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Sandhu RK, Qureshi H, Halperin H, Dover DC, Klassen N, Hawkins NM, Andrade JG, Kaul P. Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation. CJC Open 2024; 6:407-416. [PMID: 38487054 PMCID: PMC10935695 DOI: 10.1016/j.cjco.2023.09.021] [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: 08/08/2023] [Accepted: 09/29/2023] [Indexed: 03/17/2024] Open
Abstract
Background Healthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs. Methods All patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$). Results Among 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001). Conclusions Despite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients.
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Affiliation(s)
- Roopinder K. Sandhu
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Hena Qureshi
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Heather Halperin
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas C. Dover
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan Klassen
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathaniel M. Hawkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jason G. Andrade
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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2
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Stollings JL, Boncyk CS, Birdrow CI, Chen W, Raman R, Gupta DK, Roden DM, Rivera EL, Maiga AW, Rakhit S, Pandharipande PP, Ely EW, Girard TD, Patel MB. Antipsychotics and the QTc Interval During Delirium in the Intensive Care Unit: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352034. [PMID: 38252439 PMCID: PMC10804270 DOI: 10.1001/jamanetworkopen.2023.52034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/28/2023] [Indexed: 01/23/2024] Open
Abstract
Importance Antipsychotic medications, often prescribed for delirium in intensive care units (ICUs), may contribute to QTc interval prolongation. Objective To determine whether antipsychotics increase the QTc interval in patients with delirium in the ICU. Design, Setting, and Participants An a priori analysis of a randomized clinical trial in medical/surgical ICUs within 16 centers across the US was conducted. Participants included adults with delirium in the ICU with baseline QTc interval less than 550 ms. The study was conducted from December 2011 to August 2017. Data analysis was performed from April 25 to August 18, 2021. Interventions Patients were randomized 1:1:1 to intravenous haloperidol, ziprasidone, or saline placebo administered twice daily until resolution of delirium, ICU discharge, or 14 days. Main Outcomes and Measures Twelve-lead electrocardiograms were used to measure baseline QTc before study drug initiation and telemetry was used to measure QTc before each subsequent dose of study drug. Unadjusted day-to-day changes in QTc were calculated and multivariable proportional odds regression was used to estimate the effects of antipsychotics vs placebo on next-day maximum QTc interval, adjusting for prespecified baseline covariates and potential interactions with sex. Safety end points, including the occurrence of torsade de pointes, were evaluated. All analyses were conducted based on the intention to treat principle. Results A total of 566 patients were randomized to haloperidol (n = 192), ziprasidone (n = 190), or placebo (n = 184). Median age was 60.1 (IQR, 51.4-68.7) years; 323 were men (57%). Baseline median QTc intervals across the groups were similar: haloperidol, 458.0 (IQR, 432.0-479.0) ms; ziprasidone, 451.0 (IQR, 424.0-472.0) ms; and placebo, 452.0 (IQR, 432.0-472.0) ms. From day 1 to day 2, median QTc changed minimally: haloperidol, -1.0 (IQR, -28.0 to 15.0) ms; ziprasidone, 0 (IQR, -23.0 to 20.0) ms; and placebo, -3.5 (IQR, -24.8 to 17.0) ms. Compared with placebo, neither haloperidol (odds ratio [OR], 0.95; 95% CI, 0.66-1.37; P = .78) nor ziprasidone (OR, 1.09; 95% CI, 0.75-1.57; P = .78) was associated with next-day QTc intervals. Effects were not significantly modified by sex (P = .41 for interaction). There were 2 occurrences of nonfatal torsade de pointes, both in the haloperidol group. Neither was associated with study drug administration. Conclusions and Relevance The findings of this trial suggest that daily QTc interval monitoring during antipsychotic use may have limited value in patients in the ICU with normal baseline QTc and few risk factors for QTc prolongation. Trial Registration ClinicalTrials.gov Identifier: NCT01211522.
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Affiliation(s)
- Joanna L. Stollings
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S. Boncyk
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caroline I. Birdrow
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wencong Chen
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deepak K. Gupta
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Heart Imaging Core Lab, Vanderbilt Translational and Clinical Cardiovascular Research Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M. Roden
- Department of Medicine, Departments of Pharmacology and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Erika L. Rivera
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Amelia W. Maiga
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Anesthesia Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy D. Girard
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research, Investigation, and Systems Modeling of Acute Illness in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mayur B. Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
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3
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Dofetilide Dose Reductions and Discontinuation in Obese Compared with Nonobese Patients. J Cardiovasc Pharmacol 2022; 80:820-825. [PMID: 35976119 DOI: 10.1097/fjc.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022]
Abstract
ABSTRACT Dofetilide is an antiarrhythmic agent and primarily eliminated renally. Initial dosing is determined by creatinine clearance, calculated by total body weight in the Cockcroft-Gault equation. To date, there is no evidence comparing the dosing of dofetilide in obese versus nonobese patients. We conducted a retrospective review of 217 adults admitted for dofetilide loading to evaluate the tolerability of dofetilide in obese versus nonobese patients. The rate of dose adjustments, including dose reductions and discontinuations, was compared between obese versus nonobese patients in unadjusted and adjusted analyses. Electrocardiograms were collected throughout the loading period, and calculation of QT intervals was performed. Obese patients did not have a significantly higher frequency of dose adjustments compared with nonobese patients (51.5% vs. 44.8%, P = 0.33). Using total body weight to determine starting doses was associated with great odds of dose adjustments compared with ideal body weight (OR 3.69, P = 0.002) and adjusted body weight (OR 4.46, P = 0.02). Men required significantly fewer dose adjustments compared with women on multivariate analysis (OR 0.53, P = 0.03). Obesity is not associated with an increase in the rate of dose adjustments. Total body weight should be used with caution to calculate initial doses of dofetilide in women because it may lead to a higher rate of dose adjustments compared with ideal body weight. Additional studies are needed to confirm the optimal method for selecting starting doses of dofetilide in women, particularly those with a body mass index of ≥30.
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Gomez SE, Fazal M, Nunes JC, Shah S, Perino AC, Narayan SM, Tamirisa KP, Han JK, Rodriguez F, Baykaner T. Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01383-x. [PMID: 36224481 PMCID: PMC10097842 DOI: 10.1007/s10840-022-01383-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups. METHODS This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials. RESULTS Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection. CONCLUSION Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.
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Affiliation(s)
- Sofia E Gomez
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Muhammad Fazal
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Julio C Nunes
- Stanford Center for Clinical Research, Stanford University, Stanford, CA, USA.,Department of Psychiatry, Yale University, New Haven, CT, USA.,Cardiac Arrhythmia Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Shayena Shah
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | | | - Janet K Han
- Cardiac Arrhythmia Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine, UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Tina Baykaner
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA.
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5
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Zeitler EP, Poole JE, Albert CM, Al-Khatib SM, Ali-Ahmed F, Birgersdotter-Green U, Cha YM, Chung MK, Curtis AB, Hurwitz JL, Lampert R, Sandhu RK, Shaik F, Sullivan E, Tamirisa KP, Santos Volgman A, Wright JM, Russo AM. Arrhythmias in Female Patients: Incidence, Presentation and Management. Circ Res 2022; 130:474-495. [PMID: 35175839 DOI: 10.1161/circresaha.121.319893] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.
