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Hughes G, Young WJ, Bern H, Crook A, Lambiase PD, Goodall RL, Nunn AJ, Meredith SK. T-wave morphology abnormalities in the STREAM stage 1 trial. Expert Opin Drug Saf 2024; 23:469-476. [PMID: 38462751 DOI: 10.1080/14740338.2024.2322116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/15/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Shorter regimens for drug-resistant tuberculosis (DR-TB) have non-inferior efficacy compared with longer regimens, but QT prolongation is a concern. T-wave morphology abnormalities may be a predictor of QT prolongation. RESEARCH DESIGN AND METHODS STREAM Stage 1 was a randomized controlled trial in rifampicin-resistant TB, comparing short and long regimens. All participants had regular ECGs. QT/QTcF prolongation (≥500 ms or increase in ≥60 ms from baseline) was more common on the short regimen which contained high-dose moxifloxacin and clofazimine. Blinded ECGs were selected from the baseline, early (weeks 1-4), and late (weeks 12-36) time points. T-wave morphology was categorized as normal or abnormal (notched, asymmetric, flat-wave, flat peak, or broad). Differences between groups were assessed using Chi-Square tests (paired/unpaired, as appropriate). RESULTS Two-hundred participants with available ECGs at relevant times were analyzed (QT prolongation group n = 82; non-prolongation group n = 118). At baseline, 23% (45/200) of participants displayed abnormal T-waves, increasing to 45% (90/200, p < 0.001) at the late time point. Abnormalities were more common in participants allocated the Short regimen (75/117, 64%) than the Long (14/38, 36.8%, p = 0.003); these occurred prior to QT/QTcF ≥500 ms in 53% of the participants (Long 2/5; Short 14/25). CONCLUSIONS T-wave abnormalities may help identify patients at risk of QT prolongation on DR-TB treatment. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02409290). Current Controlled Trial number, ISRCTN78372190.
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Affiliation(s)
- Gareth Hughes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - William J Young
- Centre for Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomews Hospital, Barts Health NHS Trust, London, UK
| | - Henry Bern
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Angela Crook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, UK
- NIHR Barts Biomedical Research Centre, London, UK
| | - Ruth L Goodall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Sarah K Meredith
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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2
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Kohlbrenner D, Bisang M, Aeschbacher SS, Heusser E, Ulrich S, Bloch KE, Furian M. Automated Quantification of QT-Intervals by an Algorithm: A Validation Study in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:721-730. [PMID: 38495216 PMCID: PMC10944305 DOI: 10.2147/copd.s445412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Study Objectives To assess the diagnostic accuracy of a purpose-designed QTc-scoring algorithm versus the established hand-scoring in patients with chronic obstructive pulmonary disease (COPD) undergoing sleep studies. Methods We collected 62 overnight electrocardiogram (ECG) recordings in 28 COPD patients. QT-intervals corrected for heart rate (QTc, Bazett) were averaged over 1-min periods and quantified, both by the algorithm and by cursor-assisted hand-scoring. Hand-scoring was done blinded to the algorithm-derived results. Bland-Altman statistics and confusion matrixes for three thresholds (460, 480, and 500ms) were calculated. Results A total of 32944 1-min periods and corresponding mean QTc-intervals were analysed manually and by computer. Mean difference between manual and algorithm-based QTc-intervals was -1ms, with limits of agreement of -18 to 16ms. Overall, 2587 (8%), 357 (1%), and 0 QTc-intervals exceeding the threshold 460, 480, and 500ms, respectively, were identified by hand-scoring. Of these, 2516, 357, and 0 were consistently identified by the algorithm. This resulted in a diagnostic classification accuracy of 0.98 (95% CI 0.98/0.98), 1.00 (1.00/1.00), and 1.00 (1.00/1.00) for 460, 480, and 500ms, respectively. Sensitivity was 0.97, 1.00, and NA for 460, 480, and 500ms, respectively. Specificity was 0.98, 1.00, and 1.00 for 460, 480, and 500ms, respectively. Conclusion Overall, 8% of nocturnal 1-min periods showed clinically relevant QTc prolongations in patients with stable COPD. The automated QTc-algorithm accurately identified clinically relevant QTc-prolongations with a very high sensitivity and specificity. Using this tool, hospital sleep laboratories may identify asymptomatic patients with QTc-prolongations at risk for malignant arrhythmia, allowing them to consult a cardiologist before an eventual cardiac event.
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Affiliation(s)
- Dario Kohlbrenner
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Maya Bisang
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | | | - Emanuel Heusser
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Swiss University of Traditional Chinese Medicine, Bad Zurzach, Switzerland
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Comparison of hydroxychloroquine plus moxifloxacin versus hydroxychloroquine alone on corrected QT interval prolongation in COVID-19 patients. COR ET VASA 2021. [DOI: 10.33678/cor.2021.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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4
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Saleem S, Kannan RR. Zebrafish: A Promising Real-Time Model System for Nanotechnology-Mediated Neurospecific Drug Delivery. NANOSCALE RESEARCH LETTERS 2021; 16:135. [PMID: 34424426 PMCID: PMC8382796 DOI: 10.1186/s11671-021-03592-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
Delivering drugs to the brain has always remained a challenge for the research community and physicians. The blood-brain barrier (BBB) acts as a major hurdle for delivering drugs to specific parts of the brain and the central nervous system. It is physiologically comprised of complex network of capillaries to protect the brain from any invasive agents or foreign particles. Therefore, there is an absolute need for understanding of the BBB for successful therapeutic interventions. Recent research indicates the strong emergence of zebrafish as a model for assessing the permeability of the BBB, which is highly conserved in its structure and function between the zebrafish and mammals. The zebrafish model system offers a plethora of advantages including easy maintenance, high fecundity and transparency of embryos and larvae. Therefore, it has the potential to be developed as a model for analysing and elucidating the permeability of BBB to novel permeation technologies with neurospecificity. Nanotechnology has now become a focus area within the industrial and research community for delivering drugs to the brain. Nanoparticles are being developed with increased efficiency and accuracy for overcoming the BBB and delivering neurospecific drugs to the brain. The zebrafish stands as an excellent model system to assess nanoparticle biocompatibility and toxicity. Hence, the zebrafish model is indispensable for the discovery or development of novel technologies for neurospecific drug delivery and potential therapies for brain diseases.
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Affiliation(s)
- Suraiya Saleem
- Neuroscience Lab, Centre for Molecular and Nanomedical Sciences, Centre for Nanoscience and Nanotechnology, School of Bio and Chemical Engineering, Sathyabama Institute of Science and Technology (Deemed to be University), Jeppiaar Nagar, Rajiv Gandhi Salai, Chennai, Tamil Nadu, 600119, India
| | - Rajaretinam Rajesh Kannan
- Neuroscience Lab, Centre for Molecular and Nanomedical Sciences, Centre for Nanoscience and Nanotechnology, School of Bio and Chemical Engineering, Sathyabama Institute of Science and Technology (Deemed to be University), Jeppiaar Nagar, Rajiv Gandhi Salai, Chennai, Tamil Nadu, 600119, India.
