A rate-independent method of assessing QT-RR slope following conversion of atrial fibrillation

Longitudinal QTc Stability and Impact of Baseline Cardiac Rhythm on Discharge Dose in Dofetilide-treated Patients

BACKGROUND

Dofetilide suppresses AF in a dose-dependent fashion. The protective effect of AF against QT_c prolongation induced torsades de pointe and transient post-cardioversion QT_c prolongation may result in dofetilide under-dosing during initiation. Thus, the optimal timing of cardioversion for AF patients undergoing dofetilide initiation to optimize discharge dose remains unknown as does the longitudinal stability of QT_c .

OBJECTIVE

To evaluate the impact of baseline rhythm on dofetilide dosing during initiation and assess the longitudinal stability of QT_c-all (Bazzett, Fridericia, Framingham, and Hodges) over time.

METHODS

Medical records of patients who underwent pre-planned dofetilide loading at a tertiary care center between January 2016-2019 were reviewed.

RESULTS

A total of 198 patients (66±10 years, 32% female, CHADS₂ -Vasc 3 [2-4]) presented for dofetilide loading in either AF (59%) or SR (41%). Neither presenting rhythm, nor spontaneous conversion to SR impacted discharge dose. The cumulative dofetilide dose prior to cardioversion moderately correlated (r=0.36; p=0.0001) with discharge dose. Post-cardioversion QT_c-all prolongation (p<0.0001) prompted discharge dose reduction (890±224mcg vs 552±199mcg; p<0.0001) in 30% patients. QT_c-all in SR prolonged significantly during loading (p<0.0001). All patients displayed QT_c-all reduction (p<0.0001) from discharge to short-term (46 [34-65] days) that continued at long-term (360 [296-414] days) follow-ups. The extent of QT_c-all reduction over time moderately correlated with discharge QT_c-all (r=0.54-0.65; p<0.0001).

CONCLUSION

Dofetilide initiation prior to cardioversion is equivalent to initiation during SR. Significant QT_c reduction proportional to discharge QT_c is seen over time in all dofetilide-treated patients. QT_c returns to pre-loading baseline during follow-up in patients initiated in SR. This article is protected by copyright. All rights reserved.

Information transfer in QT-RR dynamics: Application to QT-correction

The relation between the electrical properties of the heart and the beating rate is essential for the heart functioning. This relation is central when calculating the “corrected QT interval” — an important measure of the risk of potentially lethal arrhythmias. We use the transfer entropy method from information theory to quantitatively study the mutual dynamics of the ventricular action potential duration (the QT interval) and the length of the beat-to-beat (RR) interval. We show that for healthy individuals there is a strong asymmetry in the information transfer: the information flow from RR to QT dominates over the opposite flow (from QT to RR), i.e. QT depends on RR to a larger extent than RR on QT. Moreover, the history of the intervals has a strong effect on the information transfer: at sufficiently long QT history length the information flow asymmetry inverts and the RR influence on QT dynamics weakens. Finally, we demonstrate that the widely used QT correction methods cannot properly capture the changes in the information flows between QT and RR. We conclude that our results obtained through a model-free informational perspective can be utilised to improve and test the QT correction schemes in clinics.

Recent heart rate history affects QT interval duration in atrial fibrillation

QT interval prolongation is associated with a risk of polymorphic ventricular tachycardia. QT interval shortens with increasing heart rate and correction for this effect is necessary for meaningful QT interval assessment. We aim to improve current methods of correcting the QT interval during atrial fibrillation (AF). Digitized Holter recordings were analyzed from patients with AF. Models of QT interval dependence on RR intervals were tested by sorting the beats into 20 bins based on corrected RR interval and assessing ST-T variability within the bins. Signal-averaging within bins was performed to determine QT/RR dependence. Data from 30 patients (29 men, 69.3±7.3 years) were evaluated. QT behavior in AF is well described by a linear function (slope ~0.19) of steady-state corrected RR interval. Corrected RR is calculated as a combination of an exponential weight function with time-constant of 2 minutes and a smaller “immediate response” component (weight ~ 0.18). This model performs significantly (p<0.0001) better than models based on instantaneous RR interval only including Bazett and Fridericia. It also outperforms models based on shorter time-constants and other previously proposed models. This model may improve detection of repolarization delay in AF. QT response to heart rate changes in AF is similar to previously published QT dynamics during atrial pacing and in sinus rhythm.

