corrected QT interval (QTc) is significantly higher in the obese rat with a wider QRS complex. The incidence of PVC and VT are more intense in the obese rat. Haloperidol-induced QT prolongation in obese rats was rapidly induced than in lean, which was observed to remain till 24 h in obese groups while normalized in lean controls. Higher levels of BNP, protein carbonylation, hydroxyproline content, and relative heart weights indicated the presence of cardiac hypertrophy. The study provides preliminary evidence that obesity can be a potential risk factor for DI-LQTS with faster onset and longer subsistence.
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Affiliation(s)
- Ajay Godwin Potnuri
- Department of Animal Physiology and Pharmacology, ICMR- National Animal Resource Facility for Biomedical Research, Genome Valley, Shamirpet, Hyderabad, 500101, India
| | - Kallamadi Prathap Reddy
- Animal Facility, ICMR- National Institute of Nutrition, Jamai Osmania, Hyderabad, 500007, India
| | - Pothani Suresh
- Department of Animal Physiology and Pharmacology, ICMR- National Animal Resource Facility for Biomedical Research, Genome Valley, Shamirpet, Hyderabad, 500101, India
| | - Gulam Mohammed Husain
- Pharmacology Research Laboratory, National Research Institute of Unani Medicinefor Skin Disorders, Hyderabad, 500038, India
| | - Munawwar Husain Kazmi
- Pharmacology Research Laboratory, National Research Institute of Unani Medicinefor Skin Disorders, Hyderabad, 500038, India
| | - Nemani Harishankar
- Animal Facility, ICMR- National Institute of Nutrition, Jamai Osmania, Hyderabad, 500007, India.
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7
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Old drugs for a new indication: a review of chloroquine and analogue in COVID-19 treatment. Porto Biomed J 2021; 6:e132. [PMID: 34136717 PMCID: PMC8202634 DOI: 10.1097/j.pbj.0000000000000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/12/2021] [Accepted: 01/25/2021] [Indexed: 12/27/2022] Open
Abstract
As an innovative therapeutic strategy, drug repurposing affords old, approved, and already established drugs a chance at new indications. In the wake of the COVID-19 pandemic and the accompanied urgency for a lasting treatment, drug repurposing has come in handy to stem the debilitating effects of the disease. Among other therapeutic options currently in clinical trials, chloroquine (CQ) and the hydroxylated analogue, hydroxychloroquine (HCQ) have been frontline therapeutic options in most formal and informal clinical settings with varying degrees of efficacy against this life-threatening disease. Their status in randomized clinical trials is related to the biochemical and pharmacological profiles as validated by in vitro, in vivo and case studies. With the aim to bear a balance for their use in the long run, this review not only synopsizes findings from recent studies on the degrees of efficacy and roles of CQ/HCQ as potential anti-COVID-19 agents but also highlights our perspectives for their consideration in rational drug repositioning and use.
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8
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Kowlgi GN, Giudicessi JR, Barake W, Bos JM, Ackerman MJ. Efficacy of intentional permanent atrial pacing in the long‐term management of congenital long QT syndrome. J Cardiovasc Electrophysiol 2021; 32:782-789. [DOI: 10.1111/jce.14920] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/21/2020] [Accepted: 01/02/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Gurukripa N. Kowlgi
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Windland Smith Rice Genetic Heart Rhythm Clinic Mayo Clinic Rochester Minnesota USA
| | - John R. Giudicessi
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Windland Smith Rice Genetic Heart Rhythm Clinic Mayo Clinic Rochester Minnesota USA
| | - Walid Barake
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Windland Smith Rice Genetic Heart Rhythm Clinic Mayo Clinic Rochester Minnesota USA
| | - J. Martijn Bos
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Biomedical Sciences Mayo Clinic Rochester Minnesota USA
| | - Michael J. Ackerman
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Windland Smith Rice Genetic Heart Rhythm Clinic Mayo Clinic Rochester Minnesota USA
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine Mayo Clinic Rochester Minnesota USA
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9
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Jayanthi R, Girijasivam SP, Gaur A. Association of blood pressure and BMI to corrected QT interval in young adults. Can J Physiol Pharmacol 2021; 99:894-899. [PMID: 33517855 DOI: 10.1139/cjpp-2020-0520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hypertension is often associated with obesity. Uncontrolled hypertension can lead to uncorrected cardiac dysautonomia that makes cardiac repolarization abnormally prolonged. Modern dietary habits, stress, and bad lifestyle habits make young adults vulnerable to hazards of health. We planned to study the association of body mass index (BMI) and blood pressure (BP) with corrected QT (QTc) intervals in young adults. After obtaining the written informed consent, 171 subjects were randomly selected in the age group of 18-35 years. A general history and physical examination were done before recording the BMI and BP. A 12-lead electrocardiogram was recorded and QTc calculated using Bazett's formula. The values obtained were compared and statistical analysis done. Of the 171 subjects 14.03% were hypertensive. The QTc interval was found to be prolonged in females and it is prolonged with age, BMI, and BP. QTc was significantly increased among the prehypertensive and hypertensive group and with the overweight and (or) obese BMI group compared with the normotensives and normal BMI group suggesting an altered autonomic homeostasis. This warrants lifestyle modification at a younger age to reduce the cardiovascular risk.
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Affiliation(s)
- Ramkumar Jayanthi
- Department of Physiology, Chengalpattu Medical College, Chengalpattu, India
| | | | - Archana Gaur
- Department of Physiology, AIIMS Jodhpur, Jodhpur, India
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10
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Risk of cardiac events with azithromycin-A prediction model. PLoS One 2020; 15:e0240379. [PMID: 33057356 PMCID: PMC7561086 DOI: 10.1371/journal.pone.0240379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/11/2020] [Indexed: 12/03/2022] Open
Abstract
Previous studies have suggested an increased risk of cardiac events with azithromycin, but the predictors of such events are unknown. We sought to develop and validate two prediction models to identify such predictors. We used data from Truven Marketscan Database (01/2009 to 06/2015). Using a split-sample approach, we developed two prediction models, which included baseline demographics, clinical conditions (Model 1), concurrent use of any drug (Model 1) and therapeutic class (Model 2) with a risk of QT-prolongation (CQT-Rx). Patients enrolled in a health plan for 365 days before and five days after dispensing of azithromycin (episodes). Cardiac events included syncope, palpitations, ventricular arrhythmias, cardiac arrest as a primary diagnosis for hospitalization including death. For each model, a backward elimination of predictors using logistic regression was applied to identify predictors in 100 random samples of the training cohort. Predictors prevalent in >50% of the models were included in the final model. A score for the Assessment of Cardiac Risk with Azithromycin (ACRA) was generated using the training cohort then tested in the validation cohort. A cohort of 20,134,659 episodes with 0.03% cardiac events were included. Over 60% included females with mean age of 40.1±21.3 years. Age, sex, history of syncope, cardiac dysrhythmias, non-specific chest pain, and presence of a CQT-Rx were included as predictors for Model-1 (c-statistic = 0.68). For Model-2 (c-statistic = 0.64), predictors included age, sex, anti-arrhythmic agents, anti-emetics, antidepressants, loop diuretics, and ACE inhibitors. ACRA score is available online (bit.ly/ACRA_2020). The ACRA score may help identify patients who are at higher risk of cardiac events following treatment with azithromycin. Providers should assess the risk-benefit of using azithromycin and consider alternative antibiotics among high-risk patients.