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5
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Bakhshaliyev N, Özdemir R. The impact of hydroxychloroquine-azithromycin combination on Tpeak-to-end and Tpeak-to-end/QT ratio during a short treatment course. Ann Noninvasive Electrocardiol 2021; 26:e12846. [PMID: 33956361 PMCID: PMC8293593 DOI: 10.1111/anec.12846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Since there was no proven treatment of coronavirus disease 2019 (COVID-19), hydroxychloroquine-azithromycin (HCQ-AZM) combination is being used in different countries as a treatment option. Many controversies exist related to the safety and effectiveness of this combination, and questions about how HCQ-AZM combination affects the ventricular repolarization are still unknown. OBJECTIVE The aim of the study was to show whether the hydroxychloroquine-azithromycin (HCQ-AZM) combination prolonged Tpeak-to-end (TpTe) duration and TpTe/QT interval ratio or not. METHODS One hundred and twenty-six consequent COVID-19(+) patients meeting the study criteria were enrolled in this study. Baseline ECGs were obtained immediately after hospitalization and before commencing the HCQ-AZM combination. On-treatment ECG was obtained 24-48 hr after the loading dose of HCQ/AZM. ECG parameters including PR interval, QRS duration, QT interval, QTc interval, TpTe duration, and TpTe/QT interval ratio were assessed. Demographic and laboratory findings were collected from an electronic recording system. RESULTS ECGs of 126 COVID-19(+) patients who received HCQ-AZM combination were assessed. Mean baseline QTc (by Fridericia formula), TpTe, and TpTe/QT ratio were 420.0 ± 26.5 ms, 82.43 ± 9.77 ms, and 0.22 ± 0.02, respectively. On-treatment QTc, TpTe and TpTe/QT ratio were 425.7 ± 27.18 ms, 85.17 ± 11.17 ms, and 0.22 ± 0.03, respectively. No statistically significant acute impacts of HCQ-AZM combination on TpTe duration and TpTe/QT interval ratio were observed compared with baseline values. No ventricular tachycardia/fibrillation and the significant conduction delays were seen during in-hospital follow-up. CONCLUSION HCQ-AZM combination increased TpTe duration. However, no significant impact on TpTe/QT interval ratio was observed.
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6
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Community pharmacist use of mobile
ECG
to inform drug therapy decision making for patients receiving
QTc
prolonging medications. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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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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Jiang E, Raubenheimer JE, Isbister GK, Chan BSH, Buckley NA. Machine read frontal QRS-T angle and QTc is no substitute for manual measurement of QTc in pro-arrhythmic drug overdose. J Electrocardiol 2021; 65:151-156. [PMID: 33640634 DOI: 10.1016/j.jelectrocard.2021.02.006] [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: 10/01/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To investigate whether there is an association between the blocking of cardiac potassium channels, which is characterised by a prolonged QTc interval and the frontal QRS-T angle after overdose by QT prolonging drugs. METHODS We obtained patient medical records associated with QT prolonging drugs from 3 different hospitals: the Calvary Mater Newcastle Hospital (CMNH), Royal Prince Alfred Hospital (RPAH) and Prince of Wales Hospital (POWH). RPAH and POWH admissions were taken between 4/01/2017 to 1/11/2019, and CMNH admissions were taken between 4/01/2013 to 24/06/2018. Demographic information and details of overdose were collected. All admission ECGs were manually measured. Linear regression was used to assess the relationship between various QTc formulas and the frontal QRS-T angle. A Bland-Altman plot was used to examine agreement between manual and machine QT intervals. RESULTS 144 patients met the inclusion criteria for analysis. None of the patients developed torsades de pointes (TdP). There was no linear association between the QRS-T angle and the various QTc formulas (For QRS-T angle: QTcRTH: p = 0.76, QTcB: p = 0.83, QTcFri: p = 0.90, QTcFra: p = 0.13, QTcH: p = 0.97; For square root transformation of the QRS-T angle: QTcRTH: p = 0.18, QTcB: p = 0.33, QTcFri: p = 0.95, QTcFra: p = 0.47, QTcH: p = 0.33). Agreement between machine and manual QT measurements was low. CONCLUSIONS The frontal QRS-T angle cannot substitute the QTc in assessing the blockage of cardiac potassium channels in drug induced long QT syndrome. We also support the consensus that despite the availability of machine measurements of the QT interval, manual measurements should also be performed.
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Affiliation(s)
- Eric Jiang
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jacques E Raubenheimer
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Betty S H Chan
- Clinical Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Nicholas A Buckley
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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9
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Rashid U, Virk A, Nawaz R, Mahmood T, Fatima Z. Overt long QT syndrome in children presenting with seizure disorders in Pakistan. Ann Pediatr Cardiol 2021; 14:485-489. [PMID: 35527745 PMCID: PMC9075568 DOI: 10.4103/apc.apc_10_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/23/2021] [Accepted: 05/28/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Objective: Materials and Methods: Results: Conclusions:
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10
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Isaksen JL, Ghouse J, Graff C, Olesen MS, Holst AG, Pietersen A, Nielsen JB, Skov MW, Kanters JK. Electrocardiographic T-wave morphology and risk of mortality. Int J Cardiol 2020; 328:199-205. [PMID: 33321127 DOI: 10.1016/j.ijcard.2020.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/10/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electrocardiographic T-wave morphology is used in drug safety studies as an adjunct to the QTc interval, but few measurements of T-wave morphology can be interpreted in clinical practice. Morphology combination score (MCS) is a combination of T-wave flatness/peakedness, asymmetry, and notching, enabling easy visual assessment of T-wave morphology. We aimed to test the association between T-wave morphology, quantified by MCS, and mortality. METHODS We included electrocardiograms recorded in 2001-2011 from 342,294 primary care patients. Using Cox regression, we evaluated the association between MCS, cardiovascular death, and all-cause mortality, adjusting for heart rate, QTc, QT-prolonging drugs, diabetes, ischemic heart disease, hypertension, and congestive heart failure. RESULTS 270,039 individuals (44% men, median age 55 [inter-quartile range: 42-67 years]) were included and followed for a median of 9.3 years, during which time 13,489 (5.0%) died from cardiovascular causes and 50,481 (18.7%) from any cause. High values of MCS (i.e. asymmetric, flattened, and/or notched T waves) were associated with an adjusted mortality Hazard Ratio of 1.75 (95% CI 1.62-1.89) and 1.61 (1.43-1.92) for women and men, respectively. Low values of MCS (i.e. peaked and symmetric T waves) were associated with a Hazard Ratio of 1.18 (1.08-1.28) and 1.71 (1.48-1.98) for women and men, respectively. CONCLUSIONS In a large primary care population, we found that T-wave asymmetry, flatness, and notching provided prognostic information on mortality independent of heart rate, QTc, and baseline comorbidities.