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Affiliation(s)
- Emily P Zeitler
- The Geisel School of Medicine at Dartmouth, Hanover, NH (E.P.Z.).,Division of Cardiology, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, NH (E.P.Z.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.M.A.-K.)
| | | | | | - Yong-Mei Cha
- Mayo Clinic, St Mary's Campus, Rochester, MN (F.A.-A., Y.-M.C.)
| | | | - Anne B Curtis
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo General Medical Center, NY (A.B.C.)
| | | | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (R.L.)
| | - Roopinder K Sandhu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Fatima Shaik
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
| | | | | | | | - Jennifer M Wright
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI (J.M.W.)
| | - Andrea M Russo
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
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6
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Qi Z, Yang S, Li M, Qu J, Han Q, Zheng J, Wang H. Risk factors and predictors of QTc prolongation in critically ill Chinese patients. Am J Emerg Med 2021; 49:24-28. [PMID: 34051398 DOI: 10.1016/j.ajem.2021.05.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To recognize and validate the predictor of risk factors for ICU patients with QTc intervals ≥500 ms. METHODS We retrospectively reviewed 160 ICU patients with their medical electronic records including all demographic data, diagnosis measurements, ECGs and medication from March 1, 2018 to December 1, 2018. All information of patients' baseline, comorbidities, electrolytes and Long QT syndrome (LQTS)-inducing medications of patients with QT interval corrected (QTc) ≥ 500 ms (n = 80) and <500 ms (n = 80) were collected and analyzed using univariate and multivariate analyses to find predictors. RESULTS Comparing to patients with QTc < 500 ms, patients with QTc ≥ 500 ms had increased SOFA (P = 0.010) and APACHE II scores (P = 0.002), longer lengths of ICU stays (P < 0.001), greater incidence of congestive heart failure (P = 0.005) and more preset risk factors (P < 0.001). The frequency of administration of mosapride (P = 0.015), amiodarone (P = 0.027) and number of combined LQTS-inducing medications (P = 0.012) were greater in patients with QTc ≥ 500 ms than in those with QTc < 500 ms. But after multivariate analysis, we found that risk factors related to a QTc ≥ 500 ms were only congestive heart failure (OR: 5.28), number of combined LQTS-inducing medications (OR: 1.60) and APACHE II score (OR: 1.08). CONCLUSIONS For critically ill patients, congestive heart failure, number of combined LQTS-inducing medications and APACHE II score are proved as risk factors associated with QTc > 500 ms.
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Affiliation(s)
- Zhidong Qi
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Sibo Yang
- Department of Pediatrics, The 1st Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ming Li
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jingdong Qu
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiuyuan Han
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Junbo Zheng
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huaiquan Wang
- Department of Critical Care, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China.
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7
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Ballouz S, Mangala MM, Perry MD, Heitmann S, Gillis JA, Hill AP, Vandenberg JI. Co-expression of calcium and hERG potassium channels reduces the incidence of proarrhythmic events. Cardiovasc Res 2020; 117:2216-2227. [PMID: 33002116 DOI: 10.1093/cvr/cvaa280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 01/02/2023] Open
Abstract
AIMS Cardiac electrical activity is extraordinarily robust. However, when it goes wrong it can have fatal consequences. Electrical activity in the heart is controlled by the carefully orchestrated activity of more than a dozen different ion conductances. While there is considerable variability in cardiac ion channel expression levels between individuals, studies in rodents have indicated that there are modules of ion channels whose expression co-vary. The aim of this study was to investigate whether meta-analytic co-expression analysis of large-scale gene expression datasets could identify modules of co-expressed cardiac ion channel genes in human hearts that are of functional importance. METHODS AND RESULTS Meta-analysis of 3653 public human RNA-seq datasets identified a strong correlation between expression of CACNA1C (L-type calcium current, ICaL) and KCNH2 (rapid delayed rectifier K+ current, IKr), which was also observed in human adult heart tissue samples. In silico modelling suggested that co-expression of CACNA1C and KCNH2 would limit the variability in action potential duration seen with variations in expression of ion channel genes and reduce susceptibility to early afterdepolarizations, a surrogate marker for proarrhythmia. We also found that levels of KCNH2 and CACNA1C expression are correlated in human-induced pluripotent stem cell-derived cardiac myocytes and the levels of CACNA1C and KCNH2 expression were inversely correlated with the magnitude of changes in repolarization duration following inhibition of IKr. CONCLUSION Meta-analytic approaches of multiple independent human gene expression datasets can be used to identify gene modules that are important for regulating heart function. Specifically, we have verified that there is co-expression of CACNA1C and KCNH2 ion channel genes in human heart tissue, and in silico analyses suggest that CACNA1C-KCNH2 co-expression increases the robustness of cardiac electrical activity.
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Affiliation(s)
- Sara Ballouz
- Garvan-Weizmann Centre for Cellular Genomics, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst NSW 2010, Australia.,University of New South Wales, Sydney, Kensington, NSW 2052, Australia.,Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, Cold Spring Harbor, One Bungtown Road, NY 11724, USA
| | - Melissa M Mangala
- Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Matthew D Perry
- University of New South Wales, Sydney, Kensington, NSW 2052, Australia.,Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Stewart Heitmann
- Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Jesse A Gillis
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, Cold Spring Harbor, One Bungtown Road, NY 11724, USA
| | - Adam P Hill
- University of New South Wales, Sydney, Kensington, NSW 2052, Australia.,Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Jamie I Vandenberg
- University of New South Wales, Sydney, Kensington, NSW 2052, Australia.,Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
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8
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Chorin E, Wadhwani L, Magnani S, Dai M, Shulman E, Nadeau-Routhier C, Knotts R, Bar-Cohen R, Kogan E, Barbhaiya C, Aizer A, Holmes D, Bernstein S, Spinelli M, Park DS, Stefano C, Chinitz LA, Jankelson L. QT interval prolongation and torsade de pointes in patients with COVID-19 treated with hydroxychloroquine/azithromycin. Heart Rhythm 2020; 17:1425-1433. [PMID: 32407884 PMCID: PMC7214283 DOI: 10.1016/j.hrthm.2020.05.014] [Citation(s) in RCA: 196] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background There is no known effective therapy for patients with coronavirus disease 2019 (COVID-19). Initial reports suggesting the potential benefit of hydroxychloroquine/azithromycin (HY/AZ) have resulted in massive adoption of this combination worldwide. However, while the true efficacy of this regimen is unknown, initial reports have raised concerns about the potential risk of QT interval prolongation and induction of torsade de pointes (TdP). Objective The purpose of this study was to assess the change in corrected QT (QTc) interval and arrhythmic events in patients with COVID-19 treated with HY/AZ. Methods This is a retrospective study of 251 patients from 2 centers who were diagnosed with COVID-19 and treated with HY/AZ. We reviewed electrocardiographic tracings from baseline and until 3 days after the completion of therapy to determine the progression of QTc interval and the incidence of arrhythmia and mortality. Results The QTc interval prolonged in parallel with increasing drug exposure and incompletely shortened after its completion. Extreme new QTc interval prolongation to >500 ms, a known marker of high risk of TdP, had developed in 23% of patients. One patient developed polymorphic ventricular tachycardia suspected as TdP, requiring emergent cardioversion. Seven patients required premature termination of therapy. The baseline QTc interval of patients exhibiting extreme QTc interval prolongation was normal. Conclusion The combination of HY/AZ significantly prolongs the QTc interval in patients with COVID-19. This prolongation may be responsible for life-threatening arrhythmia in the form of TdP. This risk mandates careful consideration of HY/AZ therapy in light of its unproven efficacy. Strict QTc interval monitoring should be performed if the regimen is given.
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Affiliation(s)
- Ehud Chorin
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Lalit Wadhwani
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Silvia Magnani
- Division of Cardiology, Department of Health Science, San Paolo Hospital, University of Milan, Milan, Italy
| | - Matthew Dai
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Eric Shulman
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Charles Nadeau-Routhier
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Robert Knotts
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Roi Bar-Cohen
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Edward Kogan
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Chirag Barbhaiya
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Michael Spinelli
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - David S Park
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Carugo Stefano
- Division of Cardiology, Department of Health Science, San Paolo Hospital, University of Milan, Milan, Italy
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York
| | - Lior Jankelson
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York.
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9
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Stabenau HF, Shen C, Zimetbaum P, Buxton AE, Tereshchenko LG, Waks JW. Global electrical heterogeneity associated with drug-induced torsades de pointes. Heart Rhythm 2020; 18:57-62. [PMID: 32781158 DOI: 10.1016/j.hrthm.2020.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Drugs belonging to diverse therapeutic classes can prolong myocardial refractoriness or slow conduction. These drugs may be effective and well-tolerated, but the risk of sudden cardiac death from torsades de pointes (TdP) remains a major concern. The corrected QT interval has significant limitations when used for risk stratification. Measurement of global electrical heterogeneity (GEH) could help identify the substrate vulnerable to drug-induced ventricular arrhythmias. OBJECTIVE The purpose of this study was to improve risk stratification for drug-induced TdP by measuring GEH on the electrocardiogram (ECG). METHODS We analyzed ECG data from a case-control study of patients with a history of drug-induced TdP as well as age- and sex-matched controls. Vectorcardiograms were constructed from ECGs. GEH was measured via the spatial ventricular gradient (SVG) vector (magnitude, azimuth, and elevation). Log odds coefficients for TdP were estimated using multivariable logistic regression. RESULTS Among 17 cases (47% male; age 58.9 ± 12.5 years) and 17 controls (29% male; age 61.0 ± 12.2 years), 34 ECGs were analyzed. SVG azimuth was significantly different between cases and controls (3.4 vs 22.0 degrees, respectively; P = 0.02). After adjusting for sex and QTc interval, odds of TdP increased by a factor of 3.2 for each 1 SD change in SVG azimuth from the control group mean (95% confidence interval 1.07-9.14; P = .04). QTc was not significant in the multivariable analysis (P = .20). CONCLUSION SVG azimuth is correlated with a history of drug-induced TdP independent of QTc. GEH measurement may help identify patients at high risk for drug-induced arrhythmias.