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Drici MD. Estimates of population-based incidence of malignant arrhythmias associated with medication use - a narrative review. Fundam Clin Pharmacol 2020; 34:416-417. [PMID: 32567700 DOI: 10.1111/fcp.12582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Milou-Daniel Drici
- Department of Clinical Pharmacology, University of Nice-Côte d'Azur Medical Center, Hôpital Pasteur, Nice cedex 1, 06001, France
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12
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Nakayama M, Tanaka N, Yamashita J, Iwasaki K. Confirmation of maximal hyperemia by the incremental dose of intracoronary papaverine. Cardiovasc Interv Ther 2020; 35:371-378. [DOI: 10.1007/s12928-020-00641-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/08/2020] [Indexed: 12/30/2022]
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13
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Mandal AKJ, Stokes SA, Missouris CG. Implantable cardioverter defibrillator for alectinib induced ventricular fibrillation. Clin Toxicol (Phila) 2019; 58:781-784. [PMID: 31631703 DOI: 10.1080/15563650.2019.1678755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Amit K J Mandal
- Departments of Cardiology and Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, Berkshire, UK
| | - Sarah A Stokes
- Departments of Cardiology and Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, Berkshire, UK
| | - Constantinos G Missouris
- Departments of Cardiology and Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, Berkshire, UK.,Department of Cardiology, University of Cyprus Medical School, Nicosia, Cyprus
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Laksman Z, Barichello S, Roston TM, Deyell MW, Krahn AD. Acute Management of Ventricular Arrhythmia in Patients With Suspected Inherited Heart Rhythm Disorders. JACC Clin Electrophysiol 2019; 5:267-283. [DOI: 10.1016/j.jacep.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/02/2019] [Accepted: 02/03/2019] [Indexed: 02/08/2023]
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15
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Prevalence of Torsades de Pointes inducing drugs usage among elderly outpatients in North Jordan Hospitals. Saudi Pharm J 2018; 26:1146-1154. [PMID: 30532635 PMCID: PMC6260490 DOI: 10.1016/j.jsps.2018.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/19/2018] [Indexed: 11/25/2022] Open
Abstract
Demonstrating the urgent need for increasing awareness of TdP's risk induced by chronically used medications. The importance of establishing an extensive pharmaceutical care for geriatric population with the aim of improving health outcomes and quality of life in elderly patients. To identify the major risk factors associated with increasing the incidence of TdP’s among geriatric patients in Jordan.
Background Torsade de Pointes (TdP) is an abnormal cardiac rhythm associated with a prolongation of QT interval. Although in most cases it spontaneously returns to the normal rhythm, TdP can lead to sudden cardiac death. Medications are the main cause of QT-prolongation and subsequent TdP flare, even though the exact mechanism of why some people evoke TdP but others do not is still unknown. It is evident that elderly patients are more susceptible to experience drug's side effects especially with chronically used medications. Objectives To describe the pattern of prescribing drugs with risk of Torsade’s de Pointes among elderly patients who were visiting different outpatient clinics in North Jordan Hospitals. Methods All patients who were aged ≥65 years old and were visiting outpatient clinics in King Abdullah University Hospital (KAUH) and Princess Basma Hospital (PBH) through December 2016 were included in the study. A total of 5319 patients’ dispending records were collected and analyzed for the prevalence of drug-induced TdP using both Microsoft Excel and the SPSS statistical software. Results A total of 5319 patients were included in the study, more than half (58.5%, n = 3114) of patients were consuming drugs with risk of TdP. Almost half (49.4%, n = 1539) of these patients were women. The majority of patients (62.3%, n = 1939) were using only one drug with TdP risk. However, other patients were found to take five or six different TdP-inducing drugs. Excluding age and gender, 94.3% (n = 2937) of patients who were using TdP-inducing drugs had at least one additional risk factor of inducing TdP. Conclusion High usage of TdP-inducing drugs among geriatric patients in North Jordan demonstrated the urgent need for increasing awareness of TdP’s risk induced by commonly prescribed medications.
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Chadda KR, Ajijola OA, Vaseghi M, Shivkumar K, Huang CLH, Jeevaratnam K. Ageing, the autonomic nervous system and arrhythmia: From brain to heart. Ageing Res Rev 2018; 48:40-50. [PMID: 30300712 DOI: 10.1016/j.arr.2018.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/21/2018] [Accepted: 09/30/2018] [Indexed: 02/08/2023]
Abstract
An ageing myocardium possesses significant electrophysiological alterations that predisposes the elderly patient to arrhythmic risk. Whilst these alterations are intrinsic to the cardiac myocytes, they are modulated by the cardiac autonomic nervous system (ANS) and consequently, ageing of the cardiac ANS is fundamental to the development of arrhythmias. A systems-based approach that incorporates the influence of the cardiac ANS could lead to better mechanistic understanding of how arrhythmogenic triggers and substrates interact spatially and temporally to produce sustained arrhythmia and why its incidence increases with age. Despite the existence of physiological oscillations of ANS activity on the heart, pathological oscillations can lead to defective activation and recovery properties of the myocardium. Such changes can be attributable to the decrease in functionality and structural alterations to ANS specific receptors in the myocardium with age. These altered ANS adaptive responses can occur either as a normal ageing process or accelerated in the presence of specific cardiac pathologies, such as genetic mutations or neurodegenerative conditions. Targeted intervention that seek to manipulate the ageing ANS influence on the myocardium may prove to be an efficacious approach for the management of arrhythmia in the ageing population.
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Affiliation(s)
- Karan R Chadda
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, United Kingdom; Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher L-H Huang
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom; Department of Biochemistry, Hopkins Building, University of Cambridge, Cambridge, CB2 1QW, United Kingdom
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, United Kingdom; Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom.
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17
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Li K, Yang J, Guo W, Lv T, Guo J, Li J, Zhang P. Video-Assisted Thoracoscopic Left Cardiac Sympathetic Denervation in Chinese Patients with Long QT Syndrome. Int Heart J 2018; 59:1346-1351. [DOI: 10.1536/ihj.17-727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kun Li
- School of Clinical Medicine, Tsinghua University
| | - Jing Yang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital
| | - Wenjia Guo
- School of Clinical Medicine, Tsinghua University
| | - Tingting Lv
- School of Clinical Medicine, Tsinghua University
| | - Jihong Guo
- Department of Cardiology, Peking University People's Hospital
| | - Jianfeng Li
- Department of Cardiology, Peking University People's Hospital
| | - Ping Zhang
- School of Clinical Medicine, Tsinghua University
- Department of Cardiology, Beijing Tsinghua Changgung Hospital
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18
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Gurkan S, Liu F, Chain A, Gutstein DE. A Study to Assess the Proarrhythmic Potential of Mirtazapine Using Concentration-QTc (C-QTc) Analysis. Clin Pharmacol Drug Dev 2018; 8:449-458. [PMID: 30052325 DOI: 10.1002/cpdd.605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/28/2018] [Indexed: 11/11/2022]
Abstract
Most new chemical entities with systemic availability are required to be tested in a study specifically designed to exclude drug-induced corrected QT interval (QTc) effects, the so-called thorough QT/QTc study. Mirtazapine (Remeron™) is an antidepressant indicated for the treatment of episodes of major depression, which was originally approved in 1994 without a thorough QT study. To evaluate the proarrhythmic potential of mirtazapine, we performed a QT/QTc study with a novel design including implementation of an analysis of the relationship between drug concentration and the QTc interval as the primary assessment of proarrhythmic potential of mirtazapine. The least squares mean differences of the corrected QT interval between mirtazapine and placebo at the geometric mean maximum concentration of drug in blood plasma (90% confidence interval) were 2.39 milliseconds (0.70, 4.07) at the 45-mg dose and 4.00 milliseconds (1.18, 6.83) at the 75-mg dose level of mirtazapine. Modeling of the concentration/QTc relationship for moxifloxacin confirmed that the assay method was adequately sensitive. This trial showed a positive relationship between mirtazapine concentrations and prolongation of the QTc interval. However, the degree of QT prolongation observed with both 45-mg and 75-mg doses of mirtazapine was not at a level generally considered to be clinically meaningful. This study further demonstrates that analysis of the relationship between drug concentration and the QTc interval may be a reasonable alternative to traditional TQT studies to assess risk of QT prolongation.