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Affiliation(s)
- Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Ghouse
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Morten S Olesen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Anders G Holst
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Adrian Pietersen
- Copenhagen General Practitioners' Laboratory, Copenhagen, Denmark
| | - Jonas B Nielsen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Morten W Skov
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Park CS, Cho HJ, Choi EK, Lee SE, Kim MS, Kim JJ, Choi JO, Jeon ES, Hwang KK, Chae SC, Baek SH, Kang SM, Yoo B, Choi DJ, Ahn Y, Kim KH, Cho MC, Oh BH, Lee HY. J-curve relationship between corrected QT interval and mortality in acute heart failure patients. Korean J Intern Med 2020; 35:1371-1384. [PMID: 32380800 PMCID: PMC7652667 DOI: 10.3904/kjim.2019.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/03/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND/AIMS This study investigated the prognostic power of corrected QT (QTc) interval in patients with acute heart failure (AHF) according to sex. METHODS We analyzed multicenter Korean Acute Heart Failure registry with patients with AHF admitted from 2011 to 2014. Among them, we analyzed 4,990 patients who were followed up to 5 years. Regarding QTc interval based on 12 lead electrocardiogram, patients were classified into quartiles according to sex. RESULTS During follow-up with median 43.7 months, 2,243 (44.9%) patients died. The relationship between corrected QT interval and all-cause mortality followed a J-curve relationship. In Kaplan-Meier analysis, both sex had lowest mortality in the second QTc quartile. There were significant prognostic differences between the second and the fourth quartiles in male (log-rank p = 0.002), but not in female (log-rank p = 0.338). After adjusting covariates, the third (hazard ratio [HR], 1.185; 95% confidence interval [CI], 1.001 to 1.404; p = 0.049) and the fourth (HR, 1.404; 95% CI, 1.091 to 1.535; p = 0.003) quartiles demonstrated increased risk of mortality compared to the second quartile in male. In female, however, there was no significant difference across quartiles. QTc interval was associated with 5-year all-cause mortality in J-shape with nadir of 440 to 450 ms in male and 470 to 480 ms in female. CONCLUSION QTc interval was an independent predictor of overall death in male, but its significance decreased in female. The relationship between QTc interval and all-cause mortality was J-shaped in both sex.
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Affiliation(s)
- Chan Soon Park
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Eun Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Kyung-Kuk Hwang
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sang Hong Baek
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byungsu Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong-Ju Choi
- Cardiovascular Center, Division of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Youngkeun Ahn
- Heart Research Center, Chonnam National University, Gwangju, Korea
| | - Kye-Hoon Kim
- Heart Research Center, Chonnam National University, Gwangju, Korea
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung-Hee Oh
- Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Correspondence to Hae Young Lee, M.D. Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-0698, Fax: +82-2-3674-0805, E-mail:
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12
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Bakhshaliyev N, Uluganyan M, Enhos A, Karacop E, Ozdemir R. The effect of 5-day course of hydroxychloroquine and azithromycin combination on QT interval in non-ICU COVID19(+) patients. J Electrocardiol 2020; 62:59-64. [PMID: 32827987 PMCID: PMC7417268 DOI: 10.1016/j.jelectrocard.2020.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/19/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The combination of Hydroxychloroquine (HCQ) and azithromycin showed effectiveness as a treatment for COVID-19 and is being used widely all around the world. Despite that those drugs are known to cause prolonged QT interval individually there is no study assessing the impact of this combination on electrocardiography (ECG). This study aimed to assess the impact of a 5-day course of HCQ and azithromycin combination on ECG in non-ICU COVID19(+) patients. METHODS In this retrospective observational study, we enrolled 109 COVID19(+) patients who required non-ICU hospitalization. All patients received 5-day protocol of HCQ and azithromycin combination. On-treatment ECGs were repeated 3-6 h after the second HCQ loading dose and 48-72 h after the first dose of the combination. ECGs were assessed in terms of rhythm, PR interval, QRS duration, QT and QTc intervals. Baseline and on-treatment ECG findings were compared. Demographic characteristics, laboratory results were recorded. Daily phone call-visit or bed-side visit were performed by attending physician. RESULTS Of the 109 patients included in the study, the mean age was 57.3 ± 14.4 years and 48 (44%) were male. Mean baseline PR interval was 158.47 ± 25.10 ms, QRS duration was 94.00 ± 20.55 ms, QTc interval was 435.28 ± 32.78 ms, 415.67 ± 28.51, 412.07 ± 25.65 according to Bazett's, Fridericia's and Framingham Heart Study formulas respectively. ∆PR was -2.94 ± 19.93 ms (p = .55), ∆QRS duration was 5.18 ± 8.94 ms (p = .03). ∆QTc interval was 6.64 ± 9.60 ms (p = .5), 10.67 ± 9.9 ms (p = .19), 14.14 ± 9.68 ms (p = .16) according to Bazett's, Fridericia's and Framingham Heart Study formulas respectively. There were no statistically significant differences between QTc intervals. No ventricular tachycardia, ventricular fibrillation or significant conduction delay was seen during follow-up. There was no death or worsening heart function. CONCLUSION The 5-day course of HCQ- AZM combination did not lead to clinically significant QT prolongation and other conduction delays compared to baseline ECG in non-ICU COVID19(+) patients.
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Affiliation(s)
| | | | - Asim Enhos
- Bezmialem Vakif University, Department of Cardiology, Turkey
| | - Erdem Karacop
- Bezmialem Vakif University, Department of Cardiology, Turkey
| | - Ramazan Ozdemir
- Bezmialem Vakif University, Department of Cardiology, Turkey
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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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14
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Poor Agreement but Good Predictive Value Between Automated and Manual QTc Intervals in Pediatric Emergency Department Electrocardiograms. Pediatr Emerg Care 2020; 36:286-290. [PMID: 32483080 DOI: 10.1097/pec.0000000000002125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES QTc interval is significant because prolongation may lead to ventricular dysrhythmia. Computerized electrocardiogram machines typically measure QT interval length and, using an algorithm assessment of multiple leads, calculate a QTc value. Manual measurement of the QT interval used to calculate the QTc value is more time-consuming but potentially more accurate. In this study, we compare the automated QTc calculation with the QTc value calculated using manual QT measurements. METHODS We prospectively obtained 350 resting 12-lead electrocardiograms (ECGs) in children aged 2 to 14 years in an academic pediatric emergency department. Manual measurement of the QT interval was performed and the QTc was calculated using the 2 most commonly used correction methods, Bazzet and Fridericia formulas. The paired values were used to perform a Bland-Altman analysis and create a receiver operating characteristic curve. RESULTS Bland-Altman analysis determined that QT-automated and QTc-Bazett had an average difference of 3.8 milliseconds, with a standard deviation of 86 milliseconds (95% confidence interval = -161 to 176). An automated QTc value of 455 milliseconds was sensitive to detect manual QTc values of greater than 480 milliseconds. CONCLUSIONS In children with resting ECGs, there is a poor agreement between the automated QTc produced by a computerized electrocardiogram and the QTc value obtained using manual QT measurement. Statistically and clinically relevant discrepancy between the automated QTc and QTc values calculated after manual QT measurement was present. Automated QTc values may be used as a screening tool to detect prolonged QTc, but for accurate determination of QTc, manual measurement is necessary.
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Ruiz Diaz JC, Frenkel D, Aronow WS. The relationship between atypical antipsychotics drugs, QT interval prolongation, and torsades de pointes: implications for clinical use. Expert Opin Drug Saf 2020; 19:559-564. [PMID: 32189527 DOI: 10.1080/14740338.2020.1745184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Increased mortality has been observed in patients with mental health disorders. Specifically, exposure to antipsychotic medications conveys a greater than 2 fold risk of sudden death, thought to be mediated through effects on QT prolongation and risk of torsades de pointes.Areas covered: We review the association between antipsychotic drugs and sudden cardiac death, the physiologic basis for these associations, assessment of patients at risk, and strategies to minimize risk of sudden cardiac death.Expert opinion: Despite the prevalence of antipsychotic medication use for many decades, there remain considerable challenges in reducing the associated risk of sudden cardiac death. A structured algorithm that incorporates patient clinical factors and antipsychotic drug factors may improve risk assessment and reduce the risk of adverse cardiac events. Future advancements in genetics and artificial intelligence may allow for enhanced risk stratification and predicting response (efficacy and adverse effects) to therapy.
