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Oshima Y, Tanaka A, Fukuki M, Otsuki A, Hisatome I. A Case of High-Dose Intravenous MgSO 4 and Hemoperfusion for Aconite Poisoning with Chronic Kidney Disease. Yonago Acta Med 2024; 67:270-279. [PMID: 39176192 PMCID: PMC11335928 DOI: 10.33160/yam.2024.08.012] [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: 07/03/2024] [Accepted: 07/29/2024] [Indexed: 08/24/2024]
Abstract
Aconite contains four highly toxic diester-diterpene alkaloids, including aconitine, mesaconitine, hypaconitine, and jesaconitine, in all plant parts. Aconite has been used as for suicide, murder, and as an arrow poison since ancient Greek and Roman times. Ventricular tachyarrhythmias are the most common cause of death in aconite poisoning, and antiarrhythmic drugs and cardioversion are ineffective. A 61-year-old woman ingested the crushed raw roots of a single aconite plant. An ambulance brought her to the Tottori University Hospital 30 min after ingestion. She had a history of chronic stage 5 kidney disease but was not on dialysis. Her heart rate (HR) was 120 bpm upon arrival. The patient developed sustained supraventricular tachycardia (SVT) at an HR of 165 bpm with frequent premature ventricular contractions (PVCs) 15 min after arrival. She then developed sustained monomorphic ventricular tachycardia (VT) at an HR of 200 bpm 20 min after arrival, which progressed to pulseless polymorphic VT. Cardioversion was unsuccessful. External cardiac massage restored spontaneous circulation; however, her underlying rhythm remained sustained SVT with frequent PVCs. These arrhythmias repeatedly led to circulatory arrest. She was administered six intravenous boluses of 2 g of MgSO4 in the emergency department, which prevented her from going into sustained pulseless VT. Hemoperfusion (HP) with activated charcoal was performed 1.5 h after arrival. The aconitine, mesaconitine, and hypaconitine plasma concentrations were high at 8.9, 23.5, and 5.5 ng/mL, respectively, before the start of HP but decreased to 1.7, 4.0, and 2.7 ng/mL, respectively, after 7 h of HP. She returned to sinus rhythm on the second day of hospitalization; however, the patient required maintenance hemodialysis. We concluded that high-dose IV MgSO4 is an effective treatment for fatal tachyarrhythmias due to aconite poisoning, and that in cases of renal failure, HP may be required to remove aconite toxins from the body.
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Affiliation(s)
- Yoshiaki Oshima
- Division of Anesthesiology and Critical Care Medicine, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
- Department of Anesthesiology, Yonago Medical Center, Yonago 683-0006, Japan
| | - Akira Tanaka
- Division of Anesthesiology and Critical Care Medicine, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Masaharu Fukuki
- Department of Cardiology, Yonago Medical Center, Yonago 683-0006, Japan
| | - Akihiro Otsuki
- Division of Anesthesiology and Critical Care Medicine, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Ichiro Hisatome
- Department of Cardiology, Yonago Medical Center, Yonago 683-0006, Japan
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Campinas A, Pereira Santos M, Sousa MJ, Gomes C, Torres S. Amiodarone-Induced Electrical Storm: A Nightmare in the Emergency Room. Cureus 2023; 15:e49494. [PMID: 38152805 PMCID: PMC10751592 DOI: 10.7759/cureus.49494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Drug-induced long QT syndrome (LQTS) is defined as prolonged corrected QT interval (QTc ≥460 ms) plus polymorphic ventricular arrhythmia fitting the description of torsades de pointes temporally associated with the administration of a drug or combination of drugs. Amiodarone therapy is a known uncommon cause of acquired QT interval prolongation that should not be underestimated. We present a case of an iatrogenic electrical storm with atrial fibrillation (AF) in which amiodarone was administered to attempt chemical cardioversion, resulting in an unnoticed prolongation of the QT interval, with subsequent repeated polymorphic ventricular tachycardia, managed with isoproterenol. Concomitant drugs and slight electrolyte disturbances potentiated this phenomenon. Given the widespread use of this drug in the emergency department, our case highlights a pertinent matter for all medical emergency practitioners. Additionally, it stresses the significance of potential precipitating factors, such as electrolyte imbalances, which are clinical conditions very frequent in the emergency context, along with the importance of recognizing drug interactions. Finally, this case also emphasizes the vital importance of closely monitoring the patient's receiving amiodarone.
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Affiliation(s)
- Andreia Campinas
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | | | - Maria João Sousa
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Catarina Gomes
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Severo Torres
- Cardiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
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Pegu B, Singh R. Anesthetic management of a young primigravida a case of symptomatic long QT syndrome with a permanent pacemaker in-situ undergoing lower segment cesarean section delivery: A case report. Saudi J Anaesth 2023; 17:256-259. [PMID: 37260636 PMCID: PMC10228844 DOI: 10.4103/sja.sja_688_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 06/02/2023] Open
Abstract
The patient with Long QT syndrome (LQTS) presents a unique challenge to the anesthesiologist. The anesthetic management of such patients requires a good knowledge of the pathophysiology of this rare disease. General anesthesia (GA) or combined spinal epidural anesthesia (CSEA) are the most preferred anesthetic techniques among anesthesiologists for such patients posted for the lower segment cesarean section delivery. In this report, we would like to share our experience of anesthetic management of a young primigravida, a case of symptomatic LQTS with a permanent pacemaker in situ. Anesthetic technique used for the lower segment cesarean section delivery was single-shot spinal anesthesia using a combination of a local anesthetic and strong opioid in the lumber subarachnoid space. Until recently, only one report in the literature has described this single-shot spinal technique for such cases. The advantages of single shot spinal over GA and CSEA can be utilized in a select group of these patients, which include fast onset, dense, reliable block with low local anesthetic toxicity, reduced catecholamine release, and relatively prolonged analgesia when combined with an opioid.
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Affiliation(s)
- Baby Pegu
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ram Singh
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Schulze Westhoff M, Schröder S, Heck J, Pfister T, Jahn K, Krause O, Wedegärtner F, Bleich S, Kahl KG, Krüger THC, Groh A. Determinants of severe QT c prolongation in a real-world gerontopsychiatric setting. Front Psychiatry 2023; 14:1157996. [PMID: 37032947 PMCID: PMC10076587 DOI: 10.3389/fpsyt.2023.1157996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/08/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction QTc prolongation carries the risk of ventricular tachyarrhythmia (Torsades de Pointes) and sudden cardiac death. Psychotropic drugs can affect ventricular repolarization and thus prolong the QTc interval. The present study sought to investigate the risk factors (pharmacological and non-pharmacological) of severe QTc prolongation in gerontopsychiatric patients. Methods Electrocardiograms of patients on a gerontopsychiatric ward were screened for QTc prolongation. Medication lists were examined utilizing the AzCERT classification. Potential drug interactions were identified with the electronic drug interaction program mediQ. Results The overall prevalence of QTc prolongation was 13.6%, with 1.9% displaying severe QTc prolongation (≥ 500 ms). No statistically significant differences between patients with moderate and severe QTc prolongation were identified; however, patients with severe QTc prolongation tended to take more drugs (p = 0.063). 92.7% of patients with QTc prolongation took at least one AzCERT-listed drug, most frequently risperidone and pantoprazole. Risperidone and pantoprazole, along with pipamperone, were also most frequently involved in potential drug interactions. All patients displayed additional risk factors for QTc prolongation, particularly cardiac diseases. Conclusion In addition to the use of potentially QTc-prolonging drugs, other risk factors, especially cardiac diseases, appear to be relevant for the development of QTc prolongation in gerontopsychiatric patients. Pantoprazole was frequently involved in potential drug interactions and should generally not be used for more than 8 weeks in geriatric populations. As clinical consequences of QTc prolongation were rare, potentially QTc-prolonging drugs should not be used overcautiously; their therapeutic benefit should be considered as well. It is paramount to perform diligent benefit-risk analyses prior to the initiation of potentially QTc-prolonging drugs and to closely monitor their clinical (side) effects.
