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Robison RD, Singh M, Jiang L, Riester M, Duprey M, McGeary JE, Goyal P, Wu WC, Erqou S, Zullo A, Rudolph JL, Rogus-Pulia N. Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure. J Am Med Dir Assoc 2023; 24:1303-1310. [PMID: 37478895 PMCID: PMC10527768 DOI: 10.1016/j.jamda.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF). DESIGN Retrospective cohort. SETTINGS AND PARTICIPANTS AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019. METHODS We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment. RESULTS The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7). CONCLUSIONS AND IMPLICATIONS In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.
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Affiliation(s)
- Raele Donetha Robison
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health (SMPH), Madison, WI, USA
| | - Mriganka Singh
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA
| | - Melissa Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Matthew Duprey
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Wen-Chih Wu
- Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Sebhat Erqou
- Warren Alpert Medical School of Brown University, Providence, RI, USA; Division of Cardiology, Providence VA Medical Center, Providence, RI, USA; Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Andrew Zullo
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Nicole Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health (SMPH), Madison, WI, USA; Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
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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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Dorfman JD. Near Hanging: Evaluation and Management. Chest 2022; 163:855-860. [PMID: 36372303 PMCID: PMC9647002 DOI: 10.1016/j.chest.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022] Open
Abstract
Prior to the COVID-19 pandemic, the incidence of self-harm was already on the rise. Hanging/suffocation accounted for 50% of the increase in suicide attempts and remains the second leading cause of death from self-harm in the United States. Studies on the management of near-hanging patients are lacking, and most published literature is retrospective. Following airway and circulation assessment, clinical examination and imaging, namely CT angiography, remain the standard for identifying the injuries associated with near hanging: cervical spine fracture, blunt cerebrovascular injury, laryngeal injury, and injury to the trachea and oropharynx. These injuries, however, are uncommon, and each occur in < 5% of patients in most series. In a large series of critically ill near-hanging patients, > 50% survived to hospital discharge; however, cardiac arrest predicted a poor outcome. The management of asphyxia-related arrest remains controversial. Targeted temperature management has only been studied in a single large multicenter trial, which was retrospective. Given the significant selection bias of targeted temperature management in the treatment of the most ill patients, no firm recommendations can be made. Finally, for survivors, the underlying mental health issues must be addressed to avoid recurrent suicide attempts. Thirty percent of patients in a large near-hanging series were admitted for their second suicide attempt.
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Affiliation(s)
- Jon D Dorfman
- Division of Trauma and Surgical Critical Care, UMass Memorial, Worcester, MA.
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4
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QTc Prolongation in Poison Center Exposures to CredibleMeds List of Substances with "Known Risk of Torsades de Pointes". Cardiovasc Toxicol 2022; 22:866-877. [PMID: 35930218 DOI: 10.1007/s12012-022-09764-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Abstract
Many drugs carry some risk of QT interval prolongation, which can lead to life-threatening dysrhythmias including Torsades de Pointes (TdP). CredibleMeds.org identifies medications categorized as "Known Risk of TdP" but does not stratify risk in acute supratherapeutic ingestions. We sought to determine the proportion of cases exhibiting QTc prolongation and life-threatening dysrhythmias including ventricular tachycardia (VT)/ventricular fibrillation (VF), TdP, and asystole in patients exposed to these substances. Retrospective chart review of cases reported to our Regional Poison Center from 2014 to 2019 of exposures to one or more of the "Known Risk" substances was performed. Demographics, therapies, clinical effects, and medical outcome for each case were analyzed. There were 1125 exposures, of which 760 had a documented QTc interval. QTc ≥ 500 ms was reported in 138 (18.2%) of the 760 cases. The most common "Known Risk" substances were citalopram, escitalopram and cocaine. Although not in the "Known Risk" category, mirtazapine, amitriptyline, diphenhydramine, and trazodone had a statistically significant association with QTc > 500 ms. Life-threatening dysrhythmias occurred in 13 cases, with VT/VF in 6 of the 760 (0.8%) cases, and one case of TdP. Flecainide (OR 11.1, 95% CI 2.2-55.8) and methadone (OR 7.1, 95% CI 2.1-23.4) were associated with increased risk of all life-threatening dysrhythmias. Exposures to medications on the Credible Meds list of "Known Risk of TdP" QTc prolongation is common, but life-threatening dysrhythmias are rare. Mirtazapine, amitriptyline, diphenhydramine, and trazodone were associated with prolonged QTc. Flecainide and methadone had the highest associated risk of life-threatening dysrhythmias.