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Affiliation(s)
- Juan Carlos Ruiz Diaz
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Daniel Frenkel
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Impact of Safety Warning on Domperidone Prescribing for Geriatric Patients in South Korea: Analysis of National Insurance Claim Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16162985. [PMID: 31434200 PMCID: PMC6719182 DOI: 10.3390/ijerph16162985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
Domperidone is a dopamine antagonist used for the symptomatic management of nausea and vomiting. Many countries banned or add a black box warning due to an increased risk of serious adverse cardiac effects. In 2014, the Korea Ministry of Food and Drug Safety also released a safety warning to carefully consider adverse cardiac effects when prescribing domperidone. Therefore, we conducted this study to analyze the impact of the safety warning on domperidone prescribing. This study included patients 65 years or older who used national health insurance services in the years 2011 and 2016, using the national patient sample dataset in South Korea. We analyzed the characteristics of domperidone prescribing and compared on pre- and post-safety warning. Prescribing frequency of domperidone was significantly reduced from 603,962 cases in 2011 to 24,623 cases in 2016. In 2011, 53,272 (8.8%) prescriptions were for greater than 30 mg/day, whereas only 200 (0.8%) prescriptions were in 2016. The number of patients with one or more comorbidities and electrocardiogram monitoring showed positive changes after the safety warning. In conclusion, after the 2014 safety letter was issued, domperidone was more safely prescribed in various aspects in elderly patients, including frequency of prescribing, maximum daily dose, and duration of continuous prescription.
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17
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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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18
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Shin SY, Hong JY, Lee DH. Delayed diagnosis of long QT syndrome in a patient with seizures. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907918754921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Long QT syndrome accompanied by a seizure episode is often misdiagnosed as primary epilepsy. Although patients with Long QT syndrome who are misdiagnosed and improperly managed are likely to result in fatality, their first clinical manifestations are seizure episodes in many cases. Case presentation: A 17-year-old boy visited the emergency department with poorly controlled seizure during epilepsy treatment was found to have been misdiagnosed with epilepsy when he was 7 years old. His electrocardiography showed a prolonged QT interval. After careful re-evaluation, he was finally diagnosed with Long QT syndrome and recovered without any seizure episodes in the absence of anti-epileptic agents. Discussion and conclusion: Careful initial assessment including repetitive electrocardiography, when abnormal, is required for those who visit the emergency department with a seizure or who show no definite abnormalities in diagnostic work up process.
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Affiliation(s)
- Seung Yong Shin
- Division of Cardiology, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Cardiology, Chung-Ang University Hospital, Seoul, Korea
| | - Jun Young Hong
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
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19
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Coppola C, Rienzo A, Piscopo G, Barbieri A, Arra C, Maurea N. Management of QT prolongation induced by anti-cancer drugs: Target therapy and old agents. Different algorithms for different drugs. Cancer Treat Rev 2017; 63:135-143. [PMID: 29304463 DOI: 10.1016/j.ctrv.2017.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 01/04/2023]
Abstract
The side effects of anticancer drugs still play a critical role in survival and quality of life. Although the recent progresses of cancer therapies have significantly improved the prognosis of oncologic patients, side effects of antineoplastic treatments are still responsible for the increased mortality of cancer survivors. Cardiovascular toxicity is the most dangerous adverse effect induced by anticancer therapies. A survey conducted by the National Health and Nutrition Examination, showed that 1807 cancer survivors followed up for seven years: 51% died of cancer and 33% of heart disease (Vejpongsa and Yeh, 2014). Moreover, the risk of cardiotoxicity persists even with the targeted therapy, the newer type of cancer treatment, due to the presence of on-target and off-target effects related to this new class of drugs. The potential cardiovascular toxicity of anticancer agents includes: QT prolongation, arrhythmias, myocardial ischemia, stroke, hypertension (HTN), thromboembolism, left ventricular dysfunction and heart failure (HF). Compared to other cardiovascular disorders, the interest in QT prolongation and its complications is fairly recent. However, oncologists have to deal with it and to evaluate the risk-benefit ratio before starting the treatment or during the same. Electrolyte abnormalities, low levels of serum potassium and several drugs may favour the acquired QT prolongation. Treatment of marked QT prolongation includes cardiac monitoring, caution in the use or suspension of cancer drugs and correction of electrolyte abnormalities (hypokalaemia, hypomagnesaemia, hypocalcaemia). Syndrome of QT prolongation can be associated with potentially fatal cardiac arrhythmias and its treatment consists of intravenous administration of magnesium sulphate and the use of electrical cardioversion.
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Affiliation(s)
- Carmela Coppola
- Division of Cardiology, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy
| | - Anna Rienzo
- Division of Cardiology, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy
| | - Giovanna Piscopo
- Division of Cardiology, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy
| | - Antonio Barbieri
- Animal Facility Unit, Department of Translational Research, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy
| | - Claudio Arra
- Animal Facility Unit, Department of Translational Research, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy
| | - Nicola Maurea
- Division of Cardiology, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Naples, Italy.
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20
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Pro-arrhythmic effects of low plasma [K +] in human ventricle: An illustrated review. Trends Cardiovasc Med 2017; 28:233-242. [PMID: 29203397 DOI: 10.1016/j.tcm.2017.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/18/2017] [Accepted: 11/05/2017] [Indexed: 12/25/2022]
Abstract
Potassium levels in the plasma, [K+]o, are regulated precisely under physiological conditions. However, increases (from approx. 4.5 to 8.0mM) can occur as a consequence of, e.g., endurance exercise, ischemic insult or kidney failure. This hyperkalemic modulation of ventricular electrophysiology has been studied extensively. Hypokalemia is also common. It can occur in response to diuretic therapy, following renal dialysis, or during recovery from endurance exercise. In the human ventricle, clinical hypokalemia (e.g., [K+]o levels of approx. 3.0mM) can cause marked changes in both the resting potential and the action potential waveform, and these may promote arrhythmias. Here, we provide essential background information concerning the main K+-sensitive ion channel mechanisms that act in concert to produce prominent short-term ventricular electrophysiological changes, and illustrate these by implementing recent mathematical models of the human ventricular action potential. Even small changes (~1mM) in [K+]o result in significant alterations in two different K+ currents, IK1 and HERG. These changes can markedly alter in resting membrane potential and/or action potential waveform in human ventricle. Specifically, a reduction in net outward transmembrane K+ currents (repolarization reserve) and an increased substrate input resistance contribute to electrophysiological instability during the plateau of the action potential and may promote pro-arrhythmic early after-depolarizations (EADs). Translational settings where these insights apply include: optimal diuretic therapy, and the interpretation of data from Phase II and III trials for anti-arrhythmic drug candidates.