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Affiliation(s)
- Martin Schulze Westhoff
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
- *Correspondence: Martin Schulze Westhoff,
| | - Sebastian Schröder
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Johannes Heck
- Hannover Medical School, Institute for Clinical Pharmacology, Hannover, Germany
| | - Tabea Pfister
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Kirsten Jahn
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Olaf Krause
- Hannover Medical School, Institute for General Practice and Palliative Care, Hannover, Germany
- Center for Medicine of the Elderly, DIAKOVERE Henriettenstift, Hannover, Germany
| | - Felix Wedegärtner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Kai G. Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Tillmann H. C. Krüger
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
- Center for Systemic Neursocience, Hannover, Germany
| | - Adrian Groh
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Fernandes DDA, Camões GDF, Ferreira D, Queijo C, Fontes-Ribeiro C, Gonçalves L, Pina R, António N. Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study. World J Emerg Med 2023; 14:454-461. [PMID: 37969211 PMCID: PMC10632761 DOI: 10.5847/wjem.j.1920-8642.2023.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/21/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Long QT syndrome (LQTS) is a heterogeneous syndrome that may be congenital or, more frequently, acquired. The real-world prevalence of acquired LQTS (aLQTS) in the emergency department (ED) remains to be determined. The aim of this study was to determine prevalence of aLQTS and its impact on symptoms on ED admissions. METHODS Electrocardiograms (ECG) of 5,056 consecutively patients admitted in the ED of a tertiary hospital between January 28th and March 17th of 2020 were reviewed. All patients with aLQTS were included. Clinical data with a focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without corrected QT (QTc) interval greater than 500 ms (value that is considered severely increased). RESULTS A total of 383 ECGs with prolonged QTc were recognized, corresponding to a prevalence of aLQTS at admission of 7.82%. Patients with aLQTS were more commonly men (53.3%) with an age of (73.49±14.79) years old and QTc interval of (505.3±32.4) ms. Only 20.4% of these patients with aLQTS were symptomatic. No ventricular arrhythmias were recorded. Patients with QT interval greater than 500 ms were more frequently female (59.5%; P<0.001) and were more frequently on QT prolonging drugs (77.3%; P=0.025). Main contributing factor was intake of antibiotics (odds ratio [OR] 4.680) followed by female gender (OR 2.473) and intake of antipsychotics (OR 1.925). CONCLUSION aLQTS is particularly prevalent in the ED. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made to avoid, detect and treat aLQTS as early as possible.
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Affiliation(s)
- Diogo de Almeida Fernandes
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Guilherme de Freitas Camões
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Diana Ferreira
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Carolina Queijo
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
| | - Carlos Fontes-Ribeiro
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
| | - Lino Gonçalves
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
| | - Rui Pina
- Department of Internal Medicine, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
| | - Natália António
- Department of Cardiology, Coimbra Hospital and University Centre (CHUC), Coimbra 3000-075, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra 3000-370, Portugal
- Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra 3000-548, Portugal
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Alahmadi A, Davies A, Royle J, Goodwin L, Cresswell K, Arain Z, Vigo M, Jay C. An explainable algorithm for detecting drug-induced QT-prolongation at risk of torsades de pointes (TdP) regardless of heart rate and T-wave morphology. Comput Biol Med 2021; 131:104281. [PMID: 33636421 DOI: 10.1016/j.compbiomed.2021.104281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/23/2022]
Abstract
Torsade de points (TdP), a life-threatening arrhythmia that can increase the risk of sudden cardiac death, is associated with drug-induced QT-interval prolongation on the electrocardiogram (ECG). While many modern ECG machines provide automated measurements of the QT-interval, these automated QT values are usually correct only for a noise-free normal sinus rhythm, in which the T-wave morphology is well defined. As QT-prolonging drugs often affect the morphology of the T-wave, automated QT measurements taken under these circumstances are easily invalidated. An additional challenge is that the QT-value at risk of TdP varies with heart rate, with the slower the heart rate, the greater the risk of TdP. This paper presents an explainable algorithm that uses an understanding of human visual perception and expert ECG interpretation to automate the detection of QT-prolongation at risk of TdP regardless of heart rate and T-wave morphology. It was tested on a large number of ECGs (n=5050) with variable QT-intervals at varying heart rates, acquired from a clinical trial that assessed the effect of four known QT-prolonging drugs versus placebo on healthy subjects. The algorithm yielded a balanced accuracy of 0.97, sensitivity of 0.94, specificity of 0.99, F1-score of 0.88, ROC (AUC) of 0.98, precision-recall (AUC) of 0.88, and Matthews correlation coefficient (MCC) of 0.88. The results indicate that a prolonged ventricular repolarisation area can be a significant risk predictor of TdP, and detection of this is potentially easier and more reliable to automate than measuring the QT-interval distance directly. The proposed algorithm can be visualised using pseudo-colour on the ECG trace, thus intuitively 'explaining' how its decision was made, which results of a focus group show may help people to self-monitor QT-prolongation, as well as ensuring clinicians can validate its results.
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Affiliation(s)
- Alaa Alahmadi
- Department of Computer Science, The University of Manchester, Manchester, UK.
| | - Alan Davies
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK.
| | - Jennifer Royle
- Digital Experimental Cancer Medicine Team, CRUK Manchester Institute, And the Christie NHS Foundation, Manchester, UK.
| | - Leanna Goodwin
- Digital Experimental Cancer Medicine Team, CRUK Manchester Institute, And the Christie NHS Foundation, Manchester, UK.
| | - Katharine Cresswell
- Cancer Precision Medicine and Cancer Prevention and Early Detection, NIHR Manchester Biomedical Research Centre (BRC), Manchester University NHS Foundation Trust, Manchester, UK.
| | - Zahra Arain
- Cancer Precision Medicine and Cancer Prevention and Early Detection, NIHR Manchester Biomedical Research Centre (BRC), Manchester University NHS Foundation Trust, Manchester, UK.
| | - Markel Vigo
- Department of Computer Science, The University of Manchester, Manchester, UK.
| | - Caroline Jay
- Department of Computer Science, The University of Manchester, Manchester, UK.
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Bernardi J, Aromolaran KA, Zhu H, Aromolaran AS. Circadian Mechanisms: Cardiac Ion Channel Remodeling and Arrhythmias. Front Physiol 2021; 11:611860. [PMID: 33519516 PMCID: PMC7841411 DOI: 10.3389/fphys.2020.611860] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022] Open
Abstract
Circadian rhythms are involved in many physiological and pathological processes in different tissues, including the heart. Circadian rhythms play a critical role in adverse cardiac function with implications for heart failure and sudden cardiac death, highlighting a significant contribution of circadian mechanisms to normal sinus rhythm in health and disease. Cardiac arrhythmias are a leading cause of morbidity and mortality in patients with heart failure and likely cause ∼250,000 deaths annually in the United States alone; however, the molecular mechanisms are poorly understood. This suggests the need to improve our current understanding of the underlying molecular mechanisms that increase vulnerability to arrhythmias. Obesity and its associated pathologies, including diabetes, have emerged as dangerous disease conditions that predispose to adverse cardiac electrical remodeling leading to fatal arrhythmias. The increasing epidemic of obesity and diabetes suggests vulnerability to arrhythmias will remain high in patients. An important objective would be to identify novel and unappreciated cellular mechanisms or signaling pathways that modulate obesity and/or diabetes. In this review we discuss circadian rhythms control of metabolic and environmental cues, cardiac ion channels, and mechanisms that predispose to supraventricular and ventricular arrhythmias including hormonal signaling and the autonomic nervous system, and how understanding their functional interplay may help to inform the development and optimization of effective clinical and therapeutic interventions with implications for chronotherapy.
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Affiliation(s)
- Joyce Bernardi
- Masonic Medical Research Institute, Utica, NY, United States
| | | | - Hua Zhu
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Neurological Disorders and Risk of Arrhythmia. Int J Mol Sci 2020; 22:ijms22010188. [PMID: 33375447 PMCID: PMC7795827 DOI: 10.3390/ijms22010188] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 01/08/2023] Open
Abstract
Neurological disorders including depression, anxiety, post-traumatic stress disorder (PTSD), schizophrenia, autism and epilepsy are associated with an increased incidence of cardiovascular disorders and susceptibility to heart failure. The underlying molecular mechanisms that link neurological disorders and adverse cardiac function are poorly understood. Further, a lack of progress is likely due to a paucity of studies that investigate the relationship between neurological disorders and cardiac electrical activity in health and disease. Therefore, there is an important need to understand the spatiotemporal behavior of neurocardiac mechanisms. This can be advanced through the identification and validation of neurological and cardiac signaling pathways that may be adversely regulated. In this review we highlight how dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, autonomic nervous system (ANS) activity and inflammation, predispose to psychiatric disorders and cardiac dysfunction. Moreover, antipsychotic and antidepressant medications increase the risk for adverse cardiac events, mostly through the block of the human ether-a-go-go-related gene (hERG), which plays a critical role in cardiac repolarization. Therefore, understanding how neurological disorders lead to adverse cardiac ion channel remodeling is likely to have significant implications for the development of effective therapeutic interventions and helps improve the rational development of targeted therapeutics with significant clinical implications.