Proarrhythmic and Torsadogenic Effects of Potassium Channel Blockers in Patients

The most common arrhythmia requiring drug treatment is atrial fibrillation (AF), which affects 2 to 5 million Americans and continues to be a major cause of morbidity and increased mortality. Despite recent advances in catheter-based and surgical therapies, antiarrhythmic drugs continue to be the mainstay of therapy for most patients with symptomatic AF. However, many antiarrhythmics block the rapid component of the cardiac delayed rectifier potassium current (IKr) as a major mechanism of action, and marked QT prolongation and pause-dependent polymorphic ventricular tachycardia (torsades de pointes) are major class toxicities.

Time-Dependent Changes in QT Dynamics after Initiation and Termination of Paroxysmal Atrial Fibrillation

BACKGROUND

Little is known about time-dependent changes in QT dynamics after initiation of atrial fibrillation (AF) and after restoration of sinus rhythm (SR) in patients with paroxysmal AF.

METHODS

Beat-to-beat QT and RR intervals in CM5 lead were measured automatically in 13 patients with both AF and SR on the single 24-hour Holter electrocardiology recording. QT-RR relation was analyzed at six periods of time: 1 hour before AF onset (Pre(0-1h)), 0-1 hour and 4-5 hours after AF onset (AF(0-1h) and AF(4-5h)), and 0-1 hour, 2-3 hours, and 4-5 hours after the restoration of SR (SR(0-1h), SR(2-3h), and SR(4-5h)).

RESULTS

QT-RR slope was gradually decreased after AF onset and gradually returned to the baseline level after restoration of SR. The slope became greater at SR(4-5h) than at AF(4-5h) and AF(0-1h). In patients receiving antiarrhythmic drugs (AADs; n = 5), QT-RR slope was greater at SR(4-5h) than in those not receiving AADs (n = 8).

CONCLUSION

In patients with paroxysmal AF, bradycardia-dependent QT prolongation was attenuated during AF, and was corrected and gradually augmented along with continuation of SR, especially in patients receiving AADs. This could increase the risk of developing torsade de pointes.

Genome wide analysis of drug-induced torsades de pointes: lack of common variants with large effect sizes

Marked prolongation of the QT interval on the electrocardiogram associated with the polymorphic ventricular tachycardia Torsades de Pointes is a serious adverse event during treatment with antiarrhythmic drugs and other culprit medications, and is a common cause for drug relabeling and withdrawal. Although clinical risk factors have been identified, the syndrome remains unpredictable in an individual patient. Here we used genome-wide association analysis to search for common predisposing genetic variants. Cases of drug-induced Torsades de Pointes (diTdP), treatment tolerant controls, and general population controls were ascertained across multiple sites using common definitions, and genotyped on the Illumina 610k or 1M-Duo BeadChips. Principal Components Analysis was used to select 216 Northwestern European diTdP cases and 771 ancestry-matched controls, including treatment-tolerant and general population subjects. With these sample sizes, there is 80% power to detect a variant at genome-wide significance with minor allele frequency of 10% and conferring an odds ratio of ≥2.7. Tests of association were carried out for each single nucleotide polymorphism (SNP) by logistic regression adjusting for gender and population structure. No SNP reached genome wide-significance; the variant with the lowest P value was rs2276314, a non-synonymous coding variant in C18orf21 (p  =  3×10⁻⁷, odds ratio = 2, 95% confidence intervals: 1.5–2.6). The haplotype formed by rs2276314 and a second SNP, rs767531, was significantly more frequent in controls than cases (p  =  3×10⁻⁹). Expanding the number of controls and a gene-based analysis did not yield significant associations. This study argues that common genomic variants do not contribute importantly to risk for drug-induced Torsades de Pointes across multiple drugs.