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Affiliation(s)
- Hans F Stabenau
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Peter Zimetbaum
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alfred E Buxton
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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10
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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11
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Stabenau HF, Shen C, Tereshchenko LG, Waks JW. Changes in global electrical heterogeneity associated with dofetilide, quinidine, ranolazine, and verapamil. Heart Rhythm 2019; 17:460-467. [PMID: 31539628 DOI: 10.1016/j.hrthm.2019.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) markers of antiarrhythmic drug (AAD) activity could be used to optimize efficacy and minimize toxicity. Vectorcardiographic global electrical heterogeneity (GEH) is associated with ventricular arrhythmias and sudden death, but it is unclear how GEH measurements change in response to AADs. OBJECTIVE The purpose of this study was to characterize acute effects of AADs on GEH measurements. METHODS We analyzed double-blind placebo-controlled trial data from healthy volunteers given 1 dose of placebo, dofetilide, quinidine, ranolazine, or verapamil on subsequent visits. Serial ECGs and plasma drug concentrations were collected. Vectorcardiographic GEH parameters (spatial ventricular gradient [SVG], spatial QRST angle, sum absolute QRST integral, and SVG-QRS peak angle) were measured. Placebo-corrected change from baseline was regressed on drug concentration stratified by sex using linear mixed effects models. RESULTS Among 22 persons (11 (50%) male median age 27 ± 5 years), 5232 ECGs were analyzed. Dofetilide and quinidine were associated with significant changes in more GEH parameters (5) compared with verapamil (2) and ranolazine (1). The most notable change occurred in SVG azimuth, with largest changes (degrees per unit normalized drug concentration) in dofetilide (6.1; 95% confidence interval [CI] 4.2-8.0) and quinidine (9.4; 95% CI 6.7-12.0), and smaller effects in verapamil (4.4; 95% CI 2.9-5.9) and ranolazine (5.4; 95% CI 3.5-7.3). AAD-induced GEH changes significantly differed in men and women. CONCLUSION AADs change GEH measurements. These changes, which differ by sex, are likely driven by alterations in ion channel function and dispersion of depolarization or repolarization. GEH measurement may allow early assessment of favorable or adverse AAD effects.
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Affiliation(s)
- Hans Friedrich Stabenau
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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12
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Safety of rapid switching from amiodarone to dofetilide in atrial fibrillation patients with an implantable cardioverter–defibrillator. Heart Rhythm 2019; 16:990-995. [DOI: 10.1016/j.hrthm.2019.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Indexed: 11/20/2022]
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13
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Weberndörfer V, Beinart R, Ricciardi D, Ector J, Mahfoud M, Szeplaki G, Hemels M. Sex differences in rate and rhythm control for atrial fibrillation. Europace 2019; 21:690-697. [DOI: 10.1093/europace/euy295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/28/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Vanessa Weberndörfer
- Cardiology Department, Heart Center Lucerne, Spitalstrasse, Luzern, Switzerland
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roy Beinart
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Leviev Heart Institute, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Danilo Ricciardi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Joris Ector
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Mohanad Mahfoud
- Service de cardiologie, Centre hospitalier sud francilien, 116 boulevard jean Jaures, Corbeil-Essonnes, France
| | - Gabor Szeplaki
- Heart and Vascular Centre, Mater Private Hospital, 72 Eccles Street, Dublin 7, Ireland
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Martin Hemels
- Department of Cardiology, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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14
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Potentially modifiable factors of dofetilide-associated risk of torsades de pointes among hospitalized patients with atrial fibrillation. J Interv Card Electrophysiol 2018; 54:189-196. [DOI: 10.1007/s10840-018-0476-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/11/2018] [Indexed: 01/08/2023]
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15
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Linde C, Bongiorni MG, Birgersdotter-Green U, Curtis AB, Deisenhofer I, Furokawa T, Gillis AM, Haugaa KH, Lip GYH, Van Gelder I, Malik M, Poole J, Potpara T, Savelieva I, Sarkozy A. Sex differences in cardiac arrhythmia: a consensus document of the European Heart Rhythm Association, endorsed by the Heart Rhythm Society and Asia Pacific Heart Rhythm Society. Europace 2018; 20:1565-1565ao. [PMID: 29961863 DOI: 10.1093/europace/euy067] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital, S-17176 Stockholm, Sweden
| | | | | | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | | | - Anne M Gillis
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute of Alberta, Alberta, Canada
| | - Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Thrombosis Research Unit, Aalborg University, Denmark
| | - Isabelle Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London
| | - Jeannie Poole
- University of Washington Medical center, Seattle, Washington, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Irina Savelieva
- St. George's, University of London, Cranmer Terrace, London, UK
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
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16
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Pokorney SD, Yen DC, Campbell KB, Allen LaPointe NM, Sheng S, Thomas L, Bahnson TD, Daubert JP, Picini JP, Jackson KP, Thomas KL, Al-Khatib SM. Dofetilide dose reductions and discontinuations in women compared with men. Heart Rhythm 2018; 15:478-484. [DOI: 10.1016/j.hrthm.2018.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Indexed: 11/30/2022]
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17
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Cheng G, Wu J, Han W, Sun C. F463L increases the potential of dofetilide on human ether-a-go-go-related gene (hERG) channels. Microsc Res Tech 2018; 81:663-668. [PMID: 29573040 DOI: 10.1002/jemt.23021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 02/02/2018] [Accepted: 03/02/2018] [Indexed: 11/11/2022]
Abstract
Mutations in genes related to long QT syndrome (LQTS) is recognized as an independent risk of drug-induced LQTS. We previously screened a mutation F463L in a Chinese patient with LQT2, syncope, and epilepsy. Here, we planned to illustrate how F463L influences the action of dofetilide on hERG channels. F463L-hERG plasmids were transfected into the stable Human Embryonic Kidney 293 (HEK293) cells expressing WT-hERG to generate heterozygous mutant (WT + F463L-hERG). Whole-cell patch clamp and laser confocal scanning microscopy were used to evaluate electrophysiological consequences and the membrane distribution of hERG protein. In comparison of WT-hERG channels exposed to dofetilide, heterozygous F463L-hERG channels showed a reduction in the density of tail currents when exposed amidarone. F463L-hERG also altered the action of dofetilide on the gating properties of hERG channels. Images of dofetilide-treated cells expressing heterozygous F463L showed a severe retention and reduction of protein expression on the membrane compared to WT. In conclusion, dofetilide displays a powerful inhibitory effect on the currents from cells expressing heterozygous F463L, thus showing an additive suppression of currents by F463L with dofetilide.
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Affiliation(s)
- Gong Cheng
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R.,Cardiovascular Medicine, Shaanxi Provincial People's Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710068, China
| | - Jine Wu
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R
| | - Wenqi Han
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R
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18
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Dunnink A, Stams TRG, Bossu A, Meijborg VMF, Beekman JDM, Wijers SC, De Bakker JMT, Vos MA. Torsade de pointes arrhythmias arise at the site of maximal heterogeneity of repolarization in the chronic complete atrioventricular block dog. Europace 2018; 19:858-865. [PMID: 28525920 DOI: 10.1093/europace/euw087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/09/2016] [Indexed: 01/04/2023] Open
Abstract
Aims The chronic complete atrioventricular block (CAVB) dog is highly sensitive for drug-induced torsade de pointes (TdP) arrhythmias. Focal mechanisms have been suggested as trigger for TdP onset; however, its exact mechanism remains unclear. In this study, detailed mapping of the ventricles was performed to assess intraventricular heterogeneity of repolarization in relation to the initiation of TdP. Methods and results In 8 CAVB animals, 56 needles, each containing 4 electrodes, were inserted in the ventricles. During right ventricular apex pacing (cycle length: 1000-1500 ms), local unipolar electrograms were recorded before and after administration of dofetilide to determine activation and repolarization times (RTs). Maximal RT differences were calculated in the left ventricle (LV) within adjacent electrodes in different orientations (transmural, vertical, and horizontal) and within a square of four needles (cubic dispersion). Dofetilide induced TdP in five out of eight animals. Right ventricle-LV was similar between inducible and non-inducible dogs at baseline (327 ± 30 vs. 345 ± 17 ms) and after dofetilide administration (525 ± 95 vs. 508 ± 15 ms). All measurements of intraventricular dispersion were not different at baseline, but this changed for horizontal (206 ± 20 vs. 142 ± 34 ms) and cubic dispersion (272 ± 29 vs. 176 ± 48 ms) after dofetilide: significantly higher values in inducible animals. Single ectopic beats and the first TdP beat arose consistently from a subendocardially located electrode terminal with the shortest RT in the region with largest RT differences. Conclusion Chronic complete atrioventricular block dogs susceptible for TdP demonstrate higher RT differences. Torsade de pointes arises from a region with maximal heterogeneity of repolarization suggesting that a minimal gradient is required in order to initiate TdP.