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21
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Sandau KE, Funk M, Auerbach A, Barsness GW, Blum K, Cvach M, Lampert R, May JL, McDaniel GM, Perez MV, Sendelbach S, Sommargren CE, Wang PJ. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e273-e344. [DOI: 10.1161/cir.0000000000000527] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Trenor B, Cardona K, Saiz J, Noble D, Giles W. Cardiac action potential repolarization revisited: early repolarization shows all-or-none behaviour. J Physiol 2017; 595:6599-6612. [PMID: 28815597 PMCID: PMC5663823 DOI: 10.1113/jp273651] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/09/2017] [Indexed: 12/15/2022] Open
Abstract
In healthy mammalian hearts the action potential (AP) waveform initiates and modulates each contraction, or heartbeat. As a result, AP height and duration are key physiological variables. In addition, rate-dependent changes in ventricular AP duration (APD), and variations in APD at a fixed heart rate are both reliable biomarkers of electrophysiological stability. Present guidelines for the likelihood that candidate drugs will increase arrhythmias rely on small changes in APD and Q-T intervals as criteria for safety pharmacology decisions. However, both of these measurements correspond to the final repolarization of the AP. Emerging clinical evidence draws attention to the early repolarization phase of the action potential (and the J-wave of the ECG) as an additional important biomarker for arrhythmogenesis. Here we provide a mechanistic background to this early repolarization syndrome by summarizing the evidence that both the initial depolarization and repolarization phases of the cardiac action potential can exhibit distinct time- and voltage-dependent thresholds, and also demonstrating that both can show regenerative all-or-none behaviour. An important consequence of this is that not all of the dynamics of action potential repolarization in human ventricle can be captured by data from single myocytes when these results are expressed as 'repolarization reserve'. For example, the complex pattern of cell-to-cell current flow that is responsible for AP conduction (propagation) within the mammalian myocardium can change APD and the Q-T interval of the electrocardiogram alter APD stability, and modulate responsiveness to pharmacological agents (such as Class III anti-arrhythmic drugs).
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Affiliation(s)
- Beatriz Trenor
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Karen Cardona
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Javier Saiz
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Denis Noble
- University Laboratory of PhysiologyUniversity of OxfordOxfordOX1 3PTUK
| | - Wayne Giles
- Faculties of Kinesiology and MedicineUniversity of CalgaryCalgaryAlbertaCanadaT2N 1N4
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23
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Waddell‐Smith K, Gow RM, Skinner JR. How to measure a QT interval. Med J Aust 2017; 207:107-110. [DOI: 10.5694/mja16.00442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 10/31/2016] [Indexed: 01/09/2023]
Affiliation(s)
| | - Robert M Gow
- Children's Hospital of Eastern Ontario, Ottawa, Canada
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Singh BN, Wadhani N. Antiarrhythmic and Proarrhythmic Properties of QT-Prolonging Antianginal Drugs. J Cardiovasc Pharmacol Ther 2016; 9 Suppl 1:S85-97. [PMID: 15378133 DOI: 10.1177/107424840400900107] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In recent years there has been a major reorientation of drug therapy for cardiac arrhythmias, its changing role, and above all, a radical change in the class of arrhythmia drugs because of their impact on mortality. The decline in the use of sodium-channel blockers has led to an expanding use of β-blockers and simple or complex class III agents for controlling cardiac arrhythmias. Success with these agents in the context of their side effects has spurred the development of compounds with simpler ion-channel blocking properties that have less complex adverse reactions. The resulting so-called pure class III agents, such as dofetilide or ibutilide, were found to have antifibrillatory effects in atrial fibrillation and flutter and in ventricular tachyarrhythmias. Such agents are effective and have diversity, but they have come into therapeutics with a price: the sometimes-fatal torsades de pointes. The drug amiodarone, a complex compound that was synthesized as an antianginal agent, has been an exception in this regard. Its therapeutic use is associated with a negligibly low incidence of torsades de pointes, even though the drug produces significant bradycardia and QT lengthening to 500 to 700 msec. Recent electrophysiologic studies suggest that this paradox is likely due to the differential block of ion channels in endocardium, epicardium, midmyocardial (M) cells, and Purkinje fibers in the ventricular myocardium. There is also clinical evidence suggesting that amiodarone reduces the “torsadogenic” effects of pure class III agents. Ranolazine was also synthesized for the development of antianginal properties that stem from a partial inhibition of fatty acid oxidation; it too has been found to have electrophysioloigic properties. These are somewhat similar to those of amiodarone on ion channels in endocardium, epicardium, M cells, and Purkinje fibers in the ventricular myocardium, but the drug does not prolong the QT interval to the same extent as amiodarone does. Thus, the drug produces modest increases in repolarization as judged by its effects on the action potential duration (APD) without the potential for the development of torsades de pointes. By virtue of its suppressant action on early afterdepolarizations and triggered activity in Purkinje fibers and M cells, the drug appears to have a powerful potential for reducing the torsadogenic proclivity of conventional class III antiarrhythmic compounds. The rationale for the therapeutic niche for amiodarone, and especially in the case of ranolazine, in the prevention of drug-induced torsades de pointes is discussed.
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Affiliation(s)
- Bramah N Singh
- Division of Cardiology, Veterans Administration Greater Los Angeles Healthcare System and the David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, CA 90073, USA.
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Maurea N, Spallarossa P, Cadeddu C, Madonna R, Mele D, Monte I, Novo G, Pagliaro P, Pepe A, Tocchetti CG, Zito C, Mercuro G. A recommended practical approach to the management of target therapy and angiogenesis inhibitors cardiotoxicity: an opinion paper of the working group on drug cardiotoxicity and cardioprotection, Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2016; 17 Suppl 1:S93-S104. [PMID: 27183530 PMCID: PMC4927319 DOI: 10.2459/jcm.0000000000000383] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Indexed: 12/21/2022]
Abstract
The US National Cancer Institute estimates that cardiotoxicity (CTX) from target therapy refers mostly to four groups of drugs: epidermal growth factor receptor 2 inhibitors, angiogenic inhibitors, directed Abelson murine leukemia viral oncogene homolog inhibitors, and proteasome inhibitors. The main cardiotoxic side-effects related to antiepidermal growth factor receptor 2 therapy are left ventricular systolic dysfunction and heart failure. Angiogenesis inhibitors are associated with hypertension, left ventricular dysfunction/heart failure, myocardial ischemia, QT prolongation, and thrombosis. Moreover, other agents may be related to CTX induced by treatment. In this study, we review the guidelines for a practical approach for the management of CTX in patients under anticancer target therapy.
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Affiliation(s)
- Nicola Maurea
- Division of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori ‘Fondazione Giovanni Pascale’ – IRCCS, Naples
| | | | - Christian Cadeddu
- Department of Medical Sciences ‘Mario Aresu’, University of Cagliari, Cagliari
| | - Rosalinda Madonna
- Institute of Cardiology, Center of Excellence on Aging, ‘G. d’Annunzio’ University, Chieti
| | - Donato Mele
- Cardiology Unit, University Hospital of Ferrara, Ferrara
| | - Ines Monte
- Department of General Surgery and Medical-Surgery Specialties, University of Catania, Catania
| | - Giuseppina Novo
- Chair and Division of Cardiology, University of Palermo, Palermo
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Turin, Turin
| | - Alessia Pepe
- U.O.C. Magnetic Resonance Imaging, Fondazione G. Monasterio C.N.R., Pisa
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples
| | - Concetta Zito
- U.O.C. Cardiology Intensive Unit, A.O.U. Policlinico ‘G. Martino’, University of Messina, Messina, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences ‘Mario Aresu’, University of Cagliari, Cagliari
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Interleukin-1β gene variants are associated with QTc interval prolongation following cardiac surgery: a prospective observational study. Can J Anaesth 2016; 63:397-410. [PMID: 26858093 DOI: 10.1007/s12630-015-0576-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 10/13/2015] [Accepted: 12/21/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND We characterized cardiac surgery-induced dynamic changes of the corrected QT (QTc) interval and tested the hypothesis that genetic factors are associated with perioperative QTc prolongation independent of clinical and procedural factors. METHODS All study subjects were ascertained from a prospective study of patients who underwent elective cardiac surgery during August 1999 to April 2002. We defined a prolonged QTc interval as > 440 msec, measured from 24-hr pre- and postoperative 12-lead electrocardiograms. The association of 37 single nucleotide polymorphisms (SNPs) in 21 candidate genes -involved in modulating arrhythmia susceptibility pathways with postoperative QTc changes- was investigated in a two-stage design with a stage I cohort (n = 497) nested within a stage II cohort (n = 957). Empirical P values (Pemp) were obtained by permutation tests with 10,000 repeats. RESULTS After adjusting for clinical and procedural risk factors, we selected four SNPs (P value range, 0.03-0.1) in stage I, which we then tested in the stage II cohort. Two functional SNPs in the pro-inflammatory cytokine interleukin-1β (IL1β), rs1143633 (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.53 to 0.95; Pemp = 0.02) and rs16944 (OR, 1.31; 95% CI, 1.01 to 1.70; Pemp = 0.04), remained independent predictors of postoperative QTc prolongation. The ability of a clinico-genetic model incorporating the two IL1B polymorphisms to classify patients at risk for developing prolonged postoperative QTc was superior to a clinical model alone, with a net reclassification improvement of 0.308 (P = 0.0003) and an integrated discrimination improvement of 0.02 (P = 0.000024). CONCLUSION The results suggest a contribution of IL1β in modulating susceptibility to postoperative QTc prolongation after cardiac surgery.