Dofetilide promotes repolarization abnormalities in perfused Guinea-pig heart

PURPOSE

Dofetilide is class III antiarrhythmic agent which prolongs cardiac action potential duration because of selective inhibition of I (Kr), the rapid component of the delayed rectifier K(+) current. Although clinical studies reported on proarrhythmic risk associated with dofetilide treatment, the contributing electrophysiological mechanisms remain poorly understood. This study was designed to determine if dofetilide-induced proarrhythmia may be attributed to abnormalities in ventricular repolarization and refractoriness.

METHODS

The monophasic action potential duration and effective refractory periods (ERP) were assessed at distinct epicardial and endocardial sites along with volume-conducted ECG recordings in isolated, perfused guinea-pig heart preparations.

RESULTS

Dofetilide was found to produce the reverse rate-dependent prolongation of ventricular repolarization, increased the steepness of action potential duration rate adaptation, and amplified transepicardial variability in electrical restitution kinetics. Dofetilide also prolonged the T peak-to-end interval on ECG, and elicited a greater prolongation of endocardial than epicardial ERP, thereby increasing transmural dispersion of refractoriness. At epicardium, dofetilide prolonged action potential duration to a greater extent than ERP, thus extending the critical interval for ventricular re-excitation. This change was associated with triangulation of epicardial action potential because of greater dofetilide-induced prolonging effect at 90 % than 30 % repolarization. Premature ectopic beats and spontaneous short-lasting episodes of monomorphic ventricular tachycardia were observed in 44 % of dofetilide-treated heart preparations.

CONCLUSIONS

Proarrhythmic potential of dofetilide in guinea-pig heart is attributed to steepened electrical restitution, increased transepicardial variability in electrical restitution kinetics, amplified transmural dispersion of refractoriness, increased critical interval for ventricular re-excitation, and triangulation of epicardial action potential.

Enhanced sensitivity to drug-induced QT interval lengthening in patients with heart failure due to left ventricular systolic dysfunction

Patients with heart failure (HF) are at increased risk for drug-induced torsades de pointes (TdP) due to unknown mechanisms. Our objective was to determine if sensitivity to drug-induced QT interval lengthening is enhanced in patients with HF. In this multicenter, prospective study, 15 patients with atrial fibrillation or flutter requiring conversion to sinus rhythm were enrolled: 6 patients with New York Heart Association class II to III HF (mean ejection fraction [EF], 30% ± 9%), and 9 controls (mean EF, 53% ± 6%). Patients received ibutilide 1 mg intravenously. Blood samples and 12-lead electrocardiograms were obtained prior to and during 48 hours postinfusion. Serum ibutilide concentrations at 50% maximum effect on Fridericia-corrected QT (QT(F)) intervals (EC(50)) were determined, and areas under the effect (QT(F) interval vs time) curves (AUECs) were calculated. Ibutilide concentration-QT(F) relationships were best described by a sigmoidal E(max) model with a hypothetical effect compartment. Median [interquartile range] AUEC from 0 to 4 hours was larger in the HF group than in controls (1.86 [1.86-1.93] vs 1.82 [1.81-1.84] s·h; P = .04). Median EC(50) was lower in the HF group (0.48 [0.46-0.49] vs 1.85 [1.10-3.23] μg/L; P = .008). Sensitivity to drug-induced QT interval lengthening is enhanced in patients with systolic HF, which may contribute to the increased risk of drug-induced TdP.

Drug-induced long QT syndrome

The drug-induced long QT syndrome is a distinct clinical entity that has evolved from an electrophysiologic curiosity to a centerpiece in drug regulation and development. This evolution reflects an increasing recognition that a rare adverse drug effect can profoundly upset the balance between benefit and risk that goes into the prescription of a drug by an individual practitioner as well as the approval of a new drug entity by a regulatory agency. This review will outline how defining the central mechanism, block of the cardiac delayed-rectifier potassium current I(Kr), has contributed to defining risk in patients and in populations. Models for studying risk, and understanding the way in which clinical risk factors modulate cardiac repolarization at the molecular level are discussed. Finally, the role of genetic variants in modulating risk is described.