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Alahmadi A, Davies A, Vigo M, Jay C. Pseudo-colouring an ECG enables lay people to detect QT-interval prolongation regardless of heart rate. PLoS One 2020; 15:e0237854. [PMID: 32853262 PMCID: PMC7451551 DOI: 10.1371/journal.pone.0237854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/04/2020] [Indexed: 01/08/2023] Open
Abstract
Drug-induced long QT syndrome (diLQTS), characterized by a prolongation of the QT-interval on the electrocardiogram (ECG), is a serious adverse drug reaction that can cause the life-threatening arrhythmia Torsade de Points (TdP). Self-monitoring for diLQTS could therefore save lives, but detecting it on the ECG is difficult, particularly at high and low heart rates. In this paper, we evaluate whether using a pseudo-colouring visualisation technique and changing the coordinate system (Cartesian vs. Polar) can support lay people in identifying QT-prolongation at varying heart rates. Four visualisation techniques were evaluated using a counterbalanced repeated measures design including Cartesian no-colouring, Cartesian pseudo-colouring, Polar no-colouring and Polar pseudo-colouring. We used a multi-reader, multi-case (MRMC) receiver operating characteristic (ROC) study design within a psychophysical paradigm, along with eye-tracking technology. Forty-three lay participants read forty ECGs (TdP risk n = 20, no risk n = 20), classifying each QT-interval as normal/abnormal, and rating their confidence on a 6-point scale. The results show that introducing pseudo-colouring to the ECG significantly increased accurate detection of QT-interval prolongation regardless of heart rate, T-wave morphology and coordinate system. Pseudo-colour also helped to reduce reaction times and increased satisfaction when reading the ECGs. Eye movement analysis indicated that pseudo-colour helped to focus visual attention on the areas of the ECG crucial to detecting QT-prolongation. The study indicates that pseudo-colouring enables lay people to visually identify drug-induced QT-prolongation regardless of heart rate, with implications for the more rapid identification and management of diLQTS.
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Affiliation(s)
- Alaa Alahmadi
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
| | - Alan Davies
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Markel Vigo
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
| | - Caroline Jay
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
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Xiong GL, Pinkhasov A, Mangal JP, Huang H, Rado J, Gagliardi J, Demoss D, Karol D, Suo S, Lang M, Stern M, Spearman EV, Onate J, Annamalai A, Saliba Z, Heinrich T, Fiedorowicz JG. QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2020; 135:110138. [PMID: 32442893 DOI: 10.1016/j.jpsychores.2020.110138] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/30/2020] [Accepted: 05/07/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.
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Affiliation(s)
- Glen L Xiong
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America.
| | - Aaron Pinkhasov
- Department of Behavioral Health, NYU Winthrop Hospital, Mineola, NY, United States of America
| | - Jed P Mangal
- Department of Behavioral Health, Martin Army Community Hospital, Ft Benning, GA, United States of America
| | - Heather Huang
- Departments of Psychiatry and Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Jeffrey Rado
- Psychiatry and General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Jane Gagliardi
- Departments of Psychiatry and Behavioral Sciences, and Internal Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Dustin Demoss
- Department of Psychiatry, University of North Texas Health Science Center, United States of America
| | - David Karol
- Department of Psychiatry and Behavioral Neuroscience, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Shannon Suo
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Michael Lang
- Departments of Psychiatry and Internal Medicine, East Carolina University, Greenville, NC, United States of America
| | - Marsha Stern
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - E Vanessa Spearman
- Departments of Internal Medicine and Psychiatry, Medical College of Georgia at Augusta University Medical Center, Augusta, GA, United States of America
| | - John Onate
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Aniyizhai Annamalai
- Departments of Psychiatry and Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Zeina Saliba
- Department of Psychiatry & Behavioral Sciences and Department of Emergency Medicine, The George Washington University, Washington, D.C, Department of Obstetrics & Gynecology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Thomas Heinrich
- Departments of Psychiatry and Behavioral Medicine, Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jess G Fiedorowicz
- Departments of Psychiatry, Epidemiology, and Internal Medicine, University of Iowa, Iowa City, IA, United States of America
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Morissette P, Polak S, Chain A, Zhai J, Imredy JP, Wildey MJ, Travis J, Fitzgerald K, Fanelli P, Passini E, Rodriguez B, Sannajust F, Regan C. Combining an in silico proarrhythmic risk assay with a tPKPD model to predict QTc interval prolongation in the anesthetized guinea pig assay. Toxicol Appl Pharmacol 2020; 390:114883. [PMID: 31981640 PMCID: PMC7322544 DOI: 10.1016/j.taap.2020.114883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/03/2020] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Human-based in silico models are emerging as important tools to study the effects of integrating inward and outward ion channel currents to predict clinical proarrhythmic risk. The aims of this study were 2-fold: 1) Evaluate the capacity of an in silico model to predict QTc interval prolongation in the in vivo anesthetized cardiovascular guinea pig (CVGP) assay for new chemical entities (NCEs) and; 2) Determine if a translational pharmacokinetic/pharmacodynamic (tPKPD) model can improve the predictive capacity. In silico simulations for NCEs were performed using a population of human ventricular action potential (AP) models. PatchXpress® (PX) or high throughput screening (HTS) ion channel data from respectively n = 73 and n = 51 NCEs were used as inputs for the in silico population. These NCEs were also tested in the CVGP (n = 73). An M5 pruned decision tree-based regression tPKPD model was used to evaluate the concentration at which an NCE is liable to prolong the QTc interval in the CVGP. In silico results successfully predicted the QTc interval prolongation outcome observed in the CVGP with an accuracy/specificity of 85%/73% and 75%/77%, when using PX and HTS ion channel data, respectively. Considering the tPKPD predicted concentration resulting in QTc prolongation (EC5%) increased accuracy/specificity to 97%/95% using PX and 88%/97% when using HTS. Our results support that human-based in silico simulations in combination with tPKPD modeling can provide correlative results with a commonly used early in vivo safety assay, suggesting a path toward more rapid NCE assessment with reduced resources, cycle time, and animal use. Cardiac electrophysiological in silico model predicts QTc interval prolongation in the guinea pig. PKPD model predicts relevant QTc interval prolongation concentration in guinea pig. Combining the models improves the accuracy of predicting guinea pig QTc effects. Combining models accelerates assessment of QTc with lower resources and animal use.
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Affiliation(s)
- Pierre Morissette
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA.
| | - Sebastian Polak
- Certara UK Limited, Simcyp Division, Sheffield, UK; Jagiellonian University Medical College, Faculty of Pharmacy, Krakow, Poland
| | - Anne Chain
- Pharmacokinetics, Pharmacodynamics and Drug Metabolism (PPDM), Merck & Co., Inc., Rahway, NJ, USA
| | - Jin Zhai
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - John P Imredy
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Mary Jo Wildey
- Pharmacology, Screening and Informatics, Merck & Co., Kenilworth, NJ, USA
| | - Jeffrey Travis
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Kevin Fitzgerald
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Patrick Fanelli
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Elisa Passini
- Computational Cardiovascular Science Group, Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Blanca Rodriguez
- Computational Cardiovascular Science Group, Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Frederick Sannajust
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Christopher Regan
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
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Alahmadi A, Davies A, Vigo M, Jay C. Can laypeople identify a drug-induced QT interval prolongation? A psychophysical and eye-tracking experiment examining the ability of nonexperts to interpret an ECG. J Am Med Inform Assoc 2019; 26:404-411. [PMID: 30848818 PMCID: PMC7787352 DOI: 10.1093/jamia/ocy183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 01/10/2023] Open
Abstract
Objective The study sought to quantify a layperson’s ability to detect drug-induced QT interval prolongation on an electrocardiogram (ECG) and determine whether the presentation of the trace affects such detection. Materials and Methods Thirty layperson participants took part in a psychophysical and eye-tracking experiment. Following training, participants completed 21 experimental trials, in which each trial consisted of 2 ECGs (a baseline and a comparison stimulus, both with a heart rate of 60 beats/min). The experiment used a 1 alternative forced-choice paradigm, in which participants indicated whether or not they perceived a difference in the QT interval length between the 2 ECGs. The ECG trace was presented in 3 ways: a single complex with the signals aligned by the R wave, a single complex without alignment, and a 10-second rhythm strip. Performance was analyzed using the psychometric function to estimate the just noticeable difference threshold, along with eye-tracking metrics. Results The just noticeable difference 50% and 75% thresholds were 30 and 88 ms, respectively, showing that the majority of laypeople were able to detect a clinically significant QT-prolongation at a low normal heart rate. Eye movement data indicated that people were more likely to appraise the rhythm strip stimulus systematically and accurately. Conclusions People can quickly be trained to self-monitor, which may help with more rapid identification of drug-induced long QT syndrome and prevent the development of life-threatening complications. The rhythm strip is a better form of presentation than a single complex, as it is less likely to be misinterpreted due to artifacts in the signal.