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Abstract
Ventricular repolarization is a complex electrical phenomenon which represents a crucial stage in electrical cardiac activity. It is expressed on the surface electrocardiogram by the interval between the start of the QRS complex and the end of the T wave or U wave (QT). Several physiological, pathological and iatrogenic factors can influence ventricular repolarization. It has been demonstrated that small perturbations in this process can be a potential trigger of malignant arrhythmias, therefore the analysis of ventricular repolarization represents an interesting tool to implement risk stratification of arrhythmic events in different clinical settings. The aim of this review is to critically revise the traditional methods of static analysis of ventricular repolarization as well as those for dynamic evaluation, their prognostic significance and the possible application in daily clinical practice.
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Chowdhury M, Wong J, Cheng A, Khilkin M, Palma E. Methadone Therapy in Underserved Urban Community: QTc Prolongation and Life-Threatening Ventricular Arrhythmias. Cardiovasc Ther 2016; 33:127-33. [PMID: 25825202 DOI: 10.1111/1755-5922.12120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS Methadone has been associated with QTc prolongation and ventricular arrhythmias but the prevalence of QTc prolongation and association with ventricular arrhythmias remains unclear. We investigated this in our inner city urban community (Bronx, New York) that has a large number of patients on methadone. METHODS Telemetry records, nursing documentation and electronic charts of 291 patients spanning856 encounters were evaluated. QT was manually measured from ECG utilizing standardized QT measurement guidelines and was corrected for heart rate using Hodges formula. QTc >470 ms in males and >480 ms in females was considered to be prolonged. RESULTS Patients had prolonged QTc, QTc >500 ms and ventricular arrhythmias during 25.6%, 14.1% and 3.4% of encounters, respectively. There was a very weak dose dependent relationship between methadone dose and QTc (Spearman's rho = 0.09).In addition to methadone, patients were on at least one QT prolonging drugs during 39% of the encounters. Patients who were receiving two interacting drugs in addition to methadone had the highest prevalence (29%) of QTc prolongation. CONCLUSION Although the prevalence of QTc prolongation among patients on methadone therapy is high, the prevalence of ventricular arrhythmia is relatively low. Hospitalized patients on sustained methadone therapy are frequently on multiple additional QTc prolonging drugs. There is no significant dose dependent relationship between methadone dose and QTc. However, the concurrent use of methadone and interacting drugs lead to an increased prevalence of QTc prolongation.
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Affiliation(s)
- Mohsin Chowdhury
- Department of Internal Medicine, Yale School of Medicine/Yale-New Haven Hospital, New Haven, CT, USA
| | - Jason Wong
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | - Angela Cheng
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - Michael Khilkin
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Eugen Palma
- Department of Cardiovascular Medicine, Montefiore Medical Center, Bronx, NY, USA
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Abstract
Many pharmaceutical agents interact with cardiac ion channels resulting in abnormal ventricular repolarization and prolongation of the QT interval. In rare circumstances, this has resulted in the development of the potentially life-threatening arrhythmia, torsades de pointes. It is recognized, however, that accurate measurement of the QT interval is challenging, and it is a poor predictor for the development of this arrhythmia. Nevertheless, QT interval monitoring is an essential part of pharmaceutical development, and significant increases in the QT interval may prevent a drug from gaining approval.
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Affiliation(s)
- Michael G Fradley
- Division of Cardiovascular Medicine, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA.
| | - Javid Moslehi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, 2220 Pierce Avenue, Nashville, TN 37232, USA; Division of Hematology-Oncology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, 2220 Pierce Avenue, Nashville, TN 37232, USA; Cardio-Oncology Program, Vanderbilt University School of Medicine, 2220 Pierce Avenue, Nashville, TN 37232, USA
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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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Hjalmarsson C, Bergfeldt L. Is Prolonged QTc Sufficient to Predict Survival in Patients with Intracerebral Hemorrhage? Ann Noninvasive Electrocardiol 2014; 19:205-6. [DOI: 10.1111/anec.12142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Clara Hjalmarsson
- Department of Cardiology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Lennart Bergfeldt
- Department of Cardiology; Sahlgrenska University Hospital; Gothenburg Sweden
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Dealing with global safety issues : was the response to QT-liability of non-cardiac drugs well coordinated? Drug Saf 2013; 36:167-82. [PMID: 23417505 DOI: 10.1007/s40264-013-0016-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Drug-induced torsade de pointes (TdP) is a potentially fatal iatrogenic entity. Its reporting rate in association with non-cardiac drugs increased exponentially from the early 1990s and was associated with an increasing number of new non-cardiac drugs whose proarrhythmic liability was not appreciated pre-marketing. This epidemic provoked a comprehensive global response from drug regulators, drug developers and academia, which resulted in stabilization of the reporting rate of TdP. This commentary reviews the chronology and nature of, and the reasons for, this response, examines its adequacy, and proposes future strategies for dealing with such iatrogenic epidemics more effectively. It is concluded that the response was piecemeal and lacked direction. No one entity was responsible, with the result that important contributions from regulators, industry and academia lacked coordination. While the process of dealing with QT crisis seemed to have worked reasonably well in this instance, it does not seem wise to expect the next crisis in drug development to be managed as well. Future crises will need better management and the challenge is to implement a system set up to respond globally and efficiently to a perceived drug-related hazard. In this regard, we discuss the roles of new tools the legislation has provided to the regulators and the value of an integrated expert assessment of all pre-approval data that may signal a potential safety issue in the postmarketing period. We also discuss the roles of other bodies such as the WHO Collaborating Centre for International Drug Monitoring, CIOMS and the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).