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Affiliation(s)
- Albert Dunnink
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
| | - Thom R G Stams
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
| | - Alexandre Bossu
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
| | - Veronique M F Meijborg
- Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Jet D M Beekman
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
| | - Sofieke C Wijers
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
| | - Jacques M T De Bakker
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands.,Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Marc A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, Utrecht 3584 CM, The Netherlands
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19
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Moore JC, Trager L, Anzia LE, Saliba W, Bassiouny M, Bhargava M, Chung M, Desai M, Garberich R, Lever H, Lindsay BD, Sengupta J, Tchou P, Wazni O, Wilkoff BL. Dofetilide for suppression of atrial fibrillation in hypertrophic cardiomyopathy: A case series and literature review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:396-401. [DOI: 10.1111/pace.13310] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/02/2018] [Accepted: 02/10/2018] [Indexed: 12/18/2022]
Affiliation(s)
| | | | | | - Walid Saliba
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Mohamed Bassiouny
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Mandeep Bhargava
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Mina Chung
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Milind Desai
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Harry Lever
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Bruce D. Lindsay
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | | | - Patrick Tchou
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Oussama Wazni
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
| | - Bruce L. Wilkoff
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Cleveland OH USA
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20
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Dan GA, Martinez-Rubio A, Agewall S, Boriani G, Borggrefe M, Gaita F, van Gelder I, Gorenek B, Kaski JC, Kjeldsen K, Lip GYH, Merkely B, Okumura K, Piccini JP, Potpara T, Poulsen BK, Saba M, Savelieva I, Tamargo JL, Wolpert C, Sticherling C, Ehrlich JR, Schilling R, Pavlovic N, De Potter T, Lubinski A, Svendsen JH, Ching K, Sapp JL, Chen-Scarabelli C, Martinez F. Antiarrhythmic drugs–clinical use and clinical decision making: a consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy (ISCP). Europace 2018; 20:731-732an. [DOI: 10.1093/europace/eux373] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/11/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Gheorghe-Andrei Dan
- Colentina University Hospital, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Antoni Martinez-Rubio
- University Hospital of Sabadell (University Autonoma of Barcelona), Plaça Cívica, Campus de la UAB, Barcelona, Spain
| | - Stefan Agewall
- Oslo University Hospital Ullevål, Norway
- Institute of Clinical Sciences, University of Oslo, Søsterhjemmet, Oslo, Norway
| | - Giuseppe Boriani
- Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martin Borggrefe
- Universitaetsmedizin Mannheim, Medizinische Klinik, Mannheim, Germany
| | - Fiorenzo Gaita
- Department of Medical Sciences, University of Turin, Citta' della Salute e della Scienza Hospital, Turin, Italy
| | - Isabelle van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bulent Gorenek
- Department of Cardiology, Eskisehir Osmangazi University, Büyükdere Mahallesi, Odunpazarı/Eskişehir, Turkey
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Keld Kjeldsen
- Copenhagen University Hospital (Holbæk Hospital), Holbæk, Institute for Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Centre For Cardiovascular Sciences, City Hospital, Birmingham, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ken Okumura
- Saiseikai Akumamoto Hospital, Kumamoto, Japan
| | | | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Magdi Saba
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Irina Savelieva
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Juan L Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense Madrid, Madrid, Spain
| | - Christian Wolpert
- Department of Medicine - Cardiology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Joachim R Ehrlich
- Medizinische Klinik I-Kardiologie, Angiologie, Pneumologie, Wiesbaden, Germany
| | - Richard Schilling
- Barts Heart Centre, Trustee Arrhythmia Alliance and Atrial Fibrillation Association, London, UK
| | - Nikola Pavlovic
- Department of Cardiology, University Hospital Centre Sestre milosrdnice, Croatia
| | | | - Andrzej Lubinski
- Uniwersytet Medyczny w Łodzi, Kierownik Kliniki Kardiologii Interwencyjnej, i Zaburzeń Rytmu Serca, Kierownik Katedry Chorób Wewnętrznych i Kardiologii, Uniwersytecki Szpital Kliniczny im WAM-Centralny Szpital Weteranów, Poland
| | | | - Keong Ching
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | | | - Felipe Martinez
- Instituto DAMIC/Fundacion Rusculleda, Universidad Nacional de Córdoba, Córdoba, Argentina
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Arrhythmogenic drugs can amplify spatial heterogeneities in the electrical restitution in perfused guinea-pig heart: An evidence from assessments of monophasic action potential durations and JT intervals. PLoS One 2018; 13:e0191514. [PMID: 29352276 PMCID: PMC5774816 DOI: 10.1371/journal.pone.0191514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/06/2018] [Indexed: 01/01/2023] Open
Abstract
Non-uniform shortening of the action potential duration (APD90) in different myocardial regions upon heart rate acceleration can set abnormal repolarization gradients and promote arrhythmia. This study examined whether spatial heterogeneities in APD90 restitution can be amplified by drugs with clinically proved proarrhythmic potential (dofetilide, quinidine, procainamide, and flecainide) and, if so, whether these effects can translate to the appropriate changes of the ECG metrics of ventricular repolarization, such as JT intervals. In isolated, perfused guinea-pig heart preparations, monophasic action potentials and volume-conducted ECG were recorded at progressively increased pacing rates. The APD90 measured at distinct ventricular sites, as well as the JTpeak and JTend values were plotted as a function of preceding diastolic interval, and the maximum slopes of the restitution curves were determined at baseline and upon drug administration. Dofetilide, quinidine, and procainamide reverse rate-dependently prolonged APD90 and steepened the restitution curve, with effects being greater at the endocardium than epicardium, and in the right ventricular (RV) vs. the left ventricular (LV) chamber. The restitution slope was increased to a greater extent for the JTend vs. the JTpeak interval. In contrast, flecainide reduced the APD90 restitution slope at LV epicardium without producing effect at LV endocardium and RV epicardium, and reduced the JTpeak restitution slope without changing the JTend restitution. Nevertheless, with all agents, these effects translated to the amplified epicardial-to-endocardial and the LV-to-RV non-uniformities in APD90 restitution, paralleled by the increased JTend vs. JTpeak difference in the restitution slope. In summary, these findings suggest that arrhythmic drug profiles are partly attributable to the accentuated regional heterogeneities in APD90 restitution, which can be indirectly determined through ECG assessments of the JTend vs. JTpeak dynamics at variable pacing rates.
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Johannesen L, Garnett C, Luo M, Targum S, Sørensen JS, Mehrotra N. Quantitative Understanding of QTc Prolongation and Gender as Risk Factors for Torsade de Pointes. Clin Pharmacol Ther 2017; 103:304-309. [PMID: 29219167 DOI: 10.1002/cpt.783] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
Several risk factors for development of a potentially fatal ventricular arrhythmia, torsade de pointes, have been observed, including female gender. However, in most investigations, only few torsade events were included and/or rarely were postdose heart rate corrected QT (QTc) measurements included, as a surrogate of drug exposure. We developed a multivariate logistic regression model using data from 22,214 patients (33% women) with 84 torsade events (56% women) to evaluate the relationship between risk factors for torsade using data from four anti-arrhythmic drug development programs. Before model development, we evaluated different QT/QTc postdose metrics (average, maximum, etc.) to determine which QT metric should be included into the model. The developed multivariate model showed that, after accounting for known risk factors for torsade and postdose QTc, that female gender remained a significant risk factor for torsade.