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5
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Rajendram R, Alghamdi AA, Alanazi MA. Acquired long QT syndrome due to antiemetics, COVID-19 and Blastocystis hominis induced exacerbation of congenital chloride losing diarrhoea. BMJ Case Rep 2022; 15:15/4/e246175. [PMID: 35473697 PMCID: PMC9045059 DOI: 10.1136/bcr-2021-246175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Congenital chloride losing diarrhoea (CCLD) is a rare disease caused by mutations in an intestinal chloride/bicarbonate ion exchange channel. Few reports describe CCLD in adults and none has described the impact of a parasitic infection on CCLD. Severe diarrhoea may result in hypokalaemia with QT interval prolongation. Treatment with antiemetics may further increase the QT interval. To raise awareness of this preventable complication, we describe the course of a woman in her 20s with CCLD who developed COVID-19 and a Blastocystis hominis infestation. Treatment with antiemetics and hypokalaemia resulted in prolongation of the QT interval to 640 ms. While, the QT interval normalised with discontinuation of antiemetics and electrolyte replacement, patients with CCLD must take precautions to prevent gastrointestinal infections. Regardless, whenever patients with CCLD present to hospital, the authors recommend monitoring the QT interval and avoiding medications that predispose to torsade de pointes.
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Affiliation(s)
- Rajkumar Rajendram
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, Al Riyadh Province, Saudi Arabia .,Department of Medicine, King Abdulaziz Medical City, Riyadh, Al Riyadh Province, Saudi Arabia
| | - Ahmed Abdullah Alghamdi
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Al Riyadh Province, Saudi Arabia
| | - Mohammed Ayed Alanazi
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Al Riyadh Province, Saudi Arabia
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6
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Jirak P, Mirna M, Rezar R, Motloch LJ, Lichtenauer M, Jordan J, Binneboessel S, Tank J, Limper U, Jung C. How spaceflight challenges human cardiovascular health. Eur J Prev Cardiol 2022; 29:1399-1411. [PMID: 35148376 DOI: 10.1093/eurjpc/zwac029] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/08/2022] [Accepted: 02/06/2022] [Indexed: 11/14/2022]
Abstract
The harsh environmental conditions in space, particularly weightlessness and radiation exposure, can negatively affect cardiovascular function and structure. In the future, preventive cardiology will be crucial in enabling safe space travel. Indeed, future space missions destined to the Moon and from there to Mars will create new challenges to cardiovascular health while limiting medical management. Moreover, commercial spaceflight evolves rapidly such that older persons with cardiovascular risk factors will be exposed to space conditions. This review provides an overview on studies conducted in space and in terrestrial models, particularly head-down bedrest studies. These studies showed that weightlessness elicits a fluid shift towards the head, which likely predisposes to the spaceflight-associated neuro-ocular syndrome, neck vein thrombosis, and orthostatic intolerance after return to Earth. Moreover, cardiovascular unloading produces cardiopulmonary deconditioning which may be associated with cardiac atrophy. In addition to limiting physical performance, the mechanism further worsens orthostatic tolerance after return to Earth. Finally, space conditions may directly affect vascular health, however, the clinical relevance of these findings in terms of morbidity and mortality is unknown. Targeted preventive measures, which are referred to as countermeasures in aerospace medicine, and technologies to identify vascular risks early on will be required to maintain cardiovascular performance and health during future space missions.