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33
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Lenihan DJ, Kowey PR. Overview and management of cardiac adverse events associated with tyrosine kinase inhibitors. Oncologist 2013; 18:900-8. [PMID: 23918069 PMCID: PMC3755926 DOI: 10.1634/theoncologist.2012-0466] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 06/17/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Small-molecule tyrosine kinase inhibitors (TKIs) may provide an effective therapeutic option in patients with hematologic malignancies and solid tumors. However, cardiovascular (CV) events, including hypertension, heart failure, left ventricular systolic dysfunction, and QT prolongation, have emerged as potential adverse events (AEs) with TKI therapy. PURPOSE We review what is known about the mechanism of action of CV AEs associated with TKI use and discuss therapeutic interventions that may prevent and manage these events in clinical practice. METHODS References for this review were identified through searches of PubMed and Medline databases, and only papers published in English were considered. Search terms included "cardiac," "cardiovascular," "cancer," and "kinase inhibitor." Related links in the databases were reviewed, along with relevant published guidelines. RESULTS Although the link between rising blood pressure (BP) and CV AEs is observed but not proven, good clinical practice supports an aggressive policy on proper long-term BP management. There are insufficient data from randomized controlled clinical trials to show indisputably that aggressive or effective heart failure therapy in patients receiving TKIs will fundamentally change outcomes; however, clinical practice suggests that this is an effective long-term approach. Recognizing that QT prolongation is associated with TKI use facilitates identification of patients at high risk for this CV AE and increases awareness of the need for routine electrocardiograms and electrolyte monitoring for those receiving TKI treatment. CONCLUSION Regular monitoring, early recognition, and appropriate interventions for CV AEs can help more patients derive the benefit of long-term TKI therapy.
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Affiliation(s)
- Daniel J Lenihan
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee 37232-8802, USA.
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Taylor D, Lenox-Smith A, Bradley A. A review of the suitability of duloxetine and venlafaxine for use in patients with depression in primary care with a focus on cardiovascular safety, suicide and mortality due to antidepressant overdose. Ther Adv Psychopharmacol 2013; 3:151-61. [PMID: 24167687 PMCID: PMC3805457 DOI: 10.1177/2045125312472890] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Depression and anxiety disorders are among the most common disorders treated by general practitioners (GPs) in the UK. Since both disorders are associated with a significantly increased risk of suicide, including with antidepressant overdose, the safety of antidepressants in overdose is of paramount importance. Numerous updates relating to antidepressant safety have been issued by regulators in the UK which may have eroded GP confidence in antidepressants. Venlafaxine, a serotonin nor adrenaline reuptake inhibitor (SNRI) had primary care prescribing restrictions placed on it in 2004 due to concerns about cardiotoxicity and mortality in overdose. Although a review of the evidence led to a reversal of the majority of restrictions in 2006, evidence suggests GPs may still be cautious in their prescribing of venlafaxine and possibly other SNRI antidepressants for patients with depression and anxiety disorders. This paper reviews the evidence pertaining to the safety of SNRI antidepressants from a perspective of cardiovascular safety and overdose. The currently available evidence suggests a marginally higher toxicity of venlafaxine in overdose compared with another SNRI duloxetine and the selective serotonin reuptake inhibitors (SSRIs), although this may be related to differential patterns of prescribing in high-risk patients. Based on this review SNRIs have a positive risk benefit profile in the treatment of depression and generalized anxiety disorder in primary care, especially as second-line agents to SSRIs.
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Affiliation(s)
- David Taylor
- Pharmacy Department, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
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35
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de Esch C, Slieker R, Wolterbeek A, Woutersen R, de Groot D. Zebrafish as potential model for developmental neurotoxicity testing. Neurotoxicol Teratol 2012; 34:545-53. [DOI: 10.1016/j.ntt.2012.08.006] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 08/24/2012] [Accepted: 08/28/2012] [Indexed: 11/26/2022]
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36
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Arrêt cardiaque et syndrome du QT long. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0177-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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37
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Abstract
The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.
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Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
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38
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Blaufox AD, Tristani-Firouzi M, Seslar S, Sanatani S, Trivedi B, Fischbach P, Paul T, Young ML, Tisma-Dupanovic S, Silva J, Cuneo B, Fournier A, Singh H, Tanel RE, Etheridge SP. Congenital long QT 3 in the pediatric population. Am J Cardiol 2012; 109:1459-65. [PMID: 22360817 DOI: 10.1016/j.amjcard.2012.01.361] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/10/2012] [Accepted: 01/10/2012] [Indexed: 11/29/2022]
Abstract
There is insufficient knowledge concerning long-QT (LQT) 3 in the pediatric population to determine whether recommendations for more aggressive therapy in these patients are appropriate. An international multicenter review of 43 children with cardiac sodium channel (SCN5A) mutations and clinical manifestations of LQT syndrome without overlap of other SCN5A syndromes was undertaken to describe the clinical characteristics of LQT3 in children. Patients were aged 7.6 ± 5.9 years at presentation and were followed for 4.7 ± 3.9 years. There was significant intrasubject corrected QT interval (QTc) variability on serial electrocardiography. Forty-two percent presented with severe symptoms or arrhythmia and exhibited longer QTc intervals compared to asymptomatic patients. None of the 14 patients who underwent primary prevention implantable cardioverter-defibrillator (ICD) implantation received appropriate shocks in 41 patient-years of follow-up, while 2 of 6 patients who underwent secondary prevention ICD implantation received appropriate shocks in 30 patient-years of follow-up. Half of patients who underwent ICD implantation experienced inappropriate shocks or ICD-related complications. Mexiletine significantly shortened the QTc interval, and QTc shortening was greater in patients with longer pretreated QTc intervals. Two ICD patients with frequent appropriate ICD shocks showed immediate clinical improvement, with elimination of appropriate ICD shocks after mexiletine loading. In conclusion, severe symptoms are common in children with LQT3 and are associated with longer QTc intervals. ICD implantation is associated with significant morbidity. Mexiletine shortens the QTc interval, and it may be beneficial.
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Affiliation(s)
- Andrew D Blaufox
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, USA.
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Thanavaro KL, Thanavaro JL. Methadone-induced torsades de pointes: A twist of fate. Heart Lung 2011; 40:448-53. [DOI: 10.1016/j.hrtlng.2010.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 12/16/2010] [Accepted: 12/17/2010] [Indexed: 01/08/2023]
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40
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Link MS, Exner DV, Anderson M, Ackerman M, Al-Ahmad A, Knight BP, Markowitz SM, Kaufman ES, Haines D, Asirvatham SJ, Callans DJ, Mounsey JP, Bogun F, Narayan SM, Krahn AD, Mittal S, Singh J, Fisher JD, Chugh SS. HRS policy statement: clinical cardiac electrophysiology fellowship curriculum: update 2011. Heart Rhythm 2011; 8:1340-56. [PMID: 21699868 DOI: 10.1016/j.hrthm.2011.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Indexed: 01/29/2023]
Affiliation(s)
- Mark S Link
- Tufts Medical Center, Boston, Massachusetts, USA
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41
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Haraoka K, Morita H, Saito Y, Toh N, Miyoshi T, Nishii N, Nagase S, Nakamura K, Kohno K, Kusano KF, Kawaguchi K, Ohe T, Ito H. Fragmented QRS is associated with torsades de pointes in patients with acquired long QT syndrome. Heart Rhythm 2010; 7:1808-14. [DOI: 10.1016/j.hrthm.2010.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 09/07/2010] [Indexed: 10/19/2022]
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42
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Scholz EP, Zitron E, Katus HA, Karle CA. Cardiovascular ion channels as a molecular target of flavonoids. Cardiovasc Ther 2010; 28:e46-52. [PMID: 20633021 DOI: 10.1111/j.1755-5922.2010.00212.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Flavonoids are a class of naturally occurring polyphenols abundant in edibles and beverages of plant origin. Epidemiological studies consistently associate high flavonoid intake with a reduced risk for the development of cardiovascular diseases. So far these beneficial effects have been mainly attributed to nonspecific antioxidant and antiinflammatory properties. However, there is an increasing body of evidence that flavonoids specifically target molecular structures including cardiovascular ion channels. Playing a pivotal role in the regulation of vascular tone and cardiac electric activity, ion channels represent a major target for the induction of antihypertensive and cardioprotective effects. Thus, pharmacological properties of flavonoids on cardiovascular ion channels, ion currents and tissue preparations are being increasingly addressed in experimental studies. Whereas it has become clear that cardiovascular ion channels represent an important molecular target of flavonoids, the published data have not yet been systematically reviewed.