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Affiliation(s)
- Alaa Alahmadi
- University of Manchester, School of Computer Science, Manchester, UK
| | - Alan Davies
- University of Manchester, School of Computer Science, Manchester, UK
| | - Markel Vigo
- University of Manchester, School of Computer Science, Manchester, UK
| | - Caroline Jay
- University of Manchester, School of Computer Science, Manchester, UK
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Bo M, Ceccofiglio A, Mussi C, Bellelli G, Nicosia F, Riccio D, Martone AM, Langellotto A, Tonon E, Tava G, Boccardi V, Abete P, Tibaldi M, Aurucci ML, Fonte G, Falcone Y, Ungar A. Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope. Eur J Intern Med 2019; 61:34-39. [PMID: 30482635 DOI: 10.1016/j.ejim.2018.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 09/19/2018] [Accepted: 10/16/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12‑lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. RESULTS Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza-Molinette, C Bramante 88, 10126 Torino, Italy
| | - Alice Ceccofiglio
- Syncope Unit, Department of Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Chiara Mussi
- O.U. of Geriatrics, Department of Biomedical Sciences, Metabolics and Neurosciences, University of Modena and Reggio Emilia, Italy
| | - Giuseppe Bellelli
- Department of Health Sciences, University of Milano Bicocca and Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - Franco Nicosia
- Medicine and Geriatric Unit - Spedali Civili of Brescia, Brescia, Italy
| | - Daniela Riccio
- Geriatric Department, SS, Trinità Hospital, Cagliari, Italy
| | - Anna M Martone
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Gianni Tava
- Geriatric Unit, Santa Chiara Hospital, Trento, Italy
| | - Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples, Federico II, Naples, Italy
| | - Michela Tibaldi
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza-Molinette, C Bramante 88, 10126 Torino, Italy
| | - Maria L Aurucci
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza-Molinette, C Bramante 88, 10126 Torino, Italy.
| | - Gianfranco Fonte
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza-Molinette, C Bramante 88, 10126 Torino, Italy
| | - Yolanda Falcone
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza-Molinette, C Bramante 88, 10126 Torino, Italy
| | - Andrea Ungar
- Syncope Unit, Department of Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Marshall SD, Myles PS. Anaesthetists’ Knowledge of the QT Interval in a Teaching Hospital. Anaesth Intensive Care 2019; 33:773-6. [PMID: 16398384 DOI: 10.1177/0310057x0503300612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many drugs used in anaesthesia may prolong the QT interval of the electrocardiogram (ECG), and recent U.S. Food and Drug Administration guidelines mandate monitoring of the ECG before, during and after droperidol administration. We surveyed 41 trainee and consultant anaesthetists in our Department to determine current practice and knowledge of the QT interval to investigate if this is a practical proposition. A response rate of 98% (40/41) was obtained. The majority of respondents expressed moderate to high levels of confidence in interpreting the ECG, and this was related to years of training (rho 0.36, P=0.024). A total of 27 respondents (65%) were able to correctly identify the QT interval on a schematic representation of the ECG, trainees 70% vs consultants 60%, P=0.51. When asked to name drugs that altered the QT interval, droperidol was included by 11 of the 40 respondents (28%); trainees 10% vs consultants 45%, OR 7.4 (95% CI: 1.3–41), P=0.013. Torsades de Pointes was correctly identified as a possible consequence of a prolonged QT interval by 65% of trainees and 70% of consultants, P=0.83. The results suggest that QT interval measurement is not widely practised by anaesthetists, although its clinical significance is well known, and interpretation would be unreliable without further education.
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16
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Suarez K, Mack R, Hardegree EL, Chiles C, Banchs JE, Gonzalez MD. Isoproterenol suppresses recurrent torsades de pointes in a patient with long QT syndrome type 2. HeartRhythm Case Rep 2018; 4:576-579. [PMID: 30581736 PMCID: PMC6301889 DOI: 10.1016/j.hrcr.2018.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Keith Suarez
- Division of Cardiology, Department of Medicine, Baylor Scott & White Health, Scott & White Memorial Hospital, Temple, Texas
| | - Ryan Mack
- Division of Cardiology, Department of Medicine, Baylor Scott & White Health, Scott & White Memorial Hospital, Temple, Texas
| | - Evan L Hardegree
- Division of Cardiology, Department of Medicine, Baylor Scott & White Health, Scott & White Memorial Hospital, Temple, Texas
| | - Christopher Chiles
- Division of Cardiology, Department of Medicine, Baylor Scott & White Health, Scott & White Memorial Hospital, Temple, Texas
| | - Javier E Banchs
- Division of Cardiology, Department of Medicine, Baylor Scott & White Health, Scott & White Memorial Hospital, Temple, Texas
| | - Mario D Gonzalez
- Penn State Heart & Vascular Institute, Penn State Hershey Health, Hershey, Pennsylvania
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Abstract
Pharmacogenetics is an emerging area of medicine, and more work is needed to fully integrate it into a clinical setting for the benefit of patients. Genetic markers can influence the action of many drugs, including those that prevent and treat cardiovascular conditions. Genotyping is not yet commonplace, but guidelines are being put in place to help practitioners determine the effect a genetic marker may have on certain drugs. With advancements in genetic technology and falling costs, genotyping could be available to all patients via a simple saliva test. This would be a cost-effective way for practitioners to determine the most effective treatment for individuals, reducing "trial and error," adverse effects, and rehospitalization rates and increasing patient compliance. Cardiovascular diseases are the leading causes of death worldwide, so using the most effective medication to treat or prevent them is of utmost importance in reducing incidence and mortality.
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Perioperative management of patients with congenital or acquired disorders of the QT interval. Br J Anaesth 2018; 120:629-644. [DOI: 10.1016/j.bja.2017.12.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/16/2017] [Accepted: 01/14/2018] [Indexed: 12/19/2022] Open
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Abstract
Psychotropic literature in recent years has become very concerned with the cardiac safety of certain psychotropic medication. This paper reviews some of the cardiac factors to be considered in the safer selection of psychotropic drugs for the vulnerable patient in everyday clinical practice.
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20
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MacKenzie M, Hall R. Pharmacogenomics and pharmacogenetics for the intensive care unit: a narrative review. Can J Anaesth 2016; 64:45-64. [PMID: 27752976 DOI: 10.1007/s12630-016-0748-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/31/2016] [Accepted: 09/30/2016] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Knowledge of how alterations in pharmacogenomics and pharmacogenetics may affect drug therapy in the intensive care unit (ICU) has received little study. We review the clinically relevant application of pharmacogenetics and pharmacogenomics to drugs and conditions encountered in the ICU. SOURCE We selected relevant literature to illustrate the important concepts contained within. PRINCIPAL FINDINGS Two main approaches have been used to identify genetic abnormalities - the candidate gene approach and the genome-wide approach. Genetic variability in response to drugs may occur as a result of alterations of drug-metabolizing (cytochrome P [CYP]) enzymes, receptors, and transport proteins leading to enhancement or delay in the therapeutic response. Of relevance to the ICU, genetic variation in CYP-450 isoenzymes results in altered effects of midazolam, fentanyl, morphine, codeine, phenytoin, clopidogrel, warfarin, carvedilol, metoprolol, HMG-CoA reductase inhibitors, calcineurin inhibitors, non-steroidal anti-inflammatory agents, proton pump inhibitors, and ondansetron. Changes in cholinesterase enzyme function may affect the disposition of succinylcholine, benzylisoquinoline muscle relaxants, remifentanil, and hydralazine. Genetic variation in transport proteins leads to differences in the response to opioids and clopidogrel. Polymorphisms in drug receptors result in altered effects of β-blockers, catecholamines, antipsychotic agents, and opioids. Genetic variation also contributes to the diversity and incidence of diseases and conditions such as sepsis, malignant hyperthermia, drug-induced hypersensitivity reactions, cardiac channelopathies, thromboembolic disease, and congestive heart failure. CONCLUSION Application of pharmacogenetics and pharmacogenomics has seen improvements in drug therapy. Ongoing study and incorporation of these concepts into clinical decision making in the ICU has the potential to affect patient outcomes.
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Affiliation(s)
- Meghan MacKenzie
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada.,College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Richard Hall
- Departments of Anesthesia, Pain Management and Perioperative Medicine and Critical Care Medicine and Pharmacology, Dalhousie University and the Nova Scotia Health Authority, Halifax, NS, B3H 3A7, Canada.