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Affiliation(s)
- Lars Johannesen
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Man Luo
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shari Targum
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jens Stampe Sørensen
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nitin Mehrotra
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Osadchii OE. Role of abnormal repolarization in the mechanism of cardiac arrhythmia. Acta Physiol (Oxf) 2017; 220 Suppl 712:1-71. [PMID: 28707396 DOI: 10.1111/apha.12902] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In cardiac patients, life-threatening tachyarrhythmia is often precipitated by abnormal changes in ventricular repolarization and refractoriness. Repolarization abnormalities typically evolve as a consequence of impaired function of outward K+ currents in cardiac myocytes, which may be caused by genetic defects or result from various acquired pathophysiological conditions, including electrical remodelling in cardiac disease, ion channel modulation by clinically used pharmacological agents, and systemic electrolyte disorders seen in heart failure, such as hypokalaemia. Cardiac electrical instability attributed to abnormal repolarization relies on the complex interplay between a provocative arrhythmic trigger and vulnerable arrhythmic substrate, with a central role played by the excessive prolongation of ventricular action potential duration, impaired intracellular Ca2+ handling, and slowed impulse conduction. This review outlines the electrical activity of ventricular myocytes in normal conditions and cardiac disease, describes classical electrophysiological mechanisms of cardiac arrhythmia, and provides an update on repolarization-related surrogates currently used to assess arrhythmic propensity, including spatial dispersion of repolarization, activation-repolarization coupling, electrical restitution, TRIaD (triangulation, reverse use dependence, instability, and dispersion), and the electromechanical window. This is followed by a discussion of the mechanisms that account for the dependence of arrhythmic vulnerability on the location of the ventricular pacing site. Finally, the review clarifies the electrophysiological basis for cardiac arrhythmia produced by hypokalaemia, and gives insight into the clinical importance and pathophysiology of drug-induced arrhythmia, with particular focus on class Ia (quinidine, procainamide) and Ic (flecainide) Na+ channel blockers, and class III antiarrhythmic agents that block the delayed rectifier K+ channel (dofetilide).
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Affiliation(s)
- O. E. Osadchii
- Department of Health Science and Technology; University of Aalborg; Aalborg Denmark
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Turagam MK, Afzal MR, Reddy M, Pillarisetti J, Lavu M, Atkins D, Jeffrey C, Christensen K, Pimentel R, Dendi R, Vacek J, Hurwitz J, Di Biase L, Natale A, Lakkireddy D. Practice variation in the re-initiation of dofetilide: An observational study. Int J Cardiol 2017; 236:221-225. [DOI: 10.1016/j.ijcard.2017.01.157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/11/2017] [Accepted: 01/31/2017] [Indexed: 11/30/2022]
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Osadchii OE. Assessments of the QT/QRS restitution in perfused guinea-pig heart can discriminate safe and arrhythmogenic drugs. J Pharmacol Toxicol Methods 2017; 87:27-37. [PMID: 28552278 DOI: 10.1016/j.vascn.2017.04.010] [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: 12/06/2016] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Drug-induced arrhythmia remains a matter of serious clinical concern, partly due to low prognostic value of currently available arrhythmic biomarkers. METHODS This study examined whether arrhythmogenic risks can be predicted through assessments of the rate adaptation of QT interval, ventricular effective refractory period (ERP), or the QT/QRS ratio, in perfused guinea-pig hearts. RESULTS When the maximum restitution slope was taken as a metric of proarrhythmia, neither QT interval nor ERP measurements at progressively increased pacing rates were found to fully discriminate arrhythmogenic drugs (dofetilide, quinidine, flecainide, and procainamide) from those recognized as safe antiarrhythmics (lidocaine and mexiletine). For example, the slope of QT restitution was increased by dofetilide and quinidine, but remained unchanged by flecainide, procainamide, lidocaine, and mexiletine. With ERP rate adaptation, even though the restitution slope was increased by dofetilide, all class I agents reduced the slope value independently of their safety profile. The QRS measurements revealed variable drug effects, ranging from significant use-dependent conduction slowing (flecainide, quinidine, and procainamide) to only modest increase in QRS (lidocaine and mexiletine), or no change at all (dofetilide). However, with the QT/QRS rate adaptation, the restitution slope was significantly increased by all agents which have been reported to produce proarrhythmic effects (dofetilide, quinidine, flecainide, and procainamide), but not changed by lidocaine and mexiletine. DISCUSSION These findings suggest that the slope of the QT/QRS rate adaptation can be considered as a novel electrophysiological biomarker in predicting potential arrhythmic risks associated with pharmacotherapy in cardiac patients.
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Affiliation(s)
- Oleg E Osadchii
- Department of Biomedical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark; Department of Health Science and Technology, University of Aalborg, Fredrik Bajers Vej 7E, 9220 Aalborg, Denmark.
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Electrocardiographic Predictors of Torsadogenic Risk During Dofetilide or Sotalol Initiation: Utility of a Novel T Wave Analysis Program. Cardiovasc Drugs Ther 2016; 29:433-41. [PMID: 26411977 DOI: 10.1007/s10557-015-6619-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Initiation of class III anti-arrhythmic medications requires telemetric monitoring for ventricular arrhythmias and QT prolongation to reduce the risk of torsades de pointes (TdP). Heart rate-corrected QT interval (QTc) is an indicator of risk, however it is imperfect, and subtle abnormalities of repolarization have been linked with arrhythmogenesis. PURPOSE Identification of electrocardiographic predictors of torsadogenic risk through the application of a novel T wave analysis tool. METHODS Among all patients admitted to Mayo Clinic for initiation of dofetilide or sotalol, we identified 13 cases who developed drug-induced TdP and 26 age and sex matched controls that did not develop TdP. The immediate pre-TdP ECG of those with TdP was compared to the last ECG performed prior to hospital discharge in controls using a novel T wave program that quantified subtle changes in T wave morphology. RESULTS The QTc and 12 T wave parameters successfully distinguished TdP cases from controls. The top performing parameters were the QTc in lead V3 (mean case vs control 480 vs 420 msec, p < 0.001, r = 0.72) and T wave right slope in lead I (mean case vs control -840.29 vs -1668.71 mV/s, p = 0.002, r = 0.45). The addition of T wave right slope to QTc improved prediction accuracy from 79 to 88 %. CONCLUSION Our data demonstrate that, in addition to QTc, the T wave right slope is correlated strongly with TdP risk. This suggests that a computer-based repolarization measurement tool that integrates additional data beyond the QTc may identify patients with the greatest torsadogenic potential.
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Waks JW, Zimetbaum P. Antiarrhythmic Drug Therapy for Rhythm Control in Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2016; 22:3-19. [DOI: 10.1177/1074248416651722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and affects over 33 million people worldwide. AF is associated with stroke and systemic thromboembolism, unpleasant symptoms and reduced quality of life, heart failure, and increased mortality, and treatment of AF and its complications are associated with significant cost. Antiarrhythmic drugs (AADs) can suppress AF, allowing long-term maintenance of sinus rhythm, and have the potential to relieve symptoms and reverse or prevent adverse effects associated with AF. However, large randomized controlled studies evaluating use of AADs have not demonstrated a clear benefit to maintaining sinus rhythm, and AADs often have significant limitations, including a modest rate of overall success at maintaining sinus rhythm, frequent side effects, and potentially life-threatening toxicities. Although some of the currently available AADs have been available for almost 100 years, better tolerated and more efficacious AADs have recently been developed both for long-term maintenance of sinus rhythm and for chemical cardioversion of AF to sinus rhythm. Advances in automated AF detection with cardiac implantable electronic devices have suggested that AADs might be useful for suppressing AF to allow safe discontinuation of anticoagulation in select patients who are in sinus rhythm for prolonged periods of time. AADs may also have synergistic effects with catheter ablation of AF. This review summarizes the pharmacology and clinical use of currently available AADs for treatment of AF and discusses novel AADs and future directions for rhythm control in AF.