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Affiliation(s)
- Eberhard P Scholz
- Department of Internal Medicine III (Cardiology), University Hospital Heidelberg, Heidelberg, Germany.
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43
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SY RAYMONDW, CHATTHA ISHVINDERS, KLEIN GEORGEJ, GULA LORNEJ, SKANES ALLANC, YEE RAYMOND, BENNETT MATTHEWT, KRAHN ANDREWD. Repolarization Dynamics During Exercise Discriminate Between LQT1 and LQT2 Genotypes. J Cardiovasc Electrophysiol 2010; 21:1242-6. [DOI: 10.1111/j.1540-8167.2010.01788.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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44
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Brell JM. Prolonged QTc interval in cancer therapeutic drug development: defining arrhythmic risk in malignancy. Prog Cardiovasc Dis 2010; 53:164-72. [PMID: 20728704 DOI: 10.1016/j.pcad.2010.05.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anticancer therapy drug development is an arduous task, taking 10 to 15 years to complete, requiring approximately 1 billion dollars, and rarely leads to Food and Drug Administration approval. Methods to predict unacceptable drug-induced toxicity, such as a prolonged QTc interval/risk of torsade de pointes, should be highly informative to quickly and accurately determine if further resources should be allocated in the continued development of an agent. Expert consensus has established guidelines to ascertain the ability of a new drug to prolong the QTc interval. Although QTc measurement is the best way to assess arrhythmic risk, it is imprecise for a variety of reasons. In addition, oncology patients have multiple risk factors for QTc prolongation at baseline. Competing interests involved in assessing arrhythmic risk of a new oncology agent include inability to precisely follow published guidelines for QTc assessment, patients' concomitant medical problems interfering with drug assessment and therefore clinical trial enrollment, patient safety concerns, general public safety concerns regarding toxicity assessment, need for discovery of more curative drug therapies, and individual patient perception of therapeutic risk vs benefit. Oncology patients are concerned about access to experimental agents, as well as early abandonment of a potentially beneficial agent because of a low estimated risk of toxicity, even if the event is catastrophic. We review the issues involved in evaluating the QTc interval-prolonging risk in new anticancer agents.
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Affiliation(s)
- Joanna M Brell
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, 6130 Executive Blvd. EPN 2017, Bethesda, MD 20892, USA.
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45
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Chattha IS, Sy RW, Yee R, Gula LJ, Skanes AC, Klein GJ, Bennett MT, Krahn AD. Utility of the recovery electrocardiogram after exercise: a novel indicator for the diagnosis and genotyping of long QT syndrome? Heart Rhythm 2010; 7:906-11. [DOI: 10.1016/j.hrthm.2010.03.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 03/03/2010] [Indexed: 11/28/2022]
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46
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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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47
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Grandinetti A, Chow DC, Miyasaki M, Low P. Association of increased QTc interval with the cardiometabolic syndrome. J Clin Hypertens (Greenwich) 2010; 12:315-320. [PMID: 20433556 PMCID: PMC8673252 DOI: 10.1111/j.1751-7176.2009.00224.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 09/02/2009] [Accepted: 09/25/2009] [Indexed: 09/12/2023]
Abstract
Recent studies indicate a high prevalence of increased QTc interval length in patients affected by the metabolic syndrome, but there is no data available to demonstrate the correlation of the QTc interval with severity of the cardiometabolic syndrome (CMS). The objective of this study was to estimate the association between increasing number of cardiometabolic abnormalities and increasing QTc interval length. Electrocardiograms were collected from 1420 participants in a cross-sectional study. The QTc interval lengths were corrected for heart rate using Bazett's formula. CMS was determined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines. Multiple linear regression models were used examining associations between increasing number of individual components of syndrome with QTc interval length. Participants with CMS had significantly longer QTc interval length, controlling for age, body mass index (BMI), sex, and ethnic group. Increasing number of CMS components was significantly associated with increased QTc interval length, even after adjusting for age, BMI, total cholesterol, fasting C peptide, and history of heart disease. These findings suggest that QTc interval length is increased in the presence of CMS and is linearly related to an increase in number of metabolic abnormalities.
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Affiliation(s)
- Andrew Grandinetti
- Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96822, USA.
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48
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Kurokawa S, Niwano S, Kiryu M, Murakami M, Ishikawa S, Yumoto Y, Moriguchi M, Niwano H, Kosukegawa T, Izumi T. Importance of Morphological Changes in T-U Waves During Bepridil Therapy as a Predictor of Ventricular Arrhythmic Event. Circ J 2010; 74:876-84. [DOI: 10.1253/circj.cj-09-0937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sayaka Kurokawa
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Shinichi Niwano
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Michiro Kiryu
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Masami Murakami
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Shoko Ishikawa
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Yoshihiro Yumoto
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | | | - Hiroe Niwano
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Tomoko Kosukegawa
- Department of Cardio-Angiology, Kitasato University School of Medicine
| | - Tohru Izumi
- Department of Cardio-Angiology, Kitasato University School of Medicine
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Unintended consequences of reducing QT-alert overload in a computerized physician order entry system. Eur J Clin Pharmacol 2009; 65:919-25. [PMID: 19415251 PMCID: PMC2729977 DOI: 10.1007/s00228-009-0654-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 03/31/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE After complaints of too many low-specificity drug-drug interaction (DDI) alerts on QT prolongation, the rules for QT alerting in the Dutch national drug database were restricted in 2007 to obviously QT-prolonging drugs. The aim of this virtual study was to investigate whether this adjustment would improve the identification of patients at risk of developing Torsades de Pointes (TdP) due to QT-prolonging drug combinations in a computerized physician order entry system (CPOE) and whether these new rules should be implemented. METHODS During a half-year study period, inpatients with overridden DDI alerts regarding QT prolongation and with an electrocardiogram recorded before and within 1 month of the alert override were included if they did not have a ventricular pacemaker and did not use the low-risk combination cotrimoxazole and tacrolimus. QT-interval prolongation and the risk of developing TdP were calculated for all patients and related to the number of patients for whom a QT-alert would be generated in the new situation with the restricted database. RESULTS Forty-nine patients (13%) met the inclusion criteria. In this study population, knowledge base-adjustment would reduce the number of alerts by 53%. However, the positive predictive value of QT alerts would not change (31% before and 30% after) and only 47% of the patients at risk of developing TdP would be identified in CPOEs using the adjusted knowledge base. CONCLUSION The new rules for QT alerting would result in a poorer identification of patients at risk of developing TdP than the old rules. This is caused by the many non-drug-related risk factors for QT prolongation not being incorporated in CPOE alert generation. The partial contribution of all risk factors should be studied and used to create clinical rules for QT alerting with an acceptable positive predictive value.
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Effects of methylphenidate hydrochloride on the cardiovascular system in vivo and in vitro: A safety pharmacology study. J Pharmacol Toxicol Methods 2009; 59:128-34. [DOI: 10.1016/j.vascn.2009.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Accepted: 01/28/2009] [Indexed: 11/17/2022]
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