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Affiliation(s)
- Sevgi Gurkan
- Merck & Co., Inc., Kenilworth, NJ, USA.,Present affiliation: OrbiMed Advisors LLC, San Francisco, CA, USA
| | - Fang Liu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - David E Gutstein
- Merck & Co., Inc., Kenilworth, NJ, USA.,Present affiliation: Janssen Pharmaceuticals, Spring House, PA, USA
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19
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Wit AL. Afterdepolarizations and triggered activity as a mechanism for clinical arrhythmias. Pacing Clin Electrophysiol 2018; 41:883-896. [PMID: 29920724 DOI: 10.1111/pace.13419] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/12/2018] [Indexed: 01/08/2023]
Abstract
Afterdepolarizations cause triggered arrhythmias. One kind occurs after repolarization is complete, delayed afterdepolarizations (DADs). Another occurs as an interruption in repolarization, early afterdepolarizations (EADs). Afterdepolarizations initiate arrhythmias when they depolarize membrane potential to threshold potential for triggering action potentials. DADs usually occur mostly when Ca2+ in the sarcoplasmic reticulum (SR) is elevated. The SR leaks some of the Ca2+ into the myoplasm through Ca2+ release channels controlled by ryanodine receptors (RyR2) during diastole. The Na+ -Ca2+ exchanger extrudes elevated diastolic Ca2+ from the cell in exchange for Na+ (1 Ca2+ for 3 Na+ ) generating inward current causing DADs. DAD amplitude increases with decreasing cycle length, causing triggered activity during an increase in heart rate or during programmed electrical stimulation (PES). Coupling interval of the first triggered impulse is directly related to initiating cycle length. EADs are associated with an increased action potential duration (APD) causing long QT (LQT). EADs are caused by net inward currents (ICaL , INCX ) as a consequence. Hundreds of mutations can cause congenital LQT by altering repolarizing ion channels. Acquired LQT results from drug interaction with repolarizing ion channels. EAD-triggered ventricular tachycardia is polymorphic and called "torsade de pointes." Effects of PES on EAD-triggered activity is related to effects of cycle length on APD. Shortening cycle length prevents EADs by accelerating repolarization. Typical PES protocols inhibit formation of EADs which can be therapeutic.
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Affiliation(s)
- Andrew L Wit
- Department of Pharmacology, College of Physicians and Surgeons of Columbia University, New York City, NY, USA
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20
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The effects of ageing and adrenergic challenge on electrocardiographic phenotypes in a murine model of long QT syndrome type 3. Sci Rep 2017; 7:11070. [PMID: 28894151 PMCID: PMC5593918 DOI: 10.1038/s41598-017-11210-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/21/2017] [Indexed: 01/19/2023] Open
Abstract
Long QT Syndrome 3 (LQTS3) arises from gain-of-function Nav1.5 mutations, prolonging action potential repolarisation and electrocardiographic (ECG) QT interval, associated with increased age-dependent risk for major arrhythmic events, and paradoxical responses to β-adrenergic agents. We investigated for independent and interacting effects of age and Scn5a+/ΔKPQ genotype in anaesthetised mice modelling LQTS3 on ECG phenotypes before and following β-agonist challenge, and upon fibrotic change. Prolonged ventricular recovery was independently associated with Scn5a+/ΔKPQ and age. Ventricular activation was prolonged in old Scn5a+/ΔKPQ mice (p = 0.03). We associated Scn5a+/ΔKPQ with increased atrial and ventricular fibrosis (both: p < 0.001). Ventricles also showed increased fibrosis with age (p < 0.001). Age and Scn5a+/ΔKPQ interacted in increasing incidences of repolarisation alternans (p = 0.02). Dobutamine increased ventricular rate (p < 0.001) and reduced both atrioventricular conduction (PR segment-p = 0.02; PR interval-p = 0.02) and incidences of repolarisation alternans (p < 0.001) in all mice. However, in Scn5a+/ΔKPQ mice, dobutamine delayed the changes in ventricular repolarisation following corresponding increases in ventricular rate. The present findings implicate interactions between age and Scn5a+/ΔKPQ in prolonging ventricular activation, correlating them with fibrotic change for the first time, adding activation abnormalities to established recovery abnormalities in LQTS3. These findings, together with dynamic electrophysiological responses to β-adrenergic challenge, have therapeutic implications for ageing LQTS patients.
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21
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Locati ET, Bagliani G, Padeletti L. Normal Ventricular Repolarization and QT Interval: Ionic Background, Modifiers, and Measurements. Card Electrophysiol Clin 2017; 9:487-513. [PMID: 28838552 DOI: 10.1016/j.ccep.2017.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The QT interval on surface electrocardiogram represents the sum of depolarization and repolarization process of the ventricles. The ventricular recovery process, reflected by ST segment and T wave, mainly depends on the transmembrane outward transport of potassium ions to reestablish the endocellular electronegativity. Outward potassium channels represent a heterogeneous family of ionic carriers, whose global kinetics is modulated by heart rate and autonomic nervous activity. Several cardiac and noncardiac drugs and disease conditions, and several mutations of genes encoding ionic channels, generating distinct genetic channellopathies, may affect the ventricular repolarization, provoke QT interval prolongation and shortening, and increase the susceptibility to ventricular arrhythmias.
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Affiliation(s)
- Emanuela T Locati
- Electrophysiology Unit, Cardiology Division, Cardiovascular Department, ASST GOM Niguarda Hospital, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy.