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Affiliation(s)
- Jonathan W. Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Peter Zimetbaum
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Chowdhury M, Wong J, Cheng A, Khilkin M, Palma E. Methadone Therapy in Underserved Urban Community: QTc Prolongation and Life-Threatening Ventricular Arrhythmias. Cardiovasc Ther 2016; 33:127-33. [PMID: 25825202 DOI: 10.1111/1755-5922.12120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS Methadone has been associated with QTc prolongation and ventricular arrhythmias but the prevalence of QTc prolongation and association with ventricular arrhythmias remains unclear. We investigated this in our inner city urban community (Bronx, New York) that has a large number of patients on methadone. METHODS Telemetry records, nursing documentation and electronic charts of 291 patients spanning856 encounters were evaluated. QT was manually measured from ECG utilizing standardized QT measurement guidelines and was corrected for heart rate using Hodges formula. QTc >470 ms in males and >480 ms in females was considered to be prolonged. RESULTS Patients had prolonged QTc, QTc >500 ms and ventricular arrhythmias during 25.6%, 14.1% and 3.4% of encounters, respectively. There was a very weak dose dependent relationship between methadone dose and QTc (Spearman's rho = 0.09).In addition to methadone, patients were on at least one QT prolonging drugs during 39% of the encounters. Patients who were receiving two interacting drugs in addition to methadone had the highest prevalence (29%) of QTc prolongation. CONCLUSION Although the prevalence of QTc prolongation among patients on methadone therapy is high, the prevalence of ventricular arrhythmia is relatively low. Hospitalized patients on sustained methadone therapy are frequently on multiple additional QTc prolonging drugs. There is no significant dose dependent relationship between methadone dose and QTc. However, the concurrent use of methadone and interacting drugs lead to an increased prevalence of QTc prolongation.
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Affiliation(s)
- Mohsin Chowdhury
- Department of Internal Medicine, Yale School of Medicine/Yale-New Haven Hospital, New Haven, CT, USA
| | - Jason Wong
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | - Angela Cheng
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - Michael Khilkin
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Eugen Palma
- Department of Cardiovascular Medicine, Montefiore Medical Center, Bronx, NY, USA
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Paced QT interval as a risk factor for new-onset left ventricular systolic dysfunction and cardiac death after permanent pacemaker implantation. Int J Cardiol 2016; 203:158-63. [DOI: 10.1016/j.ijcard.2015.10.128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/28/2015] [Accepted: 10/18/2015] [Indexed: 11/30/2022]
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Parker MH, Sanoski CA. Clinical Pearls in Using Antiarrhythmic Drugs in the Outpatient Setting. J Pharm Pract 2015; 29:77-86. [DOI: 10.1177/1933719115615878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A role for oral antiarrhythmic drugs (AADs) remains in clinical practice for patients with atrial and ventricular arrhythmias in spite of advances in nonpharmacologic therapy. Pharmacists play a vital role in the appropriate use of AAD dosing, administration, adverse effects, interactions, and monitoring. Pharmacists who are involved in providing care to patients with cardiac arrhythmias must remain updated regarding the efficacy and safety of the most commonly used AADs. This review will address key issues for appropriate initiation and maintenance of commonly selected Vaughan-Williams Class Ic and III agents in the outpatient setting.
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Affiliation(s)
- Mary H. Parker
- Clinical Pharmacy Specialist Pharmacy Service, Clinic Coordinator Ambulatory Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
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Vicente J, Johannesen L, Mason JW, Pueyo E, Stockbridge N, Strauss DG. Sex differences in drug-induced changes in ventricular repolarization. J Electrocardiol 2015; 48:1081-7. [DOI: 10.1016/j.jelectrocard.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 10/23/2022]
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Abraham JM, Saliba WI, Vekstein C, Lawrence D, Bhargava M, Bassiouny M, Janiszewski D, Lindsay B, Militello M, Nissen SE, Poe S, Tanaka-Esposito C, Wolski K, Wilkoff BL. Safety of Oral Dofetilide for Rhythm Control of Atrial Fibrillation and Atrial Flutter. Circ Arrhythm Electrophysiol 2015; 8:772-6. [DOI: 10.1161/circep.114.002339] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 05/26/2015] [Indexed: 11/16/2022]
Affiliation(s)
- JoEllyn M. Abraham
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Walid I. Saliba
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Carolyn Vekstein
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - David Lawrence
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Mandeep Bhargava
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Mohamed Bassiouny
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - David Janiszewski
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Bruce Lindsay
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Michael Militello
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Steven E. Nissen
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Stacy Poe
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Christine Tanaka-Esposito
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Kathy Wolski
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
| | - Bruce L. Wilkoff
- From the Minneapolis Heart Institute, MN (J.M.A.); Department of Cardiovascular Medicine, Cleveland Clinic, OH (W.I.S., M. Bhargava, M. Bassiouny, D.J., B.L., M.M., S.E.N., S.P., C.T.-E., K.W., B.L.W.); Brown University, Providence, RI (C.V.); and Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD (D.L.)
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Assessment of efficacy of proarrhythmia biomarkers in isolated rabbit hearts with attenuated repolarization reserve. J Cardiovasc Pharmacol 2015; 64:266-76. [PMID: 24887684 DOI: 10.1097/fjc.0000000000000116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Isolated hearts with reduced repolarization reserve would be suitable for assessing the proarrhythmic liability of drugs. However, it is not known which proarrhythmia biomarkers indicate the increased susceptibility to torsades de pointes arrhythmia (TdP) in such experimental setting. Thus, we estimated the efficacy of proarrhythmia biomarkers in isolated hearts with attenuated repolarization reserve. Langendorff-perfused rabbit hearts were used. Repolarization reserve was reduced by concomitant inhibition of the rapid (IKr) and slow (IKs) delayed rectifier potassium currents by dofetilide and HMR-1556, respectively. Rate corrected QT (QTc) interval and beat-to-beat variability of the QT interval measured in sinus rhythm or irrespective of rhythm even during arrhythmias (sinus and absolute QT variability, respectively) were tested. QTc failed to predict increased proarrhythmic risk. Sinus QT variability indicated proarrhythmic liability when low concentration of dofetilide was used. However, when arrhythmias compromised sinus variability measurement during coperfusion of catecholamines and elevated concentration of dofetilide, only absolute QT variability indicated increased proarrhythmic risk. Absolute QT variability parameters seem to be the most practical and sensitive biomarkers of proarrhythmic liability in rabbit hearts with reduced repolarization reserve. Absolute QT variability parameters could serve as surrogates for torsades de pointes in drug-safety investigations in isolated rabbit hearts with attenuated repolarization reserve.
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Sauer AJ, Kaplan R, Xue J, Dorsey P, Hayes M, Shah SJ, Passman R. Electrocardiographic markers of repolarization heterogeneity during dofetilide or sotalol initiation for paroxysmal atrial fibrillation. Am J Cardiol 2014; 113:2030-5. [PMID: 24793679 DOI: 10.1016/j.amjcard.2014.03.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/06/2014] [Accepted: 03/06/2014] [Indexed: 10/25/2022]
Abstract
Serial electrocardiographic monitoring of ΔQTc as an assumed harbinger of proarrhythmia is currently recommended for dofetilide and sotalol initiation. Markers of repolarization heterogeneity such as increased peak to end of T-wave (TpTe) duration and abnormal T-wave morphology may also predict proarrhythmia. We investigated whether such T-wave measurements on baseline electrocardiogram will correlate with ΔQTc after drug initiation. An analysis of 140 consecutive patients with paroxysmal atrial fibrillation hospitalized in sinus rhythm for sotalol or dofetilide initiation was performed. Baseline and serial electrocardiograms were analyzed using QT Guard Plus software (GE Healthcare), which measured QTc and TpTe and scored T-wave morphology for asymmetry, notching, and flatness using T-wave vector magnitude and principal component analysis algorithms. Sotalol and dofetilide were administered in 71% and 29% of patients, respectively. Mean age was 61 ± 14 years, and 34% were women. After a single dose of either drug, there was a statistically significant increase in QTc and TpTe (p <0.01), as well as composite and individual T-wave markers of repolarization heterogeneity (p <0.01). QTc increased by a mean of 19 ± 30 ms after initial antiarrhythmic dose. ΔQTc was inversely related to baseline QTc and TpTe (p <0.01). After controlling for baseline QTc, there was no independent association between T-wave markers of repolarization heterogeneity and ΔQTc. In conclusion, for patients with paroxysmal atrial fibrillation admitted for dofetilide or sotalol loading, T-wave markers of increased repolarization heterogeneity are measurable within hours after initiation. A shorter baseline QTc is associated with an increased ΔQTc; however, there is no independent relation between baseline T-wave markers of repolarization heterogeneity and ΔQTc.