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Ganai SA. Strategy for enhancing the therapeutic efficacy of histone deacetylase inhibitor dacinostat: the novel paradigm to tackle monotonous cancer chemoresistance. Arch Pharm Res 2015:10.1007/s12272-015-0673-9. [PMID: 26481010 DOI: 10.1007/s12272-015-0673-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/13/2015] [Indexed: 01/01/2023]
Abstract
Histone deacetylases (HDACs) regulate gene expression by creating the closed state of chromatin via histone hypoacetylation. Histone acetylation deregulation caused by aberrant expression of classical HDACs leads to imprecise gene regulation culminating in various diseases including cancer. Histone deacetylase inhibitors (HDACi), the small-molecules modulating the biological function of HDACs have shown promising results in inducing cell cycle arrest, differentiation and apoptosis in tumour models. HDACi do not show desired cytotoxic effect when used in monotherapy due to triggering of various resistance mechanisms in cancer cells emphasizing the desperate need of novel strategies that can be used to overcome such challenges. The present article provides intricate details about the novel HDACi dacinostat (LAQ-824) against multiple myeloma and acute myeloid leukaemia. The distinct molecular mechanisms modulated by dacinostat in exerting cytotoxic effect against the defined malignancies have also been detailed. The article also explains the strategy that can be used to circumvent the conventional therapy resistant cases and for enhancing the therapeutic efficacy of dacinostat for effective anticancer therapy.
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Affiliation(s)
- Shabir Ahmad Ganai
- Plant Virology and Molecular Pathology Laboratory, Division of Plant Pathology, Sher-e-Kashmir University of Agricultural Sciences and Technology of Kashmir, Shalimar, Srinagar, 190025, India.
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Abstract
Although the following text will focus on magnesium in disease, its role in healthy subjects during physical exercise when used as a supplement to enhance performance is also noteworthy. Low serum magnesium levels are associated with metabolic syndrome, Type 2 diabetes mellitus (T2DM) and hypertension; consequently, some individuals benefit from magnesium supplementation: increasing magnesium consumption appears to prevent high blood pressure, and higher serum magnesium levels are associated with a lower risk of developing a metabolic syndrome. There are, however, conflicting study results regarding magnesium administration with myocardial infarction with and without reperfusion therapy. There was a long controversy as to whether or not magnesium should be given as a first-line medication. As the most recent trials have not shown any difference in outcome, intravenous magnesium cannot be recommended in patients with myocardial infarction today. However, magnesium has its indication in patients with torsade de pointes and has been given successfully to patients with digoxin-induced arrhythmia or life-threatening ventricular arrhythmias. Magnesium sulphate as an intravenous infusion also has an important established therapeutic role in pregnant women with pre-eclampsia as it decreases the risk of eclamptic seizures by half compared with placebo.
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Affiliation(s)
- Helmut Geiger
- Klinikum der J.W. Goethe-Universität, Medizinische Klinik III/Nephrologie, Frankfurt/Main, Germany
| | - Christoph Wanner
- Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik I, Würzburg, Germany
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Lazzerini PE, Capecchi PL, Laghi-Pasini F. Long QT Syndrome: An Emerging Role for Inflammation and Immunity. Front Cardiovasc Med 2015; 2:26. [PMID: 26798623 PMCID: PMC4712633 DOI: 10.3389/fcvm.2015.00026] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/08/2015] [Indexed: 01/07/2023] Open
Abstract
The long QT syndrome (LQTS), classified as congenital or acquired, is a multi-factorial disorder of myocardial repolarization predisposing to life-threatening ventricular arrhythmias, particularly torsades de pointes. In the latest years, inflammation and immunity have been increasingly recognized as novel factors crucially involved in modulating ventricular repolarization. In the present paper, we critically review the available information on this topic, also analyzing putative mechanisms and potential interplays with the other etiologic factors, either acquired or inherited. Accumulating data indicate inflammatory activation as a potential cause of acquired LQTS. The putative underlying mechanisms are complex but essentially cytokine-mediated, including both direct actions on cardiomyocyte ion channels expression and function, and indirect effects resulting from an increased central nervous system sympathetic drive on the heart. Autoimmunity represents another recently arising cause of acquired LQTS. Indeed, increasing evidence demonstrates that autoantibodies may affect myocardial electric properties by directly cross-reacting with the cardiomyocyte and interfering with specific ion currents as a result of molecular mimicry mechanisms. Intriguingly, recent data suggest that inflammation and immunity may be also involved in modulating the clinical expression of congenital forms of LQTS, possibly triggering or enhancing electrical instability in patients who already are genetically predisposed to arrhythmias. In this view, targeting immuno-inflammatory pathways may in the future represent an attractive therapeutic approach in a number of LQTS patients, thus opening new exciting avenues in antiarrhythmic therapy.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
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Kudlicka J, Mlcek M, Belohlavek J, Hala P, Lacko S, Janak D, Havranek S, Malik J, Janota T, Ostadal P, Neuzil P, Kittnar O. Inducibility of ventricular fibrillation during mild therapeutic hypothermia: electrophysiological study in a swine model. J Transl Med 2015; 13:72. [PMID: 25886318 PMCID: PMC4342808 DOI: 10.1186/s12967-015-0429-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 02/05/2015] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Mild therapeutic hypothermia (MTH) is being used after cardiac arrest for its expected improvement in neurological outcome. Safety of MTH concerning inducibility of malignant arrhythmias has not been satisfactorily demonstrated. This study compares inducibility of ventricular fibrillation (VF) before and after induction of MTH in a whole body swine model and evaluates possible interaction with changing potassium plasma levels. METHODS The extracorporeal cooling was introduced in fully anesthetized swine (n = 6) to provide MTH. Inducibility of VF was studied by programmed ventricular stimulation three times in each animal under the following: during normothermia (NT), after reaching the core temperature of 32°C (HT) and after another 60 minutes of stable hypothermia (HT60). Inducibility of VF, effective refractory period of the ventricles (ERP), QTc interval and potassium plasma levels were measured. RESULTS Starting at normothermia of 38.7 (IQR 38.2; 39.8)°C, HT was achieved within 54 (39; 59) minutes and the core temperature was further maintained constant. Overall, the inducibility of VF was 100% (18/18 attempts) at NT, 83% (15/18) after reaching HT (P = 0.23) and 39% (7/18) at HT60 (P = 0.0001) using the same protocol. Similarly, ERP prolonged from 140 (130; 150) ms at NT to 206 (190; 220) ms when reaching HT (P < 0.001) and remained 206 (193; 220) ms at HT60. QTc interval was inversely proportional to the core temperature and extended from 376 (362; 395) at NT to 570 (545; 599) ms at HT. Potassium plasma level changed spontaneously: decreased during cooling from 4.1 (3.9; 4.8) to 3.7 (3.4; 4.1) mmol/L at HT (P < 0.01), then began to increase and returned to baseline level at HT60 (4.6 (4.4; 5.0) mmol/L, P = NS). CONCLUSIONS According to our swine model, MTH does not increase the risk of VF induction by ventricular pacing in healthy hearts. Moreover, when combined with normokalemia, MTH exerts an antiarrhythmic effect despite prolonged QTc interval.
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Affiliation(s)
- Jaroslav Kudlicka
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
- 3rd Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Mikulas Mlcek
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
| | - Jan Belohlavek
- 2nd Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Pavel Hala
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
- Department of Cardiology, Na Homolce Hospital, Roentgenova 2/37, Prague 5, 150 30, Czech Republic.
| | - Stanislav Lacko
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
| | - David Janak
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
- 2nd Department of Surgery, Cardiovascular Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Stepan Havranek
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
- 2nd Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Jan Malik
- 3rd Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Tomas Janota
- 3rd Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 2, 128 00, Czech Republic.
| | - Petr Ostadal
- Department of Cardiology, Na Homolce Hospital, Roentgenova 2/37, Prague 5, 150 30, Czech Republic.
| | - Petr Neuzil
- Department of Cardiology, Na Homolce Hospital, Roentgenova 2/37, Prague 5, 150 30, Czech Republic.
| | - Otomar Kittnar
- Department of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00, Czech Republic.
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Akman T, Erbas O, Akman L, Yilmaz AU. Prevention of Pazopanib-Induced Prolonged Cardiac Repolarization and Proarrhythmic Effects. Arq Bras Cardiol 2014; 103:403-409. [PMID: 25229355 PMCID: PMC4262101 DOI: 10.5935/abc.20140138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 07/04/2014] [Indexed: 12/21/2022] Open
Abstract
Background Pazopanib (PZP) may induce prolonged cardiac repolarization and proarrhythmic
effects, similarly to other tyrosine kinase inhibitors. Objectives To demonstrate PZP-induced prolonged cardiac repolarization and proarrhythmic
electrophysiological effects and to investigate possible preventive effects of
metoprolol and diltiazem on ECG changes (prolonged QT) in an experimental rat
model. Methods Twenty-four Sprague-Dawley adult male rats were randomly assigned to 4 groups (n =
6). The first group (normal group) received 4 mL of tap water and the other groups
received 100 mg/kg of PZP (Votrient® tablet) perorally, via orogastric
tubes. After 3 hours, the following solutions were intraperitoneally administered
to the animals: physiological saline solution (SP), to the normal group and to the
second group (control-PZP+SP group); 1 mg/kg metoprolol (Beloc, Ampule,
AstraZeneca), to the third group (PZP+metoprolol group); and 1mg/kg diltiazem
(Diltiazem, Mustafa Nevzat), to the fourth group (PZP+diltiazem group). One hour
after, and under anesthesia, QTc was calculated by recording ECG on lead I. Results The mean QTc interval values were as follows: normal group, 99.93 ± 3.62 ms;
control-PZP+SP group, 131.23 ± 12.21 ms; PZP+metoprolol group, 89.36 ± 3.61 ms;
and PZP+diltiazem group, 88.86 ± 4.04 ms. Both PZP+metoprolol and PZP+diltiazem
groups had significantly shorter QTc intervals compared to the control-PZP+SP
group (p < 0.001). Conclusion Both metoprolol and diltiazem prevented PZP-induced QT interval prolongation.