| | - Giuseppe Bagliani
- Arrhythmology Unit, Cardiology Department, Foligno General Hospital, Via Massimo Arcamone, 06034 Foligno (PG), Italy; Cardiovascular Diseases Department, University of Perugia, Piazza Menghini 1, 06129 Perugia Italy
| | - Luigi Padeletti
- Heart and Vessels Department, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy; IRCCS Multimedica, Cardiology Department, Via Milanese, 300, 20099 Sesto San Giovanni, Italy
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22
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McIntosh RC, Chow DC, Lum CJ, Hidalgo M, Shikuma CM, Kallianpur KJ. Reduced functional connectivity between ventromedial prefrontal cortex and insula relates to longer corrected QT interval in HIV+ and HIV- individuals. Clin Neurophysiol 2017; 128:1839-1850. [PMID: 28826014 DOI: 10.1016/j.clinph.2017.07.398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 07/06/2017] [Accepted: 07/13/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Prolongation of the QT interval, i.e., measure of the time between the start of the Q wave and the end of the T wave, is a precursor to fatal cardiac arrhythmias commonly observed in individuals infected with the Human Immunodeficiency Virus (HIV), and is related to dysregulation of the autonomic nervous system. We investigated the relationship between QT interval length and resting state functional connectivity (rsFC) of the ventromedial prefrontal cortex (VMPFC), a core region of the brain that is involved with cardio-autonomic regulation. METHOD Eighteen HIV+ men on antiretroviral therapy and with no history of heart disease were compared with 26 HIV-negative control subjects who had similar demographic and cardio-metabolic characteristics. A seed-based rsFC analysis of the right and left VMPFC was performed at the individual subject level, and 2nd-level analyses were conducted to identify the following: group differences in connectivity, brain regions correlating with corrected (QTc) interval length before and after controlling for those group differences, and regions where seed-based rsFC correlates with CD4 count and QTc interval within HIV+ individuals. RESULTS HIV-negative adults showed greater rsFC between the VMPFC seed regions and several default mode network structures. Across groups greater rsFC with the left anterior insula was associated with shorter QTc intervals, whereas right posterior insula connectivity with the VMPFC correlated with greater QTc intervals. HIV patients with lower CD4 counts and higher QTc intervals showed greater rsFC between the right VMPFC and the right posterior insula and dorsal cingulate gyrus. CONCLUSIONS This study demonstrates that QTc interval lengths are associated with distinct patterns of VMPFC rsFC with posterior and anterior insula. In HIV patients, longer QTc interval and lower CD4 count corresponded to weaker VMPFC connectivity with the dorsal striatrum. SIGNIFICANCE A forebrain control mechanism may be implicated in the suppression of cardiovagal influence that confers risk for ventricular arrhythmias and sudden cardiac death in HIV+ individuals.
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Affiliation(s)
- Roger C McIntosh
- Department of Health Psychology, University of Miami, Coral Gables, FL 33124, USA.
| | - Dominic C Chow
- Hawaii Center for AIDS, Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Corey J Lum
- Hawaii Center for AIDS, Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA; Division of Cardiology, Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Melissa Hidalgo
- Department of Health Psychology, University of Miami, Coral Gables, FL 33124, USA
| | - Cecilia M Shikuma
- Hawaii Center for AIDS, Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Kalpana J Kallianpur
- Hawaii Center for AIDS, Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
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23
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Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El-Sherif N, Krol J, Kurpesa M, La Rovere MT, Lobodzinski SS, Locati ET, Mittal S, Olshansky B, Piotrowicz E, Saxon L, Stone PH, Tereshchenko L, Turitto G, Wimmer NJ, Verrier RL, Zareba W, Piotrowicz R. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Heart Rhythm 2017; 14:e55-e96. [DOI: 10.1016/j.hrthm.2017.03.038] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 12/18/2022]
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24
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Predicting the Unpredictable: Drug-Induced QT Prolongation and Torsades de Pointes. J Am Coll Cardiol 2017; 67:1639-1650. [PMID: 27150690 DOI: 10.1016/j.jacc.2015.12.063] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/20/2015] [Accepted: 12/14/2015] [Indexed: 01/09/2023]
Abstract
Drug-induced long QT syndrome (diLQTS) and congenital LQTS (cLQTS) share many features, and both syndromes can result in life-threatening torsades de pointes (TdP). Our understanding of their mechanistic and genetic similarities has led to their improved clinical management. However, our inability to prevent diLQTS has resulted in removal of many medicines from the market and from development. Genetic and clinical risk factors for diLQTS and TdP are well known and raise the possibility of TdP prevention. Clinical decision support systems (CDSS) can scan the patient's electronic health records for clinical risk factors predictive of diLQTS and warn when a drug that can cause TdP is prescribed. CDSS have reduced prescriptions of QT-prolonging drugs, but these relatively small changes lack the power to reduce TdP. The growing genetic evidence linking diLQTS to cLQTS suggests that prevention of TdP in the future may require inclusion of both genetic and clinical predictors into CDSS.
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25
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Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El‐Sherif N, Krol J, Kurpesa M, La Rovere MT, Lobodzinski SS, Locati ET, Mittal S, Olshansky B, Piotrowicz E, Saxon L, Stone PH, Tereshchenko L, Turitto G, Wimmer NJ, Verrier RL, Zareba W, Piotrowicz R. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol 2017; 22:e12447. [PMID: 28480632 PMCID: PMC6931745 DOI: 10.1111/anec.12447] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023] Open
Abstract
Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.
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Affiliation(s)
- Jonathan S. Steinberg
- Heart Research Follow‐up ProgramUniversity of Rochester School of Medicine & DentistryRochesterNYUSA
- The Summit Medical GroupShort HillsNJUSA
| | - Niraj Varma
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | | | - Peter Aziz
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Paweł Balsam
- 1st Department of CardiologyMedical University of WarsawWarsawPoland
| | | | - Daniel J. Cantillon
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Polychronis Dilaveris
- 1st Department of CardiologyUniversity of Athens Medical SchoolHippokration HospitalAthensGreece
| | - Sergio J. Dubner
- Arrhythmias and Electrophysiology ServiceClinic and Maternity Suizo Argentina and De Los Arcos Private HospitalBuenos AiresArgentina
| | | | - Jaroslaw Krol
- Department of Cardiology, Hypertension and Internal Medicine2nd Medical Faculty Medical University of WarsawWarsawPoland
| | - Malgorzata Kurpesa
- Department of CardiologyMedical University of LodzBieganski HospitalLodzPoland
| | | | | | - Emanuela T. Locati
- Cardiovascular DepartmentCardiology, ElectrophysiologyOspedale NiguardaMilanoItaly
| | | | | | - Ewa Piotrowicz
- Telecardiology CenterInstitute of CardiologyWarsawPoland
| | - Leslie Saxon
- University of Southern CaliforniaLos AngelesCAUSA
| | - Peter H. Stone
- Vascular Profiling Research GroupCardiovascular DivisionHarvard Medical SchoolBrigham & Women's HospitalBostonMAUSA
| | - Larisa Tereshchenko
- Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandORUSA
- Cardiovascular DivisionJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Gioia Turitto
- Weill Cornell Medical CollegeElectrophysiology ServicesNew York Methodist HospitalBrooklynNYUSA
| | - Neil J. Wimmer
- Vascular Profiling Research GroupCardiovascular DivisionHarvard Medical SchoolBrigham & Women's HospitalBostonMAUSA
| | - Richard L. Verrier
- Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolHarvard‐Thorndike Electrophysiology InstituteBostonMAUSA
| | - Wojciech Zareba
- Heart Research Follow‐up ProgramUniversity of Rochester School of Medicine & DentistryRochesterNYUSA
| | - Ryszard Piotrowicz
- Department of Cardiac Rehabilitation and Noninvasive ElectrocardiologyNational Institute of CardiologyWarsawPoland
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26
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Mahoney JJ, Haile CN, De La Garza R, Thakkar H, Newton TF. Electrocardiographic characteristics in individuals with cocaine use disorder. Am J Addict 2017; 26:221-227. [DOI: 10.1111/ajad.12524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/09/2017] [Accepted: 02/12/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- James J. Mahoney
- Department of Behavioral Medicine and Psychiatry; West Virginia University School of Medicine; Morgantown West Virginia
| | - Colin N. Haile
- Menninger Department of Psychiatry and Behavioral Sciences; Baylor College of Medicine; Houston Texas
| | - Richard De La Garza
- Menninger Department of Psychiatry and Behavioral Sciences; Baylor College of Medicine; Houston Texas
| | - Harsh Thakkar
- Menninger Department of Psychiatry and Behavioral Sciences; Baylor College of Medicine; Houston Texas
| | - Thomas F. Newton
- Menninger Department of Psychiatry and Behavioral Sciences; Baylor College of Medicine; Houston Texas
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27
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Elsokkari I, Abdelwahab A, Parkash R. Polymorphic ventricular tachycardia due to change in pacemaker programming. HeartRhythm Case Rep 2017; 3:243-247. [PMID: 28736705 PMCID: PMC5509919 DOI: 10.1016/j.hrcr.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ihab Elsokkari
- Address reprint requests and correspondence: Dr Ihab Elsokkari, Queen Elizabeth II Health Sciences Center, 1796 Summer Street, Halifax, Nova Scotia, B3H 3A6, Canada.Queen Elizabeth II Health Sciences Center1796 Summer StreetHalifaxNova ScotiaB3H 3A6Canada
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28
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Abstract
Syncope represents one of the most frequent reasons for consultation in the emergency department. A proper identification will allow a precise etiologic approach and the optimization of delivery of health resources.