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Tsai SF, Houmsse M, Dakhil B, Augostini R, Hummel JD, Kalbfleisch SJ, Liu Z, Love C, Rhodes T, Tyler J, Weiss R, Hamam I, Winner M, Daoud EG. QTc compared to JTc for monitoring drug-induced repolarization changes in the setting of ventricular pacing. Heart Rhythm 2013; 11:485-91. [PMID: 24252288 DOI: 10.1016/j.hrthm.2013.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND QT prolongation is a risk factor for proarrhythmia when beginning antiarrhythmic drug therapy (AAD). However, there are no data regarding monitoring repolarization changes during a ventricular paced (VP) rhythm. OBJECTIVE The purpose of this study was to compare serial changes in corrected QT and JT intervals, during native conduction (NC) and VP rhythms when initiating Class III AADs. METHODS Twenty-two patients (73% men; mean age 65 ± 11 years) with an implantable device and with <10% VP were monitored during AAD initiation (16 sotalol, 6 dofetilide). QTc and JTc were measured from ECGs obtained during NC and VP at baseline (pre-AAD) and then after each AAD dose. RESULTS During AAD loading, mean QTc increased significantly during NC (431 ± 28 ms to 463 ± 33 ms, P = .002) but not with VP (520 ± 48 ms to 538 ± 45 ms, P = .07). Mean percent increase in peak QTc during NC was significantly greater than during VP (12% vs 7%, P = .003). In contrast, peak JTc during AAD loading was not significantly different between NC and VP (P = .67). CONCLUSION When initiating AAD, the change in QTc during VP does not correlate with the change in QTc during NC; thus, the VP QTc is inadequate for monitoring repolarization changes. However, VP JTc correlates well with JTc during NC. When initiating Class III AADs in patients with VP rhythms, the JTc, and not the QTc, interval is the useful marker for assessing repolarization.
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Affiliation(s)
- Shane F Tsai
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Barrah Dakhil
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ralph Augostini
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - John D Hummel
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Steven J Kalbfleisch
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Zhengou Liu
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Charles Love
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Troy Rhodes
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Jaret Tyler
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Raul Weiss
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ismail Hamam
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Marshall Winner
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Emile G Daoud
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio.
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Brumberg G, Gera N, Pray C, Adelstein E, Barrington W, Bazaz R, Mendenhall GS, Nemec J, Voigt A, Wang NC, Schwartzman D, Saba S, Jain SK. Frequency of toxicity with chemical conversion of atrial fibrillation with dofetilide. Am J Cardiol 2013; 112:505-8. [PMID: 23706388 DOI: 10.1016/j.amjcard.2013.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/11/2013] [Accepted: 04/11/2013] [Indexed: 10/26/2022]
Abstract
Dofetilide is a class III antiarrhythmic agent approved for the maintenance of sinus rhythm in patients with persistent atrial fibrillation (AF). The goal of this study was to determine if chemical cardioversion (CCV) suggests a greater sensitivity to dofetilide and, therefore, portends a higher risk of proarrhythmia. We analyzed 99 consecutive patients with persistent AF who were loaded on dofetilide before cardioversion. CCV occurred after 2 ± 1.5 doses of dofetilide in 46 patients whereas electrical cardioversion (ECV) was required in the remaining 53 patients after 4.7 ± 1.3 doses. During index hospitalization, there were higher rates of dofetilide discontinuation because of QT prolongation or torsades de pointes (TdP) in the CCV group compared with the ECV group (24% vs 2%, p = 0.001). All patients with CCV requiring drug discontinuation converted after a single dose of dofetilide. Additionally, all 3 patients with TdP were in the CCV group. Furthermore, 15 of the 21 patients with CCV (71%) who converted after the first dose of dofetilide developed significant QT prolongation, requiring dose adjustment or discontinuation of drug. Among patients discharged on drug, AF recurrence and drug discontinuation rates were similar between groups at 2-year follow-up. In patients hospitalized for initiation of dofetilide, CCV occurs in almost 50% and is associated with higher rates of pathologic QT prolongation and TdP compared with those who require ECV. Once discharged on dofetilide, safety and efficacy is similar in both groups. In conclusion, patients with CCV may require closer monitoring for proarrhythmia.
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Epidemiology of symptomatic drug-induced long QT syndrome and torsade de pointes in Germany. Europace 2013; 16:101-8. [DOI: 10.1093/europace/eut214] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pani PP, Trogu E, Maremmani I, Pacini M. QTc interval screening for cardiac risk in methadone treatment of opioid dependence. Cochrane Database Syst Rev 2013:CD008939. [PMID: 23787716 DOI: 10.1002/14651858.cd008939.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Methadone represents today the gold standard of efficacy for the pharmacological treatment of opioid dependence. Methadone, like many other medications, has been implicated in the prolongation of the rate-corrected QT (QTc) interval of the electrocardiogram (ECG), which is considered a marker for arrhythmias such as torsade de pointes (TdP). Indications on the association between methadone, even at therapeutic dosages, and TdP or sudden cardiac death have been reported. On these bases, consensus and recommendations involving QTc screening of patients receiving methadone treatment have been developed to identify patients with QTc above the thresholds considered at risk for cardiac arrhythmias, and they provide these individuals with alternative treatment (reduction of methadone dosage; provision of alternative opioid agonist treatment; treatment of associated risk factors). OBJECTIVES To evaluate the efficacy and acceptability of QTc screening for preventing cardiac-related morbidity and mortality in methadone-treated opioid dependents. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL (to April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Cochrane Drug and Alcohol Review Group Specialised Register (Issue 3, 2013), main electronic sources of ongoing trials, specific trial databases and reference lists of all relevant papers. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs) and non-randomised studies (cohort studies, controlled before and after studies, interrupted time series studies, case control studies) examining the efficacy of QTc screening for the prevention of methadone-related mortality and morbidity in opioid addicts. DATA COLLECTION AND ANALYSIS Two review authors independently screened and extracted data from studies. MAIN RESULTS The search strategy led to the identification of 872 records. Upon full-text assessment, no study was found to meet the quality criteria used for this review. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions about the effectiveness of QTc screening strategies for preventing cardiac morbidity/mortality in methadone-treated opioid addicts. Research efforts should focus on strengthening the evidence about the effectiveness of widespread implementation of such strategies and clarifying the associated benefits and harms.
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Affiliation(s)
- Pier Paolo Pani
- Social-Health Division, Health District 8 (ASL 8) Cagliari, Cagliari, Italy.
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Abstract
Bradyarrhythmias and tachyarrhythmias are common in elderly patients as a result of aging and acquired cardiac disease. Antiarrhythmic drugs are effective in elderly patients for the management of supraventricular and ventricular arrhythmias; however, dosing of drugs must be performed with care because of age-related changes in drug pharmacokinetics, the presence of concomitant disease, and frequent drug-drug interactions. Despite the large number of antiarrhythmic drugs having different electrophysiologic actions, as described in this article, only the β-blockers have been shown to be effective in reducing mortality and to lack proarrhythmic actions.
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Melduni RM, Koshino Y, Shen WK. Management of arrhythmias in the perioperative setting. Clin Geriatr Med 2013; 28:729-43. [PMID: 23101581 DOI: 10.1016/j.cger.2012.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative arrhythmias are a common complication of surgery, with incidence ranging from 4% to 20% for noncardiothoracic procedures, depending on the type of surgery performed. The immediate postoperative period is a dynamic time and is associated with many conditions conducive to the development of postoperative arrhythmias. The presence of postoperative atrial fibrillation is associated with increased morbidity, ICU stay, length of hospitalization, and hospital costs. The associated burdens are expected to rise in the future, given that the population undergoing cardiac surgery is getting older and sicker. Thousands of patients undergo major surgery each year and a major complication of these procedures is the occurrence of perioperative arrhythmia. It is imperative for clinicians to be up-to-date on current management of these arrhythmias.
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Affiliation(s)
- Rowlens M Melduni
- Division of Cardiovascular Diseases, 200 First Street SW, Rochester, MN 55905, USA.