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Affiliation(s)
- Peter Jirak
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Moritz Mirna
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Richard Rezar
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Lukas J Motloch
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Michael Lichtenauer
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany.,Medical Faculty, University of Cologne, Germany
| | - Stephan Binneboessel
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany
| | - Ulrich Limper
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany.,Department of Anaesthesiology and Critical Care Medicine, Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
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7
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Elgassim M, Abdelrahman A, Saied ASS, Ahmed AT, Osman M, Hussain M, AlJaufi I, Salem W. Salbutamol-Induced QT Interval Prolongation in a Two-Year-Old Patient. Cureus 2022; 14:e21904. [PMID: 35273858 PMCID: PMC8901152 DOI: 10.7759/cureus.21904] [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] [Accepted: 02/04/2022] [Indexed: 11/30/2022] Open
Abstract
Salbutamol-induced QT interval prolongation is a relatively rare adverse effect of beta2-agonists. We report a case of a two-year-old female patient with no known past medical history, brought by her parents to the ED 30 minutes after ingesting a total dose of 97 mg of salbutamol solution. ECG was done for the patient when she arrived and showed sinus tachycardia with prolonged QTc (509 ms) and normal QRS complex. The patient was admitted to the Pediatric Intensive Care Unit (PICU) with persistent tachycardia and tachypnea in the initial reassessment. ECG was repeated with normal QT interval after IV Mg sulfate. The patient was observed in PICU for 12 hours with serial ECG and venous blood gas (VBG). IV potassium chloride (KCL) infusion started, and serial VBG showed normal potassium and lactate. The patient was doing well in the next six hours, with normal serial ECG, labs, and vital signs. In conclusion, salbutamol-induced QT prolongation has infrequently been reported in the literature. Although inhaled salbutamol is commonly used in clinical practice, physicians have limited experience with the severe features of its toxicity. Salbutamol is known to cause minimal side effects, which may be under-recognized and progress to serious manifestations such as hypokalemia, QT prolongation, and sudden cardiac death.
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8
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Suppa M, Marino L. Empirical Antimicrobial Therapy and QTc Interval Prolongation in Emergency Medicine. Curr Drug Saf 2021; 17:13-16. [PMID: 34212831 DOI: 10.2174/1574886316666210629150105] [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: 11/09/2020] [Revised: 04/09/2021] [Accepted: 05/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND QTc prolongation is common though dangerous clinical condition associated with increased risk of life-threatening arrhythmia torsades de pointes. The goal of this short communication is to evaluate the principal causes of risk of QTc prolongation that are observed in an emergency department and discuss the differences between drug- and non-drug-associated factors. METHODS The retrospective analysis is carried out on 130 patients that presented a QTc prolongation (>480 ms for males and >470 for female, respectively) admitted to the emergency department of a single Italian hospital. Patients with pacemaker (22) were excluded from this study. For each patient a minimum of 3 ECGs (12 leads) was recorded. Attention is paid to electrolytes disturbances and pharmacotherapy, with a particular emphasis on the use of antibiotics. RESULTS Mean age of the patients was 79.6 years (SD=11.3), and females and males were almost equally present (46.6 % F, 53.7 % M). The average QTc value is 492.2 ms (493.3 ms F, 492.8 M). The patients were divided into those with electrolytes disturbances (24.0 %), antimicrobial therapy (35.2%), both antimicrobial therapy and electrolytes disturbances (24.1 %), and other causes of QTc prolongation (16.7 %). CONCLUSION This analysis shows the relevance of the empirical therapy established at the admission, in particular for infective diseases, as an important risk factor for the prolongation of QTc. Other factors that can increase the risk are electrolytes alterations, advanced age, cardiovascular diseases, and drug-drug interaction.