These drugs may provide a promising prophylactic strategy for the prolonged QTc
interval associated with tyrosine kinase inhibitor use.
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Affiliation(s)
- Tulay Akman
- Department of Medical Oncology, Tepecik Education and Research Hospital
| | - Oytun Erbas
- Department of Physiology, Medical School, Ege University
| | - Levent Akman
- Department of Obstetrics and Gynecology, Medical School, Ege University
| | - Ahmet U Yilmaz
- Department of Medical Oncology, Medical Park Hospital, Izmir University
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Niemeijer MN, van den Berg ME, Eijgelsheim M, van Herpen G, Stricker BH, Kors JA, Rijnbeek PR. Short-term QT variability markers for the prediction of ventricular arrhythmias and sudden cardiac death: a systematic review. Heart 2014; 100:1831-6. [PMID: 25092875 DOI: 10.1136/heartjnl-2014-305671] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Sudden cardiac death (SCD) is a major health burden and is primarily caused by ventricular arrhythmias. Currently, the most well-known marker for the risk of ventricular arrhythmias is QT/QTc prolongation. Animal studies indicate that QT variability might be a better indicator. Our objective was to give an overview of the literature on QT variability in humans, therefore we performed a free-text search in PubMed and Embase from inception through February 2013. We identified nine QT variability markers in 109 studies reporting on QT variability markers, measured on the surface ECG. QT variability can be distinguished using two characteristics: heart rate normalisation and whether QT interval is measured on consecutive beats. Most study populations were small (median 48 subjects, range 1-805) and different methods, time intervals and leads for measurement were used. QT variability markers were determinants for the risk of ventricular arrhythmias, (sudden) cardiac death and total mortality. Few studies compared the predictive value of QT variability with that of QT/QTc prolongation. A study comparing all different QT variability markers is lacking. In conclusion, QT variability markers are potential determinants of ventricular arrhythmias and cardiac mortality. However, it is unclear which marker and methodology are clinically most useful as well as what reference values are reliable. More studies on larger datasets are needed to find the most accurate marker for the prediction of arrhythmias and SCD to assess its value in addition to QT/QTc duration and its role in drug-induced arrhythmia and sudden death.
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Affiliation(s)
- Maartje N Niemeijer
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marten E van den Berg
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark Eijgelsheim
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gerard van Herpen
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Inspectorate of Health Care, The Hague, The Netherlands
| | - Jan A Kors
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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27
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Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf 2014; 3:241-53. [PMID: 25083239 DOI: 10.1177/2042098612454283] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The prolonged QT interval is both widely seen and associated with the potentially deadly rhythm, Torsades de Pointes (TdP). While it can occur spontaneously in the congenital form, there is a wide array of drugs that have been implicated in the prolongation of the QT interval. Some of these drugs have either been restricted or withdrawn from the market due to the increased incidence of fatal polymorphic ventricular tachycardia. The list of drugs that cause QT prolongation continues to grow, and an updated list of specific drugs that prolong the QT interval can be found at www.qtdrugs.org. This review focuses on the mechanism of drug-induced QT prolongation, risk factors for TdP, culprit drugs, prevention and monitoring of prolonged drug-induced QT prolongation and treatment strategies.
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Affiliation(s)
- Senthil Nachimuthu
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Manish D Assar
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Jeffrey M Schussler
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital, 621 North Hall Street, Suite 500, Dallas, TX 75226, USA
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28
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Albert BB, Eckersley LG, Skinner JR, Jefferies C. QT prolongation in a child with thyroid storm. BMJ Case Rep 2014; 2014:bcr-2013-202595. [PMID: 24729112 DOI: 10.1136/bcr-2013-202595] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A 12-year-old girl presented with an acute confusional state and a 2-year history of weight loss, anxiety, agitation and recurrent fever. Thyroid function tests confirmed severe hyperthyroidism, and a diagnosis of thyroid storm was made (Burch and Wartofsky score=75). ECG showed a prolonged QTc interval of 506 ms. Acute treatment for thyroid storm consisted of Lugol's iodine, prednisolone, carbimazole and propranolol. She made a steady recovery and by 3 months her thyroid function had normalised; a repeat ECG showed a QTc within the normal range (430 ms). There was no relevant family history. This is a case of QTc prolongation with hyperthyroidism and normalisation with euthyroidism. It is not commonly recognised that hyperthyroidism in children may be associated with QTc prolongation. QTc measurement should be incorporated into management protocols for hyperthyroidism.
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29
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Venugopal A, Rajasree O, Koshy RC. Effect of anthracyclines and isoflurane on QTc interval. EGYPTIAN JOURNAL OF ANAESTHESIA 2014. [DOI: 10.1016/j.egja.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- A. Venugopal
- Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, 11, India
| | - O. Rajasree
- Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, 11, India
| | - Rachel Cherian Koshy
- Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, 11, India
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30
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Min JJ, Yoo Y, Kim TK, Lee JM. Intravenous palonosetron increases the incidence of QTc prolongation during sevoflurane general anesthesia for laparotomy. Korean J Anesthesiol 2013; 65:397-402. [PMID: 24363841 PMCID: PMC3866334 DOI: 10.4097/kjae.2013.65.5.397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 12/16/2022] Open
Abstract
Background Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. Methods We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. Results The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P < 0.001). The changes in the QTc intervals were not different between the two groups (P = 0.41). However, six patients in the palonosetron group showed a QTc interval > 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. Conclusions Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.
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Affiliation(s)
- Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yongjae Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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31
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Polymorphic Ventricular Tachycardia—Part I: Structural Heart Disease and Acquired Causes. Curr Probl Cardiol 2013; 38:463-96. [DOI: 10.1016/j.cpcardiol.2013.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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32
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Gysel M, Vieweg WVR, Hasnain M, Hancox JC, Kunanithy V, Baranchuk A. Torsades de pointes following clarithromycin treatment. Expert Rev Cardiovasc Ther 2013; 11:1485-93. [PMID: 24147515 DOI: 10.1586/14779072.2013.840535] [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] [Indexed: 11/08/2022]
Abstract
A 75-year-old woman presenting with pre-syncope, shortness of breath and nausea was admitted to the emergency department following treatment with clarithromycin. Shortly after admission she developed a prolonged QT interval leading to torsades de pointes (TdP) and cardiac arrest. She was successfully cardioverted and clarithromycin was discontinued resulting in restoration of her usual QT interval. This case is an example of acquired long QT syndrome; a disorder that can be precipitated by macrolide antibiotics such as clarithromycin. Additional risk factors present in this case include: female gender, old age, heart disease, hypokalemia and hypomagnesemia. In this manuscript we comprehensively review past cases of clarithromycin-induced long QT syndrome (LQTS) and discuss them within the context of this case.
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Affiliation(s)
- Michael Gysel
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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33
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Stroke and ventricular arrhythmias. Int J Cardiol 2013; 168:653-9. [DOI: 10.1016/j.ijcard.2013.03.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/25/2013] [Accepted: 03/17/2013] [Indexed: 12/25/2022]
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34
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Targeted cancer therapy: giving histone deacetylase inhibitors all they need to succeed. Future Med Chem 2012; 4:505-24. [PMID: 22416777 DOI: 10.4155/fmc.12.3] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Histone deacetylase inhibitors (HDACis) have now emerged as a powerful new class of small-molecule therapeutics acting through the regulation of the acetylation states of histone proteins (a form of epigenetic modulation) and other non-histone protein targets. Over 490 clinical trials have been initiated in the last 10 years, culminating in the approval of two structurally distinct HDACis - SAHA (vorinostat, Zolinza™) and FK228 (romidepsin, Istodax™). However, the current HDACis have serious limitations, including ineffectively low concentrations in solid tumors and cardiac toxicity, which is hindering their progress in the clinic. Herein, we review the primary paradigms being pursued to overcome these hindrances, including HDAC isoform selectivity, localized administration, and targeting cap groups to achieve selective tissue and cell type distribution.