Once knowing the classification of syncope; it is the clinical interrogatory what enables to discriminate which of these patients present with a neurogenic mediated syncope or a cardiac mediated syncope. The use of diagnostic methods such as the tilt test, will clarify what type of neurally mediated syncope predominates in the patient.
The electrocardiogram is the cornerstone in the identification of those patients who had a true episode of self-limited or aborted sudden death as the first manifestation of their syncope, a fact which provides prognostic and therapeutic information that will impact the morbidity and mortality.
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Affiliation(s)
- William Uribe
- Departamento de Electrofisiología, Arritmias y Marcapasos, Centros Especializados en Salud Cardiología San Vicente, Fundación Medellín y Rionegro, Colombia; Universidades CES, Medellín, Colombia; Universidad Pontificia Bolivariana, Medellín, Colombia. Address: Carrera 43 36-02, Torre Norte, Piso 11, Medellín, Colombia.
| | - Adrián Baranchuk
- Division of Cardiology, Kingston General Hospital, Queens University, Kingston, Ontario, Canada
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29
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Cubeddu LX. Drug-induced Inhibition and Trafficking Disruption of ion Channels: Pathogenesis of QT Abnormalities and Drug-induced Fatal Arrhythmias. Curr Cardiol Rev 2016; 12:141-54. [PMID: 26926294 PMCID: PMC4861943 DOI: 10.2174/1573403x12666160301120217] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/29/2016] [Indexed: 01/11/2023] Open
Abstract
Risk of severe and fatal ventricular arrhythmias, presenting as Torsade de Pointes (TdP), is increased in congenital and acquired forms of long QT syndromes (LQTS). Drug-induced inhibition of K+ currents, IKs, IKr, IK1, and/or Ito, delay repolarization, prolong QT, and increase the risk of TdP. Drug-induced interference with IKr is the most common cause of acquired LQTS/TdP. Multiple drugs bind to KNCH2-hERG-K+ channels affecting IKr, including antiarrythmics, antibiotics, antivirals, azole-antifungals, antimalarials, anticancer, antiemetics, prokinetics, antipsychotics, and antidepressants. Azithromycin has been recently added to this list. In addition to direct channel inhibition, some drugs interfere with the traffic of channels from the endoplasmic reticulum to the cell membrane, decreasing mature channel membrane density; e.g., pentamidine, geldalamicin, arsenic trioxide, digoxin, and probucol. Other drugs, such as ketoconazole, fluoxetine, norfluoxetine, citalopram, escitalopram, donepezil, tamoxifen, endoxifen, atazanavir, and roxitromycin, induce both direct channel inhibition and impaired channel trafficking. Although many drugs prolong the QT interval, TdP is a rare event. The following conditions increase the risk of drug-induced TdP: a) Disease states/electrolyte levels (heart failure, structural cardiac disease, bradycardia, hypokalemia); b) Pharmacogenomic variables (presence of congenital LQTS, subclinical ion-channel mutations, history of or having a relative with history of drug-induced long QT/TdP); c) Pharmacodynamic and kinetic factors (high doses, women, elderly, metabolism inhibitors, combining two or more QT prolonging drugs, drugs that prolong the QT and increase QT dispersion, and drugs with multiple actions on ion channels). Because most of these conditions are preventable, careful evaluation of risk factors and increased knowledge of drug use associated with repolarization abnormalities are strongly recommended.
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Affiliation(s)
- Luigi X Cubeddu
- Division of Cardio-Metabolic Research, Department of Pharmaceutical Sciences, Health professions Division, Nova Southeastern University, 3200 S. University Dr., Davie, FL, 333218, USA.
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30
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Abstract
The electrocardiographic QT interval has been extensively studied in ischaemic heart disease. Recently, there has been increasing interest in the relationship between diabetes and QT abnormalities. QT prolongation and increased QTd have been shown to predict cardiac death in both type 1 and type 2 diabetes mellitus. Although there is general agreement that QT interval is affected by cardiac ischaemia, the effect of hyperglycaemia on QT measures is controversial. There are also problems surrounding QTd. First, there is controversy as to whether the measure has any physiological meaning; secondly, there is no universally accepted method of measurement and hence no consensus about the upper limit of normal. Nevertheless, several studies have shown increased QTd in diabetic patients suggesting that assessment of the QT interval could be a cost effective way of stratifying aggressive treatment could be directed appropriately to such patients according to cardiovascular risk so that improve outcome.
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Affiliation(s)
| | - Miles Fisher
- Department of Diabetes, Glasgow Royal Infirmary, Glasgow, G4 0SF, UK
| | - Peter W Macfarlane
- University of Glasgow, Division of Cardiovascular and Medical Sciences, Royal Infirmary, Glasgow, G31 2ER, UK
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31
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Life Threatening Severe QTc Prolongation in Patient with Systemic Lupus Erythematosus due to Hydroxychloroquine. Case Rep Cardiol 2016; 2016:4626279. [PMID: 27478650 PMCID: PMC4960328 DOI: 10.1155/2016/4626279] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/15/2016] [Indexed: 11/24/2022] Open
Abstract
We present a case of a syncopal episode resulting from significant QT interval prolongation in a patient on hydroxychloroquine for the treatment of systemic lupus erythematosus and end stage renal disease. The patient had been treated with hydroxychloroquine for two years prior to presentation. After thorough workup for secondary causes of QT interval prolongation hydroxychloroquine was discontinued and the patient's QT interval shortened. The patient was treated with mexiletine to prevent sudden ventricular arrhythmias, which was unique compared to other documented cases in which lidocaine was used. The patient was noted to have mild prolongation of the QT interval on electrocardiogram prior to initiation of hydroxychloroquine therapy which was exacerbated by its use and may have been caused due to toxicity from underlying renal failure.
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32
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Dorn A, Hermann F, Ebneth A, Bothmann H, Trube G, Christensen K, Apfel C. Evaluation of a High-Throughput Fluorescence Assay Method for hERG Potassium Channel Inhibition. ACTA ACUST UNITED AC 2016; 10:339-47. [PMID: 15964935 DOI: 10.1177/1087057104272045] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The number of projects in drug development that fail in late phases because of cardiac side effects such as QT prolongation can impede drug discovery and development of projects. The molecular target responsible for QT prolongation by a wide range of pharmaceutical agents is the myocardial hERG potassium channel. It is therefore desirable to screen for compound interactions with the hERG channel at an early stage of drug development. Here, the authors report a cell-based fluorescence assay using membrane potential-sensitive fluorescent dyes and stably transfected hERG channels from CHO cells. The assay allows semiautomated screening of compounds for hERG activity on 384-well plates and is sufficiently rapid for testing a large number of compounds. The assay is robust as indicated by a Z′ factor larger than 0.6. The throughput is in the range of 10,000 data points per day, which is significantly higher than any other method presently available for hERG. The data obtained with the fluorescence assay were in qualitative agreement with those from patch-clamp electrophysiological analysis. There were no false-positive hits, and the rate of false-negative compounds is currently 12% but might be further reduced by testing compounds at higher concentration. Quantitative differences between fluorescence and electrophysiological methods may be due to the use- or voltage-dependentactivity of the antagonists.