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Affiliation(s)
- Marianna Suppa
- Emergency Department, Policlinico "Umberto I", University "La Sapienza", Rome, Italy
| | - Luca Marino
- Mechanical and Aerospace Engineering Department and Emergency Department, Policlinico "Umberto I", University "La Sapienza", Rome, Italy
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9
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Sutherland H, Miller M, Tomanec A, Xu KT, Barton T, Richman P. QTc interval changes following low-dose ondansetron administration in the emergency department. Am J Emerg Med 2021; 55:201-202. [PMID: 34238644 DOI: 10.1016/j.ajem.2021.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Haley Sutherland
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, United States of America
| | - Michael Miller
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, United States of America
| | - Alainya Tomanec
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, United States of America
| | - K Tom Xu
- Department of Emergency Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United States of America
| | - Tanya Barton
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, United States of America
| | - Peter Richman
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, United States of America.
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10
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Methadone, Metoclopramide and Metronidazole Interaction Causing Torsades de Pointes. Clin Pract 2021; 11:101-105. [PMID: 33562182 PMCID: PMC7931031 DOI: 10.3390/clinpract11010015] [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: 12/04/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 01/08/2023] Open
Abstract
There are several classes of medications that can cause prolongation of the corrected QT (QTc) interval and potentially Torsades de Pointes (TdP). Most of these medications are commonly used in the emergency department, and interaction between these medications increases the risk of this iatrogenic complication. We describe a patient on methadone therapy who developed TdP after she received metoclopramide and metronidazole. Interaction between different classes of medications can increase the risk of QTc prolongation and TdP. Awareness of this condition and its risk factors need continuous reinforcement among all hospital personnel to reduce the risk of this life-threatening complication.
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11
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Leslie E, Medenbach A, Pittman E. Unmasking Long QT Syndrome in the Emergency Department: A Case Report. Clin Pract Cases Emerg Med 2021; 5:89-92. [PMID: 33560961 PMCID: PMC7872596 DOI: 10.5811/cpcem.2020.10.48716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/08/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both. Case Report A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department. Conclusion LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
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Affiliation(s)
- Eric Leslie
- United States Naval Hospital Okinawa, Department of Emergency Medicine, Okinawa, Japan
| | - Andrew Medenbach
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
| | - Eric Pittman
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
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12
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Farinelli LA, Piacentino D, Browning BD, Brewer BB, Leggio L. Cardiovascular Consequences of Excessive Alcohol Drinking via Electrocardiogram: A Systematic Review. J Addict Nurs 2021; 32:39-45. [PMID: 33646717 PMCID: PMC7927905 DOI: 10.1097/jan.0000000000000384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ABSTRACT There is a link between excessive alcohol drinking and an increased risk to develop cardiovascular disease, including alcoholic cardiomyopathy. This association warrants further research on the potential utility for the electrocardiogram (ECG) in the participatory management of the chronic consequences of alcohol use disorder (AUD). Our goal is to enhance understanding about the pernicious role alcohol plays on cardiac health using the ECG, an accessible, cost-effective, validated tool to inform novel targeted treatments for AUD. In this systematic review of human studies, we examine the relationship between abnormal clinically significant changes to ECG variables and excessive alcohol drinking with the goal of identifying key patterns specific to quantity of alcohol consumed. Three independent reviewers and one consensus reviewer, adhering to the PRISMA guidelines, conducted an initial review on studies published from database inception to April 19, 2019, using PubMed, Embase, CINAHL and COCHRANE databases. The initial search generated 2,225 articles. The final selected number included 153 original articles. This systematic review provides evidence of patterns of clinically significant changes to ECG variables as a consequence of excessive alcohol consumption. Future directions include investigating whether a real-time assessment, such as the ECG, in conjunction with other key behavioral and cardiac measures, can help clinicians and patients realize the progressive and insidious cardiac damage because of excessive alcohol consumption. This theory-guided nurse science review supports the development of personalized symptom monitoring to deliver tailored feedback that illuminate risk factors as a potentially transformative approach in the management of AUD.