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35
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Staikou C, Chondrogiannis K, Mani A. Perioperative management of hereditary arrhythmogenic syndromes. Br J Anaesth 2012; 108:730-44. [PMID: 22499746 DOI: 10.1093/bja/aes105] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients with inherited cardiac channel disorders are at high risk of perioperative lethal arrhythmias. Preoperative control of symptoms and a multidisciplinary approach are required for a well-planned management. Good haemodynamic monitoring, adequate anaesthesia and analgesia, perioperative maintenance of normocarbia, normothermia, and normovolaemia are important. In congenital long QT syndrome, torsades de pointes should be prevented with magnesium sulphate infusion and avoidance of drugs such as droperidol, succinylcholine, ketamine, and ondansetron. Propofol and epidural anaesthesia represent safe choices, while caution is needed with volatile agents. In Brugada syndrome, β-blockers, α-agonists, and cholinergic drugs should be avoided, while isoproterenol reverses the ECG changes. Propofol, thiopental, and volatiles have been used uneventfully. In congenital sick sinus syndrome, severe bradycardia resistant to atropine may require isoproterenol or epinephrine. Anaesthetics with vagolytic properties are preferable, while propofol and vecuronium should be given with caution due to risk of inducing bradyarrhythmias. Neuraxial anaesthesia should produce the least autonomic imbalance. Arrhythmogenic right ventricular dysplasia/cardiomyopathy induces ventricular tachyarrhythmias, which should be treated with β-blockers. Generally, β-adrenergic stimulation and catecholamine release should be avoided. Halothane and pancuronium are contraindicated, while large doses of local anaesthetics and epinephrine should be avoided in neuraxial blocks. In catecholaminergic polymorphic ventricular tachycardia, β-blocker treatment should be continued perioperatively. Catecholamine release and β-agonists, such as isoproterenol, should be avoided. Propofol and remifentanil are probably safe, while halothane and pancuronium are contraindicated. Regional anaesthesia, without epinephrine, is relatively safe. In suspicious cardiac deaths, postmortem examination and familial screening are recommended.
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Affiliation(s)
- C Staikou
- Department of Anaesthesia, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis Sophias Ave., 11528 Athens, Greece.
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36
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Verheyen T, Decloedt A, De Clercq D, van Loon G. Cardiac changes in horses with atypical myopathy. J Vet Intern Med 2012; 26:1019-26. [PMID: 22646196 DOI: 10.1111/j.1939-1676.2012.00945.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 04/02/2012] [Accepted: 04/11/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Atypical myopathy (AM) is an acute, fatal rhabdomyolysis in grazing horses that mainly affects skeletal muscles. Postmortem examinations have shown that myocardial damage also occurs. Limited information is available on the effect of AM on cardiac function in affected and surviving horses. OBJECTIVES To describe electrocardiographic and echocardiographic changes associated with AM in the acute stage of the disease and after follow-up. ANIMALS Horses (n = 12) diagnosed with AM in which cardiac ultrasound examination and ECG recording were available. METHODS All horses underwent clinical examinations, serum biochemistry, electrocardiography, and echocardiography. Four surviving horses underwent the same examinations after 2-10 weeks. RESULTS All but 1 horse had increased cardiac troponin I concentrations and 10 horses had ventricular premature depolarizations (VPDs). All horses had prolonged corrected QT (QT(cf) ) intervals on the day of admission and abnormal myocardial wall motion on echocardiography. One of the surviving horses still had VPDs and prolonged QT(cf) at follow-up after 10 weeks. CONCLUSIONS AND CLINICAL IMPORTANCE The AM results in characteristic electrocardiographic and echocardiographic changes and may be associated with increased cardiac troponin I concentrations and VPDs. In survivors, abnormal cardiac function still may be found at follow-up after 10 weeks. Additional research in a larger group of horses is necessary to identify the long-term effects of AM on cardiac function.
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Affiliation(s)
- T Verheyen
- Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium.
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37
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Kallergis EM, Goudis CA, Simantirakis EN, Kochiadakis GE, Vardas PE. Mechanisms, risk factors, and management of acquired long QT syndrome: a comprehensive review. ScientificWorldJournal 2012; 2012:212178. [PMID: 22593664 PMCID: PMC3347892 DOI: 10.1100/2012/212178] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/22/2011] [Indexed: 12/19/2022] Open
Abstract
Long QT syndrome is characterized by prolongation of the corrected QT (QTc) interval on the surface electrocardiogram and is associated with precipitation of torsade de pointes (TdP), a polymorphic ventricular tachycardia that may cause sudden death. Acquired long QT syndrome describes pathologic excessive prolongation of the QT interval, upon exposure to an environmental stressor, with reversion back to normal following removal of the stressor. The most common environmental stressor in acquired long QT syndrome is drug therapy. Acquired long QT syndrome is an important issue for clinicians and a significant public health problem concerning the large number of drugs with this adverse effect with a potentially fatal outcome, the large number of patients exposed to these drugs, and our inability to predict the risk for a given individual. In this paper, we focus on mechanisms underlying QT prolongation, risk factors for torsades de pointes and describe the short- and long-term treatment of acquired long QT syndrome.
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Affiliation(s)
- Eleftherios M Kallergis
- Department of Cardiology, University Hospital of Heraklion, 711 10 Heraklion, Crete, Greece.
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38
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Bernardi M, Maggioli C, Dibra V, Zaccherini G. QT interval prolongation in liver cirrhosis: innocent bystander or serious threat? Expert Rev Gastroenterol Hepatol 2012; 6:57-66. [PMID: 22149582 DOI: 10.1586/egh.11.86] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The ECG QT interval measures the length of ventricular systole. Its prolongation is essentially caused by a delayed repolarization phase, and is associated with an increased risk of ventricular arrhythmias and sudden death in several congenital and acquired conditions. Abnormalities in cardiac electrophysiology are well documented in patients with liver cirrhosis, and the prolonged QT interval has emerged as the electrophysiological hallmark of cirrhotic cardiomyopathy. This article will focus on: first, the epidemiology of QT interval prolongation in cirrhosis; second, the potential molecular mechanisms responsible for the pathogenesis of this electrophysiological abnormality and the putative role of circulating cardiotoxins; third, its prognostic meaning; and fourth, its clinical relevance, in terms of the association between the presence of a long QT interval and the occurrence of ventricular arrhythmias in cirrhotic patients treated with drugs known to increase the QT length or exposed to stressful conditions, such as liver transplantation, gastrointestinal bleeding and shock.
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Affiliation(s)
- Mauro Bernardi
- Unità Operativa Semeiotica Medica, Department of Clinical Medicine, Alma Mater Studiorum University of Bologna, Via Albertoni 15, Bologna 40138, Italy.
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Moric-Janiszewska E, Głogowska-Ligus J, Paul-Samojedny M, Węglarz L, Markiewicz-Łoskot G, Szydłowski L. Age-and sex-dependent mRNA expression of KCNQ1 and HERG in patients with long QT syndrome type 1 and 2. Arch Med Sci 2011; 7:941-7. [PMID: 22328875 PMCID: PMC3264984 DOI: 10.5114/aoms.2011.26604] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 11/01/2010] [Accepted: 11/09/2010] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The main goal of this study was to examine the patient age and sex dependent expression of KCNQ1 and HERG genes that encode potassium channels responsible for the occurrence of long QT syndrome (LQTS). MATERIAL AND METHODS The study enrolled 43 families whose members suffered from LQTS type 1 (LQTS1) or 2 (LQTS2) or were healthy. The study attempted to prove that β-actin is a good endogenous control when determining the expression of the studied genes. Examination of gene expression was achieved with quantitative real-time PCR (QRT-PCR). Expression of the investigated genes was inferred from the analysis of the number of mRNA copies per 1 μg total RNA isolated from whole blood. RESULTS Significantly lower KCNQ1 and KCNH2 mRNA levels in healthy females than healthy males were observed (p = 0.032; p = 0.02). In male patients both transcripts were expressed at a lower level (p = 0.0084; p = 0.035). The comparison of transcriptional activity of KCNQ1 and KCNH2 in healthy adults and children revealed higher KCNQ1 and lower KCNH2 mRNA levels in healthy adults (p = 0.033; p = 0.04), higher KCNQ1 and lower KCNH2 mRNA levels in adult patients below 55 years old than in adults over 55 years old (p=0.036; p = 0.044), and significantly higher KCNQ1 and lower KCNH2 mRNA levels in adult patients (over 55 years) than in paediatric patients (below 15 years) (p=0.047; p = 0.08). CONCLUSIONS The results support the hypothesis that KCNQ1 and HERG gene expression is influenced by age and gender in human patients with long QT syndrome and in healthy subjects.