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Affiliation(s)
- Arnulf Dorn
- Hoffmann-La Roche Ltd., Pharma Research, Basel, Switzerland.
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Sardar MR, Greway A, DeAngelis M, Tysko EO, Lehmann S, Wohlstetter M, Patel R. Cardiovascular Impact of Eating Disorders in Adults: A Single Center Experience and Literature Review. Heart Views 2016; 16:88-92. [PMID: 27326349 PMCID: PMC4590190 DOI: 10.4103/1995-705x.164463] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Eating disorders have multiple medical sequelae, including potentially life-threatening cardiovascular complications. This article describes our cardiology practice experience of treating adults with eating disorders in the outpatient setting and documents baseline cardiac findings in this complex patient population. We describe our findings in patients across the spectrum of eating disorders; past studies have generally focused on anorexia only. This article also includes a review of the current literature on cardiovascular complications associated with disordered eating.
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Affiliation(s)
| | - Andrea Greway
- Lankenau Heart Institute, Cooper University Hospital, New Jersey, USA
| | - Michael DeAngelis
- Lankenau Heart Institute, Cooper University Hospital, New Jersey, USA
| | | | - Shawn Lehmann
- Renfrew Center, Cooper University Hospital, New Jersey, USA
| | | | - Riti Patel
- Lankenau Heart Institute, Cooper University Hospital, New Jersey, USA
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Havakuk O, Viskin S. Reply. J Am Coll Cardiol 2016; 67:2806-2807. [DOI: 10.1016/j.jacc.2016.03.553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 11/28/2022]
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Havakuk O, Viskin S. A Tale of 2 Diseases: The History of Long-QT Syndrome and Brugada Syndrome. J Am Coll Cardiol 2016; 67:100-8. [PMID: 26764071 DOI: 10.1016/j.jacc.2015.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/18/2015] [Accepted: 10/06/2015] [Indexed: 12/21/2022]
Abstract
The Brugada syndrome (BrS) and long-QT syndrome (LQTS) present as congenital or acquired disorders with diagnostic electrocardiograms (ST-segment elevation and prolonged QT interval, respectively) and increased risk for malignant arrhythmias. Our understanding of the 2 disease forms (congenital vs. acquired) differs. A female patient on quinidine for atrial fibrillation who develops ventricular fibrillation is diagnosed with "acquired LQTS" and is discharged with no therapy other than instructions to avoid QT-prolonging medications. In contrast, an asymptomatic male patient who develops a Brugada electrocardiogram on flecainide is diagnosed with "asymptomatic BrS" and could be referred for an electrophysiological evaluation that could result in defibrillator implantation. The typical patient undergoing defibrillator implantation for BrS is asymptomatic but has a Brugada electrocardiogram provoked by a drug. The authors describe how the histories of LQTS and BrS went through the same stages, but in different sequences, leading to different conclusions.
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Affiliation(s)
- Ofer Havakuk
- Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sami Viskin
- Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Abstract
The different responses of women and men to cardiovascular drugs reflect gender -specific variances in pharmacokinetic profiles and drug sensitivities coupled to inherent differences in the underlying physiology of each sex. Thus, many common cardiovascular drugs exhibit gender -specific therapeutic and adverse effects. For example, the QT interval of the electrocardiogram is longer in women compared to men, and accordingly, drugs that prolong the QT interval are more likely to cause lethal ventricular arrhythmias in female than male patients. As more clinical drug trials include women subjects, our improved knowledge base for assessing the risk/benefit ratio for cardiovascular drugs in women will enable us to consider gender as one factor in prescribing drugs and adjusting drug loading and maintenance dosages. This short review will present evidence for gender- related differences in the responses to common cardiovascular drugs including statins, antiplatelet and antithrombotic agents, β-blockers, digoxin, vasodilator therapies, and drugs associated with the Long QT Syndrome.
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Affiliation(s)
- Amanda J Stolarz
- Department of Pharmacology and Toxicology, College of Medicine, and College of Pharmacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR, 72205-7199, USA,
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Loperamide Induced Torsades de Pointes: A Case Report and Review of the Literature. Case Rep Med 2016; 2016:4061980. [PMID: 26989420 PMCID: PMC4775784 DOI: 10.1155/2016/4061980] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 02/01/2016] [Indexed: 01/08/2023] Open
Abstract
Abuse of over the counter drugs often gets overlooked by health care providers. Loperamide is one such over the counter drug that is often abused by drug addicts. We present here a case of a young male attaining euphoria from taking massive doses of loperamide. He developed Torsades de Pointes and subsequent cardiac arrest. We found similarities in the progression of myocardial electrical conduction abnormalities among loperamide and other previously known arrhythmogenic drugs. We intend to raise concern over the ease of availability of such drugs over the counter and increase the index of suspicion for over the counter drug abuse from our experience.
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Vlachos K, Georgopoulos S, Efremidis M, Sideris A, Letsas KP. An update on risk factors for drug-induced arrhythmias. Expert Rev Clin Pharmacol 2015; 9:117-27. [DOI: 10.1586/17512433.2016.1100073] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias, the most common of which can be subdivided into tachyarrhythmias and bradyarrhythmias. These arrhythmias may be the primary reason for ICU admission or may occur in the critically ill patient. This article addresses the occurrence of arrhythmias in the critically ill patient, and discusses their pathophysiology, implications, recognition, and management.
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Affiliation(s)
- Cynthia Tracy
- Department of Medicine, George Washington University, 2150 Pennsylvania Avenue, Northwest, Washington, DC 20037, USA.
| | - Ali Boushahri
- Cardiovascular Medicine, George Washington University, Medical Faculty Associates, 2150 Pennsylvania Avenue, Northwest, Washington, DC 20037, USA
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Meijborg VM, Chauveau S, Janse MJ, Anyukhovsky EP, Danilo PR, Rosen MR, Opthof T, Coronel R. Interventricular dispersion in repolarization causes bifid T waves in dogs with dofetilide-induced long QT syndrome. Heart Rhythm 2015; 12:1343-51. [DOI: 10.1016/j.hrthm.2015.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Indexed: 11/27/2022]
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Chakravarty S, Kluger J, Chhabra L, Ramu B, Coleman C. Corrected QT in Ventricular Paced Rhythms: What Is the Validation for Commonly Practiced Assumptions? Cardiology 2015; 130:207-10. [DOI: 10.1159/000370026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
Abstract
Introduction: Ventricular pacing (VP) may impact the accuracy of QT interval measurement, as it increases the QT by increasing the QRS duration amongst other mechanisms. We aimed to investigate the accuracy of the commonly used clinical practice of subtracting 50 ms from the corrected QT (QTc) in ventricular paced rhythms. Methods: We conducted a prospective observational study on 23 consecutive pacemaker patients. Four ECGs were recorded for each subject, 2 in their native rate and 2 following an atrial paced, atrial sensed and inhibited response to sensing and then a dual pacing, dual sensing and dual response pacing of 100 bpm to allow for an intrinsic and a ventricular paced QRS, respectively. The averaged QTc in the ventricular paced rhythm was then compared with the non-ventricular-paced QTc for individual subjects. Results: At a mean spontaneous heart rate of 66 bpm (SD ±8), the mean difference in QTc between the ventricular paced and nonpaced QRS was 48.27 ms (95% CI = 32-64.6 ms, p < 0.001). At faster paced rates, the mean QTc difference was 81.3 ms (95% CI = 35.8-126.8 ms, p = 0.002). Conclusions: The QTc measurement during VP confirms the current 50-ms subtraction assumption rule within a range of ±16 ms at an average heart rate of 66 bpm. However, at faster heart rates, the 50-ms adjustment may underestimate the QTc discrepancy between a wide and normal QRS.