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Affiliation(s)
- Lisa A. Farinelli
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore and Bethesda, MD
- College of Nursing, University of Arizona, Tucson, AZ
| | - Daria Piacentino
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore and Bethesda, MD
- Center on Compulsive Behaviors, National Institutes of Health Intramural Research Program, Bethesda, MD
| | - Brittney D. Browning
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore and Bethesda, MD
| | | | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore and Bethesda, MD
- Center on Compulsive Behaviors, National Institutes of Health Intramural Research Program, Bethesda, MD
- Medication Development Program, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, MD
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, Rhode Island
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Vasheghani M, Sarvghadi F, Beyranvand MR, Emami H. The relationship between QT interval indices with cardiac autonomic neuropathy in diabetic patients: a case control study. Diabetol Metab Syndr 2020; 12:102. [PMID: 33292470 PMCID: PMC7678155 DOI: 10.1186/s13098-020-00609-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/05/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Long QT interval (QT) and abnormal QT dispersion (QTd) are associated with sudden death. The relationship between cardiac autonomic neuropathy (CAN) and QT indices in type 2 diabetic patients were investigated. METHODS Totally 130 diabetic subjects (mean age 50.87 ± 13.9 years) were included (70 individuals with and 60 individuals without CAN). All participants had sinus cardiac rhythm. The patients who had diseases or take drugs that cause orthostatic hypotension (OH), cardiac arrhythmia and QT prolongation were excluded. After interview and examination, standard and continuous ECG was taken in supine position with deep breathing and standing up position. CAN diagnosis was based on Ewing's tests. QT, QT corrected (QTc), minimum QT (QT min), maximum QT (QT max) and mean ± SD of QT (QT mean) and QTd were assessed from standard ECG. QTc was calculated by Bazett's formula from V2 lead. QTc > 440 ms in men and QTc > 460 ms in women and QTd > 80 ms were considered abnormal. RESULTS In patients with CAN, 21.5% were symptomatic. The prevalence of abnormal QTc and QTd was 11.3% and 28.7%, respectively. There was no significant difference between the patients with or without CAN in terms of long QTc and abnormal QTd. However, the mean ± SD of QT max, QT mean and QTd was higher in the patients with CAN (P value < 0.03). The used cut points for QTc and QTd have high specificity (79% for both) and low sensitivity (30% and 37%, respectively). To use QTc and QTd as screening test for CAN in T2DM patients, the cutoff points 380 and 550 ms are suggested, respectively. CONCLUSION The prevalence of asymptomatic CAN was 3.7 times that of symptomatic CAN. In patients with CAN the QT max, QT mean and QTd were higher than those without CAN. There was no association between CAN and long QTc and abnormal QTd.
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Affiliation(s)
- Maryam Vasheghani
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzaneh Sarvghadi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Beyranvand
- Department of Cardiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Cardiology, Taleghani Educational Hospital, Tabnak St. Velenjak Region, Chamran High Way, 1985711151 Tehran , Iran
| | - Habib Emami
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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QTc Interval Prolongation Is a Proxy for Increased Short-Term Mortality. J Am Coll Cardiol 2020; 76:630-631. [DOI: 10.1016/j.jacc.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/24/2022]
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Farzanegan B, Hosseinpoor Z, Baniasadi S, Seyyedi SR, Rajabi M. An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors. Indian J Crit Care Med 2020; 24:270-275. [PMID: 32565638 PMCID: PMC7297246 DOI: 10.5005/jp-journals-10071-23411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIMS Despite the importance of abnormal QTc interval values in intensive care unit (ICU) patients, there is a paucity of information on this topic. The current study was designed to identify the incidence and predictors of QTc prolongation in medical (M), surgical (S), and emergency (E) ICUs. MATERIALS AND METHODS A prospective observational study was conducted for 6 months. Patients more than 18 years old who admitted to MICU, SICU, and EICU were included in the study. Electrocardiogram (ECG) was taken on day 1, 3, and 5 of ICU admission. The QTc intervals >460 ms in male and >470 ms in female and increased >60 ms above baseline were considered QTc prolongation. Comparative analysis was done between two groups of patients (normal vs prolonged QTc). Logistic regression models were carried out to determine the predictors of QTc prolongation. RESULTS Incidence of QTc prolongation was 6.5, 9.8, and 15.7% on day 1, 3, and 5 of ICU admission, respectively. On day 1, the history of alcohol addiction and the reason of ICU admission were associated with a prolonged QTc. A significant association was demonstrated between administration of azithromycin and QTc prolongation on day 3. High serum creatinine and hospitalization in EICU were predictors of QTc prolongation on day 5 of ICU admission. CONCLUSION The QTc prolongation is relatively common among patients admitted to ICUs and its incidence increases with increasing length of hospital stay. Predictors of QTc prolongation may be affected by the duration of ICU admission. Physicians should consider these predictors particularly before prescribing QTc-prolonging drugs. HOW TO CITE THIS ARTICLE Farzanegan B, Hosseinpoor Z, Baniasadi S, Seyyedi SR, Rajabi M. An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors. Indian J Crit Care Med 2020;24(4):270-275.