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Affiliation(s)
| | | | | | - Ludmiła Węglarz
- Department of Biochemistry, Medical University of Silesia, Sosnowiec, Poland
| | | | - Lesław Szydłowski
- 1 Department of Paediatric Cardiology, Medical University of Silesia, Katowice-Ligota, Poland
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40
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Abstract
Pediatric congenital heart disease comprises a wide spectrum of structural defects. These lesions present in a limited number of ways. An infant presenting with profound shock, cyanosis, or evidence of congestive heart failure should raise the suspicion of congenital heart disease. Although most congenital lesions are diagnosed in utero, the emergency physician must be aware of these cardinal presentations because many patients present in the postnatal period around the time that the ductus arteriosus closes. Aggressive management of cardiopulmonary instability combined with empiric use of prostaglandin E(1) and early pediatric cardiology consultation is essential for positive outcomes.
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Affiliation(s)
- Katherine Dolbec
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA.
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41
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Coleman MA, Bos JM, Phillips SD, Souza JJ, Ackerman MJ. Left Ventricular Noncompaction Syndrome Masquerading or Misdiagnosed as Congenital Long QT Syndrome: Remember QT Prolongation Does Not Equal Long QT Syndrome. CONGENIT HEART DIS 2011; 6:492-8. [DOI: 10.1111/j.1747-0803.2011.00531.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Windsor JS, Rodway G, Mukherjee R, Firth P, Shattock M, Montgomery H. Prolongation of the Corrected QT Complex - A Cause of Sudden Cardiac Death in the Mountain Environment? J ROY ARMY MED CORPS 2011; 157:63-7. [DOI: 10.1136/jramc-157-01-11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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43
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HIV Protease Inhibitors Induced Prolongation of the QT Interval: Electrophysiology and Clinical Implications. Am J Ther 2010; 17:e193-201. [DOI: 10.1097/mjt.0b013e3181ad3437] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chin JH, Park JY, Kim YK, Kim SH, Kong YG, Park PH, Hwang GS. Torsades de pointes triggered by severe diastolic hypotension with low hematocrit in the neohepatic stage of liver transplantation: a case report. Transplant Proc 2010; 42:1959-62. [PMID: 20620555 DOI: 10.1016/j.transproceed.2010.02.093] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/15/2009] [Accepted: 02/02/2010] [Indexed: 01/01/2023]
Abstract
We have described herein a 39-year-old male patient with hepatitis B virus-related cirrhosis (Child class C), showing a prolonged corrected QT interval, who developed torsades de pointes (TdP) in the neohepatic stage of liver transplantation (LT). There was no arrhythmia in the pre-anhepatic and anhepatic stages. Multiple premature ventricular complexes, ventricular tachycardia, and TdP suddenly developed at 16 minutes after graft reperfusion without any prodromal arrhythmia; they persisted for 118 seconds. Laboratory tests showed that serum potassium, calcium, and magnesium concentrations of 4.7 mmol/L, 1.05 mmol/L, and 1.85 mg/dL, respectively were within normal ranges. Likely causative factors for TdP in this patient included a prolonged corrected QT interval (553 msec), a low hematocrit (21%), and a low arterial blood pressure (systolic blood pressure, 80-90 mm Hg; diastolic blood pressure; 20-26 mm Hg) in the neohepatic stage. This case demonstrated the importance of optimal maintenance of coronary perfusion, with an adequate hematocrit level and electrolyte concentrations, to prevent the development of TdP in cirrhotic patients with a prolonged corrected QT interval during LT.
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Affiliation(s)
- J H Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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45
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Thiruvenkatarajan V, Osborn KD, Van Wijk RMAW, Euler P, Sethi R, Moodie S, Biradar V. Torsade de pointes in a patient with acute prolonged QT syndrome and poorly controlled diabetes during sevoflurane anaesthesia. Anaesth Intensive Care 2010; 38:555-9. [PMID: 20514968 DOI: 10.1177/0310057x1003800323] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a case of torsade de pointes secondary to acute QT interval prolongation in a patient with poorly controlled diabetes mellitus towards the end of a laparoscopic nephrectomy under sevoflurane anaesthesia. The patient was successfully resuscitated and made a complete recovery. Our case suggests that acute QT interval prolongation should be considered in any patient with poor glycaemic control during prolonged procedures.
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Affiliation(s)
- V Thiruvenkatarajan
- Department of Anaesthesia, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Hussain A, Ghazal S. After more than 300 defibrillation shocks, patient still alive 12 years later refractory torsade de pointes due to polypharmacy and persistent vomiting. J Saudi Heart Assoc 2010; 22:149-51. [PMID: 23960610 DOI: 10.1016/j.jsha.2010.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 04/27/2010] [Indexed: 10/19/2022] Open
Abstract
Acquired torsade de pointes ventricular tachycardia (TdP) is a rare but serious life-threatening arrhythmia caused by an array of cardiac and non-cardiac drugs. It is often refractory to pharmacological therapy and may result in death or require frequent defibrillations. In our case study a young female patient with no underlying heart disease developed very frequent sustained TdP requiring frequent defibrillations without which she would have certainly died. The ventricular arrhythmia in this patient was of multifactorial origin - cisapride, drug-drug interaction and persistent vomiting resulting in electrolyte disturbance and malnutrition. The patient survived after more than 300 defibrillation shocks over a period of 5 days and she is still alive 12 years later.
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Affiliation(s)
- Akhtar Hussain
- Cardiology Division, Internal Medicine Department, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
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Smithburger PL, Seybert AL, Armahizer MJ, Kane-Gill SL. QT prolongation in the intensive care unit: commonly used medications and the impact of drug–drug interactions. Expert Opin Drug Saf 2010; 9:699-712. [DOI: 10.1517/14740331003739188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Goitia L, Pérez P, Sebastián P, Taibo JM, Arizaga A. [Perioperative acquired long QT syndrome: a case report]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:109-114. [PMID: 20337003 DOI: 10.1016/s0034-9356(10)70173-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Acquired long QT syndrome is a rare condition whose diagnosis is of vital importance given the risk of torsade de pointes and sudden death. This syndrome may be triggered by various events in patients with a genetic predisposition. Patients usually have a normal baseline QT interval. Some of the factors that may prolong the interval are exposure to common drugs such as antibiotics or agents used for general anesthesia. Diagnosis of the condition is essential, as is knowledge of how to manage anesthesia and prevent ventricular fibrillation, which is the most feared complication. We report the case of a man with no relevant medical history who underwent emergency surgery for a peritonsillar abscess. The patient developed long QT syndrome, with several episodes of torsade de pointes and cardiorespiratory arrest.
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Affiliation(s)
- L Goitia
- Servicio Anestesiología y Reanimación, Hospital de Galdakao-Usánsolo, Vizcaya.
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Stringer J, Welsh C, Tommasello A. Methadone-associated Q-T interval prolongation and torsades de pointes. Am J Health Syst Pharm 2009; 66:825-33. [PMID: 19386945 DOI: 10.2146/ajhp070392] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The association of methadone with Q-T interval prolongation and torsades de pointes (TdP) is reviewed, and recommendations for preventing Q-T interval prolongation in methadone users are provided. SUMMARY Abnormalities in voltage-gated potassium channels have been shown to lead to prolonged action potentials that are expressed as long Q-T intervals, and methadone has been found to interact with the voltage-gated potassium channels of the myocardium. While cardiac arrhythmias in methadone users have been reported for several decades, specific reports of methadone-associated Q-T interval prolongation and TdP did not appear in the literature until the early part of the 21st century. Because not every patient experiences Q-T interval prolongation with methadone, recent research has elucidated risk factors that predispose patients to this adverse effect, including female sex, hypokalemia, high-dose methadone, drug interactions, underlying cardiac conditions, unrecognized congenital long Q-T interval syndrome, and predisposing DNA polymorphisms. Given the high mortality rates seen in untreated illicit opioid users and the clear efficacy of methadone in treating opioid addiction, the risk of using methadone, even in a patient with other risk factors for Q-T interval prolongation, may outweigh the alternative of no pharmacologic treatment. A baseline electrocardiogram (ECG), personal and family history of syncope, and a complete medication history should be obtained before a patient begins treatment with methadone. Given the apparent synergistic effects of parenteral methadone and chlorobutanol, oral methadone should be used whenever possible. CONCLUSION Q-T interval prolongation and TdP associated with the use of methadone are potentially fatal adverse effects. A thorough patient history and ECG monitoring are essential for patients treated with this agent, and alterations in treatment options may be necessary.
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Affiliation(s)
- John Stringer
- Pharmacy, Saint Barnabas Behavioral Health Center, Toms River, NJ 08754, USA.
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Choo EK, Weber FS, Schmidt TA. Torsade de Pointes after Administration of Droperidol for Nausea andVomiting. PREHOSP EMERG CARE 2009; 13:261-5. [DOI: 10.1080/10903120802706096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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