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Nakayama M, Tanaka N, Sakoda K, Hokama Y, Hoshino K, Kimura Y, Ogawa M, Yamashita J, Kobori Y, Uchiyama T, Aizawa Y, Yamashina A. Papaverine-induced polymorphic ventricular tachycardia during coronary flow reserve study of patients with moderate coronary artery disease. Circ J 2015; 79:530-6. [PMID: 25746536 DOI: 10.1253/circj.cj-14-1118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Papaverine is useful for evaluating the functional status of a coronary artery, but it may provoke malignant ventricular arrhythmia (VA). The aim of this study was to investigate the incidence, and clinical and ECG characteristics of patients with papaverine-induced VAs. METHODS AND RESULTS: The 182 consecutive patients underwent fractional flow reserve (FFR) measurement of 277 lesions. FFR was determined after intracoronary papaverine administration by standard procedures. The clinical and ECG characteristics were compared between patients with and without ventricular tachycardia (VT: ≥3 successive premature ventricular beats (PVBs), or ventricular fibrillation (VF)). After papaverine administration, the QTc interval, QTUc interval, and T-peak to U-end interval were prolonged significantly. Single PVBs on the T-wave or U-wave type developed in 29 patients (15.9%). Polymorphic VT (torsade de pointes) occurred in 5 patients (2.8%), and of those, VF developed in 3 patients (1.7%). No clinical and baseline ECG parameters were predictors for VT or VF except for sex and administration of papaverine into the left coronary artery. Excessive prolongation of QT (or QTU), T-peak to U-end intervals and giant T-U waves were found immediately prior to the ventricular tachyarrhythmias (VTAs), which were unpredictable from the baseline data. CONCLUSIONS Intracoronary administration of papaverine induced fatal VTAs, although the incidence is rare. Excessive prolongation of the QT (and QTU) interval appeared prior to VTAs; however, they were unpredictable.
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Affiliation(s)
- Masafumi Nakayama
- Department of Cardiology, Tokyo Medical University; Cardiovascular Center, Toda Central General Hospital, Saitama, Japan.
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Sorajja D, Munger TM, Shen WK. Optimal antiarrhythmic drug therapy for electrical storm. J Biomed Res 2015; 29:20-34. [PMID: 25745472 PMCID: PMC4342432 DOI: 10.7555/jbr.29.20140147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/05/2014] [Indexed: 01/08/2023] Open
Abstract
Electrical storm, defined as 3 or more separate episodes of ventricular tachycardia or ventricular fibrillation within 24 hours, carries significant morbidity and mortality. These unstable ventricular arrhythmias have been described with a variety of conditions including ischemic heart disease, structural heart disease, and genetic conditions. While implantable cardioverter defibrillator implantation and ablation may be indicated and required, antiarrhythmic medication remains an important adjunctive therapy for these persons.
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Affiliation(s)
- Dan Sorajja
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Thomas M Munger
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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Albert RK, Schuller JL. Macrolide antibiotics and the risk of cardiac arrhythmias. Am J Respir Crit Care Med 2014; 189:1173-80. [PMID: 24707986 DOI: 10.1164/rccm.201402-0385ci] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Randomized, controlled trials have demonstrated that chronic therapy with macrolide antibiotics reduces the morbidity of patients with cystic fibrosis, non-cystic fibrosis bronchiectasis, chronic obstructive pulmonary disease, and nontuberculous mycobacterial infections. Lower levels of evidence indicate that chronic macrolides are also effective in treating patients with panbronchiolitis, bronchiolitis obliterans, and rejection after lung transplant. Macrolides are known to cause torsade des pointes and other ventricular arrhythmias, and a recent observational study prompted the FDA to strengthen the Warnings and Precautions section of azithromycin drug labels. This summary describes the electrophysiological effects of macrolides, reviews literature indicating that the large majority of subjects experiencing cardiac arrhythmias from macrolides have coexisting risk factors and that the incidence of arrhythmias in absence of coexisting risk factors is very low, examines recently published studies describing the relative risk of arrhythmias from macrolides, and concludes that this risk has been overestimated and suggests an approach to patient evaluation that should reduce the relative risk and the incidence of arrhythmias to the point that chronic macrolides can be used safely in the majority of subjects for whom they are recommended.
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Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf 2014; 3:241-53. [PMID: 25083239 DOI: 10.1177/2042098612454283] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The prolonged QT interval is both widely seen and associated with the potentially deadly rhythm, Torsades de Pointes (TdP). While it can occur spontaneously in the congenital form, there is a wide array of drugs that have been implicated in the prolongation of the QT interval. Some of these drugs have either been restricted or withdrawn from the market due to the increased incidence of fatal polymorphic ventricular tachycardia. The list of drugs that cause QT prolongation continues to grow, and an updated list of specific drugs that prolong the QT interval can be found at www.qtdrugs.org. This review focuses on the mechanism of drug-induced QT prolongation, risk factors for TdP, culprit drugs, prevention and monitoring of prolonged drug-induced QT prolongation and treatment strategies.
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Affiliation(s)
- Senthil Nachimuthu
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Manish D Assar
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Jeffrey M Schussler
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital, 621 North Hall Street, Suite 500, Dallas, TX 75226, USA
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46
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da Cunha DNQ, Pereira VG, Favarato LSC, Okano BS, Daibert APF, Monteiro BS, Araujo MR, Carvalho PH, Hamlin RL, Del Carlo RJ. Acute and chronic observations of complete atrioventricular block in rats. Lab Anim 2014; 48:237-249. [PMID: 24759570 DOI: 10.1177/0023677214530905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The mechanisms of production, and gross, microscopic and electrocardiograhic findings of surgically-induced complete heart block (CHB) in the adult rat are presented. This is an effective in vivo model for establishing alternative methods to electronic pacemakers and for providing detailed information aimed at replacement, reduction and refinement of the technique. Sternal thoracotomy was employed to identify the epicardial fat pad by the aortic root, used as a landmark for cauterization of the atrioventricular (AV) node. Stable CHB was produced in 60 rats with a 70% survival rate. The best survival rate was observed in 8-week-old animals weighing 221 ± 27.6 g. Heart rate before cauterization was 387 ± 55 bpm, reduced after cauterization to 126 ± 40 bpm in the survival and to 65 ± 19 bpm in the non-survival groups. At 30 days findings were: elevated left ventricular end-diastolic pressure (21 ± 5.4 mmHg, P < 0.05); maximal rate of rise of left ventricular pressure (LVP) during isovolumetric contraction (2192 ± 235 mmHg/s, P < 0.05); maximal rate of decrease of LVP (-1658 ± 191 mmHg/s, P < 0.05); isovolumetric relaxation constant (5.7 ± 0.8 ms, P < 0.05) with wet-to-dry lung-weight ratio (78.1 ± 0.4, P < 0.05); heart weight/body weight (0.6 ± 0.1, P < 0.05); heart volume (1.8 ± 0.3 mL, P < 0.05); longitudinal diameter (20.2 ± 1.91 mm, P < 0.05); and transversal diameter (17.0 ± 1.4 mm, P < 0.05) with supported dilated cardiomyopathy which culminated in chronic heart failure. CHB hearts had increased preload and replacement of myofibrils by collagen. CHB was achieved reproducibly by cauterization of the rat AV node and/or His bundle. This led to electrophysiological, hemodynamic, and structural remodeling, and could be useful in long-term cardiac remodeling assessments and potential therapy development.