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Soltysinska E, Thomsen MB. Torsades de Pointes in the Guinea-pig heart : editorial to: "dofetilide promotes repolarization abnormalities in perfused Guinea-pig heart" by O.E. Osadchii. Cardiovasc Drugs Ther 2012; 26:437-9. [PMID: 23011586 DOI: 10.1007/s10557-012-6417-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spevak C, Hamsher C, Brown CQ, Wedam EF, Haigney MC. The clinical significance of QT interval prolongation in anesthesia and pain management: what you should and should not worry about. PAIN MEDICINE 2012; 13:1072-80. [PMID: 22680349 DOI: 10.1111/j.1526-4637.2012.01406.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The most feared drug-induced complication is fatal cardiac arrest. Torsades de pointes (TdP) is a polymorphic ventricular tachycardia occurring in the setting of a QT interval prolongation and is the most frequent type of drug-induced pro-arrhythmia. The most common mechanism of QT prolongation and TdP is blockade of the rapid component of the delayed rectifier repolarizing potassium conductance IKr. Anesthesiologists have extensive experience with QT prolonging drugs, but there are relatively few reports of TdP occurring in the perioperative setting. Nevertheless, regulatory concern regarding the drug droperidol resulted in a significant reduction in its use. Concern regarding two other agents that potently block IKr, i.e., sevoflurane and methadone, has grown, and practitioners are worried that these valuable agents may meet the same fate. In this review, the data regarding the TdP risk of droperidol, sevoflurane, and methadone are compared with particular emphasis on the different settings in which they are employed. While the three drugs are potent IKr inhibitors, little evidence exists to suggest that droperidol or sevoflurane are associated with significant proarrhythmia in the perioperative setting. Due to factors such as inhibition of the parasympathetic nervous system, prevention of hypoxia and hypercarbia, and attention to serum electrolytes, TdP is a very rare occurrence in the perioperative environment. Methadone, however, is typically given to outpatients, over long periods, and in combination with agents that inhibit its metabolism or are QT prolonging in their own right. Thus, pre- and post-drug electrocardiograms may be appropriate when prescribing methadone for outpatients, while the much lower risk for TdP (and the difficulties inherent in QT measurement in the perioperative period) render this approach unfruitful and worthy of reevaluation.
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Affiliation(s)
- Christopher Spevak
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Affiliation(s)
- Andrew J Sauer
- Center for Human Genetic Research, Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
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Nalos L, Varkevisser R, Jonsson MKB, Houtman MJC, Beekman JD, van der Nagel R, Thomsen MB, Duker G, Sartipy P, de Boer TP, Peschar M, Rook MB, van Veen TAB, van der Heyden MAG, Vos MA. Comparison of the IKr blockers moxifloxacin, dofetilide and E-4031 in five screening models of pro-arrhythmia reveals lack of specificity of isolated cardiomyocytes. Br J Pharmacol 2012; 165:467-78. [PMID: 21718297 DOI: 10.1111/j.1476-5381.2011.01558.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Drug development requires the testing of new chemical entities for adverse effects. For cardiac safety screening, improved assays are urgently needed. Isolated adult cardiomyocytes (CM) and human embryonic stem cell-derived cardiomyocytes (hESC-CM) could be used to identify pro-arrhythmic compounds. In the present study, five assays were employed to investigate their sensitivity and specificity for evaluating the pro-arrhythmic properties of I(Kr) blockers, using moxifloxacin (safe compound) and dofetilide or E-4031 (unsafe compounds). EXPERIMENTAL APPROACH Assays included the anaesthetized remodelled chronic complete AV block (CAVB) dog, the anaesthetized methoxamine-sensitized unremodelled rabbit, multi-cellular hESC-CM clusters, isolated CM obtained from CAVB dogs and isolated CM obtained from the normal rabbit. Arrhythmic outcome was defined as Torsade de Pointes (TdP) in the animal models and early afterdepolarizations (EADs) in the cell models. KEY RESULTS At clinically relevant concentrations (5-12 µM), moxifloxacin was free of pro-arrhythmic properties in all assays with the exception of the isolated CM, in which 10 µM induced EADs in 35% of the CAVB CM and in 23% of the rabbit CM. At supra-therapeutic concentrations (≥100 µM), moxifloxacin was pro-arrhythmic in the isolated rabbit CM (33%), in the hESC-CM clusters (18%), and in the methoxamine rabbit (17%). Dofetilide and E-4031 induced EADs or TdP in all assays (50-83%), and the induction correlated with a significant increase in beat-to-beat variability of repolarization. CONCLUSION AND IMPLICATIONS Isolated cardiomyocytes lack specificity to discriminate between TdP liability of the I(Kr) blocking drugs moxifloxacin and dofetilide or E4031.
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Affiliation(s)
- L Nalos
- Department of Medical Physiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
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Haigney MC. First, do no harm: QT interval screening in methadone maintenance treatment. J Addict Dis 2012; 30:309-12. [PMID: 22026521 DOI: 10.1080/10550887.2011.610704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Mark C Haigney
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Treating Cardiac Arrhythmias Detected With an Implantable Cardiac Monitor in Patients After an Acute Myocardial Infarction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 14:39-49. [DOI: 10.1007/s11936-011-0163-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Farkas AS, Rudas L, Makra P, Csík N, Leprán I, Forster T, Csanády M, Papp JG, Varró A, Farkas A. Biomarkers and endogenous determinants of dofetilide-induced torsades de pointes in α(1) -adrenoceptor-stimulated, anaesthetized rabbits. Br J Pharmacol 2010; 161:1477-95. [PMID: 20659107 PMCID: PMC3010562 DOI: 10.1111/j.1476-5381.2010.00965.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 05/31/2010] [Accepted: 06/27/2010] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Torsades de pointes (TdP) liability is a stochastic event, which indicates that unidentified factors have an important role in facilitating the initiation of TdP by increasing the probability of TdP occurrence. We sought to identify factors that facilitate drug-induced TdP. EXPERIMENTAL APPROACH We studied dofetilide-induced TdP in pentobarbital-anaesthetized, phenylephrine-sensitized rabbits, seeking biomarkers that discriminated between the animals that experienced TdP ('TdP+' animals) and those that did not ('TdP-' animals). As novel variables, the beat-to-beat variability and instability of ECG intervals were measured at preset times, irrespective of whether or not hearts were in stable sinus rhythm ('absolute' variability and instability). Autonomic activity was also determined. KEY RESULTS Dofetilide delayed repolarization and induced arrhythmias prior to TdP. The variability of the coupling interval and shape of arrhythmic beats before TdP were significantly greater in the 'TdP+' group than in the 'TdP-' group. Accordingly, the 'absolute' variability and instability of the ECG intervals were significantly elevated in the 'TdP+' group. Phenylephrine increased significantly the up-baroreflex sensitivity in the 'TdP+' group before dofetilide administration. CONCLUSIONS AND IMPLICATIONS 'Preceding' arrhythmias have characteristics that permit prediction of TdP occurrence: the more chaotic the ventricular rhythm, the greater the probability of TdP initiation. This suggests that complexity of the arrhythmic beats may play an important mechanistic role in TdP genesis. The electrical instability quantified by the novel 'absolute' variability and instability parameters correlates with the probability of TdP occurrence. Baroreflex may contribute to TdP genesis in vivo.
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Affiliation(s)
- Attila S Farkas
- 2nd Department of Internal Medicine and Cardiology Centre, University of SzegedSzeged, Hungary
| | - László Rudas
- 2nd Department of Internal Medicine and Cardiology Centre, University of SzegedSzeged, Hungary
| | - Péter Makra
- Department of Experimental Physics, University of SzegedSzeged, Hungary
| | - Norbert Csík
- Department of Electrical Engineering and Cybernetics, Faculty of Mechanical Engineering and Automation, Kecskemét CollegeKecskemét, Hungary
| | - István Leprán
- Division of Cardiovascular Pharmacology, Hungarian Academy of SciencesSzeged, Hungary
| | - Tamás Forster
- 2nd Department of Internal Medicine and Cardiology Centre, University of SzegedSzeged, Hungary
| | - Miklós Csanády
- 2nd Department of Internal Medicine and Cardiology Centre, University of SzegedSzeged, Hungary
| | - Julius Gy Papp
- Division of Cardiovascular Pharmacology, Hungarian Academy of SciencesSzeged, Hungary
- Department of Pharmacology and Pharmacotherapy, University of SzegedSzeged, Hungary
| | - András Varró
- Division of Cardiovascular Pharmacology, Hungarian Academy of SciencesSzeged, Hungary
- Department of Pharmacology and Pharmacotherapy, University of SzegedSzeged, Hungary
| | - András Farkas
- 2nd Department of Internal Medicine and Cardiology Centre, University of SzegedSzeged, Hungary
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Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2010; 55:934-47. [PMID: 20185054 DOI: 10.1016/j.jacc.2010.01.001] [Citation(s) in RCA: 275] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Farkas AS, Nattel S. Minimizing Repolarization-Related Proarrhythmic Risk in Drug Development and Clinical Practice. Drugs 2010; 70:573-603. [DOI: 10.2165/11535230-000000000-00000] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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