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Affiliation(s)
- Behrooz Farzanegan
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zeinab Hosseinpoor
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shadi Baniasadi
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed R Seyyedi
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Rajabi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Abstract
According to the National Alliance on Mental Illness, one in five adults experience a mental health condition yearly. Community-acquired pneumonia (CAP) is often treated with QTc prolonging antibiotics. The primary outcome assessed is if psychiatric diagnosis contributed to treatment failure in CAP. Outpatients with International Statistical Classification of Diseases and Related Health Problems 9 and 10 codes for CAP from January 2008 to January 2018 were analyzed retrospectively by descriptive statistics. Bivariate analysis was used to compare baseline characteristics, treatment regimens, and outcomes between those with a psychiatric diagnosis and those without. A χ-test was used for analysis of categorical variables and either the independent Student's t-test or one-way analysis of variance was used was used for analysis of continuous variables. Criteria were met by 518 patients, of which, 49% had a psychiatric diagnosis. Patients with psychiatric comorbidity were not more likely to experience treatment failure, subsequent admission, or mortality. There was no statistically significant difference between patients with a psychiatric diagnosis and those without in early or late CAP treatment failure (P=0.34 and 0.12), 30-day subsequent admission rates (P=0.41), 30-day mortality (P=0.34), or 90-day mortality (P=0.38). Psychiatric diagnosis increased the likelihood of a concomitant QTc prolonging psychiatric medication (51.78 vs. 3.40% P<0.0001), however, the prescribing rate of a QTc prolonging antibiotic was not statistically significantly different (85.3 vs. 83.4% P=0.54). Outpatients with mental illness can be treated for CAP without fear of increased risk of treatment failure compared with those without such diagnosis. This study emphasizes the necessity to consider the full patient history and diagnosis when treating patients with outpatient infections.
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Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
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Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
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Kaye P. Acquired pyloric stenosis resulting in hypokalaemic, hyperchloraemic normal anion gap metabolic acidosis. Persistent vomiting in an adult: cause and effect. BMJ Case Rep 2018; 2018:bcr-2017-222800. [PMID: 29348282 DOI: 10.1136/bcr-2017-222800] [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] [Indexed: 11/04/2022] Open
Abstract
A 24-year-old woman presented with a history of persistent vomiting for at least 3 months. This resulted in severe dehydration with risk of acute kidney injury. In addition to volume depletion, loss of gastric fluid resulted in a specific metabolic derangement-hypokalaemic, hypochloraemic normal anion gap metabolic alkalosis with a reduced ionised calcium concentration and paradoxical aciduria. These metabolic changes were reflected in her ECG. Investigation demonstrated acquired gastric outflow tract obstruction secondary to a pyloric peptic ulcer. The patient was resuscitated with intravenous crystalloid and electrolyte supplements. The acquired pyloric stenosis was treated medically with a proton pump inhibitor and Helicobacter pylori eradication therapy with excellent recovery.
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Affiliation(s)
- Philip Kaye
- Department of Emergency, Royal United Hospital, Bath, UK
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