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Affiliation(s)
| | | | | | - Barbara S Okano
- Veterinary Department, Federal University of Viçosa, Viçosa, Brazil
| | - Ana P F Daibert
- Veterinary Department, Federal University of Viçosa, Viçosa, Brazil
| | | | - Marta R Araujo
- Veterinary Department, Federal University of Viçosa, Viçosa, Brazil
| | - Pablo H Carvalho
- Veterinary Department, Federal University of Viçosa, Viçosa, Brazil
| | - Robert L Hamlin
- Veterinary Biosciences Department, The Ohio State University, Columbus, Ohio, USA
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47
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Isabelle LBL, Clarot F, Vaz E, Goullé JP, Proust B. Disopyramide and mianserin intoxication: a unique fatal case--review of the literature. J Forensic Sci 2014; 59:850-3. [PMID: 24502246 DOI: 10.1111/1556-4029.12392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 03/06/2013] [Accepted: 03/24/2013] [Indexed: 11/28/2022]
Abstract
Lethal occurrence is exceptional after disopyramide or mianserin poisoning. A case of intentional lethal intoxication with these drugs was reported, as well as a review of the literature. Pre- and postmortem blood concentrations of disopyramide or mianserin were assessed in a woman who died from acute cardiac failure after ingestion. The premortem blood concentration of disopyramide alone was considered lethal, and a toxic premortem concentration of mianserin was observed that may have increased cardiovascular failure induced by disopyramide because the metabolism of both drugs is mediated via cytochrome P450. Moreover, it was shown that the postmortem redistribution of disopyramide was limited, as pre- and postmortem concentrations were 48 and 65 mg/L, respectively. As regards mianserin, redistribution was observed after death with pre- and portmortem concentrations at 0.23 and 0.79 mg/L, respectively. This case illustrates that if postmortem blood concentration of disopyramide is known, the premortem concentration can be deduced.
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Affiliation(s)
- Le Blanc-Louvry Isabelle
- Department of Forensic Medicine, Rouen University Hospital-Charles Nicolle, 1 rue de Germont, 76031, Rouen-Cedex, France
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Abstract
Ion channels are essential for basic cellular function and for processes including sensory perception and intercellular communication in multicellular organisms. Voltage-gated potassium (Kv) channels facilitate dynamic cellular repolarization during an action potential, opening in response to membrane depolarization to facilitate K+ efflux. In both excitable and nonexcitable cells other, constitutively active, K+ channels provide a relatively constant repolarizing force to control membrane potential, ion homeostasis, and secretory processes. Of the forty known human Kv channel pore-forming α subunits that coassemble in various combinations to form the fundamental tetrameric channel pore and voltage sensor module, KCNQ1 is unique. KCNQ1 stands alone in having the capacity to form either channels that are voltage-dependent and require membrane depolarization for activation, or constitutively active channels. In mammals, KCNQ1 regulates processes including gastric acid secretion, thyroid hormone biosynthesis, salt and glucose homeostasis, and cell volume and in some species is required for rhythmic beating of the heart. In this review, the author discusses the unique functional properties, regulation, cell biology, diverse physiological roles, and involvement in human disease states of this chameleonic K+ channel.
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Chung EJ, Jeon YS, Kim HJ, Lee KH, Lee JW, Han KA, Jung SH. Torsade de pointes in liver transplantation recipient after induction of general anesthesia: a case report. Korean J Anesthesiol 2014; 66:80-4. [PMID: 24567820 PMCID: PMC3927008 DOI: 10.4097/kjae.2014.66.1.80] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 12/06/2012] [Accepted: 12/06/2012] [Indexed: 12/17/2022] Open
Abstract
Torsade de pointes (TdP) is an uncommon and specific form of polymorphic ventricular tachycardia, associated with a prolonged QT interval. Prolongation of the QT interval is the most widely recognized electrophysiological abnormality in patients with liver cirrhosis. We observed a case of TdP leading to cardiopulmonary resuscitation after the induction of general anesthesia, in a patient with liver cirrhosis scheduled for emergency cadaveric donor liver transplantation. The patient had mild QT prolongation on preoperative electrocardiography with a corrected QT (QTc) interval of 455 ms. Drugs used in the preoperative period can elongate cardiac repolarization. Sevoflurane and 5-hydroxytryptamine type 3 receptor antagonists such as palonsetron, used during general anesthesia may have triggered further QT prolongation, producing a fatal condition such as TdP. More caution and consideration in selecting drugs for anesthetic management are necessary for liver cirrhosis patients, especially in patients with preoperative QT prolongation.
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Affiliation(s)
- Eun-Jin Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yun-Seok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Joo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji-Won Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyoung-Ah Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung-Hwan Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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50
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Darpo B, Sarapa N, Garnett C, Benson C, Dota C, Ferber G, Jarugula V, Johannesen L, Keirns J, Krudys K, Ortemann-Renon C, Riley S, Rogers-Subramaniam D, Stockbridge N. The IQ-CSRC prospective clinical Phase 1 study: "Can early QT assessment using exposure response analysis replace the thorough QT study?". Ann Noninvasive Electrocardiol 2013; 19:70-81. [PMID: 24372708 DOI: 10.1111/anec.12128] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A collaboration between the Consortium for Innovation and Quality in Pharmaceutical Development and the Cardiac Safety Research Consortium has been formed to design a clinical study in healthy subjects demonstrating that the thorough QT (TQT) study can be replaced by robust ECG monitoring and exposure-response (ER) analysis of data generated from First-in-Man single ascending dose (SAD) studies. Six marketed drugs with well-characterized QTc effects were identified in discussions with FDA; five have caused QT prolongation above the threshold of regulatory concern. Twenty healthy subjects will be enrolled in a randomized, placebo-controlled study designed with the intent to have similar power to exclude small QTc effects as a SAD study. Two doses (low and high) of each drug will be given on separate, consecutive days to 9 subjects. Six subjects will receive placebo. Data will be analyzed using linear mixed-effects ER models. Criteria for QT-positive drugs will be the demonstration of an upper bound (UB) of the 2-sided 90% confidence interval (CI) of the projected QTc effect at the peak plasma level of the lower dose above the threshold of regulatory concern (currently 10 ms) and a positive slope of ER relationship. The criterion for QT-negative drug will be an UB of the CI of the projected QTc effect of the higher dose <10 ms. It is expected that a successful outcome in this study will provide evidence supporting replacement of the TQT study with ECG assessments in standard early clinical development studies for a new chemical entity.
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Affiliation(s)
- Borje Darpo
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd's Hospital, Stockholm, Sweden and iCardiac Technologies, Rochester, NY
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