QT/RR relation during atrial fibrillation based on a single beat analysis in 24-h Holter ECG: the role of the second and further preceding RR intervals in QT modification

BACKGROUND

During atrial fibrillation (AF) irregularity of RR intervals may modify QT/RR relation differently from sinus rhythm. The purpose of this study was to compare QT/RR relation based on a single-beat analysis using the first preceding RR interval with the modified RR interval reflecting not only the first preceding but also the second and further preceding RR intervals during AF.

METHODS

QT and RR intervals were measured using an automatic QT analyzing system in 32 patients who had both AF and sinus rhythm on the same 24-h Holter ECG recording. In 12 patients antiarrhythmic drugs (AADs) were administered. To reflect irregularity of the preceding RR intervals during AF, a modified RR (mRR) using a weighted average of five successive RR intervals: (5RR(1)+2RR(2)+RR(3)+RR(4)+RR(5))/10 was adopted. Linear regression analyses between QT and RR intervals were performed using the preceding RR(1) (QT/RR) and the modified RR (QT/mRR) during AF.

RESULTS

During AF the slope of QT/RR was lower than that of QT/mRR and was also lower than that of QT/RR during sinus rhythm in patients with and without AAD. Slopes of regression line in QT/RR during sinus rhythm, QT/RR and QT/mRR during AF were steeper in patients with AAD than those in patients without. Slopes of QT/RR during sinus rhythm correlated with those of QT/mRR (r=0.79, p<0.01) better than those of QT/RR (r=0.64, p<0.05) during AF. QT interval at an RR interval of 1.20s or 1.00 s obtained from QT/RR during AF was significantly smaller than that during sinus rhythm in patients with and without AAD.

CONCLUSIONS

The slope of QT/mRR during AF became closer to that of QT/RR during sinus rhythm compared with that of QT/RR during AF. QT interval during sinus rhythm could be estimated better using QT/mRR than using QT/RR during AF.

Comparison of QT/RR relation based on a 15-s averaged ECG and a single beat ECG during atrial fibrillation

BACKGROUND

The aim of this study was to compare QT/RR relation based on a 15-s averaged beat ECG with a single beat ECG during atrial fibrillation (AF) and to determine which was better to estimate the QT interval after sinus restoration.

METHODS AND RESULTS

QT and RR intervals were measured using an automatic QT analyzing system in 33 patients who had both AF and sinus rhythm on the same 24-h Holter ECG recording. In 14 patients, antiarrhythmic drugs (AAD) were administered. QT/RR relations were analyzed from ECG waves obtained by the summation of consecutive QRS-T complexes during each 15-s period (QT/RR-average) and a single beat QRS-T (QT/RR-single). During sinus rhythm, the slope of QT/RR-average did not differ from that of QT/RR-single in patients with and without AAD. On the other hand, during AF, the slope of QT/RR-average was significantly greater than that of QT/RR-single (without AAD: 0.12±0.06 vs. 0.06±0.03, P<0.001; with AAD: 0.15±0.05 vs. 0.08±0.04, P<0.001). During AF, the QT interval at an RR interval of 1.2-s (QT-1.2) determined from QT/RR-average was significantly greater than QT-1.2 from QT/RR-single in patients with and without AAD. QT-1.2 in QT/RR-single during AF was significantly smaller than that during sinus rhythm but QT-1.2 in QT/RR-average during AF was not.

CONCLUSIONS

The QT interval after sinus restoration could be estimated better using QT/RR-average than using QT/RR-single during AF.

Rate-independent QT shortening during exercise in healthy subjects: terminal repolarization does not shorten with exercise

INTRODUCTION

QT interval for a given heart rate differs between exercise and recovery (QT hysteresis) due to slow QT adaptation to changes in heart rate. We hypothesized that QT hysteresis is evident within stages of exercise and investigated which component of the QT contributes to hysteresis.

METHODS AND RESULTS

Nineteen healthy volunteers performed a staged exercise test (four stages, 3 min each). Continuous telemetry was analyzed with software to compare QT intervals in a rate-independent fashion. QRST complexes during each minute were sorted by RR interval, and complexes in bins of 20 ms width were signal-averaged. QT and QTp (onset of QRS to peak T wave) were measured, and terminal QT calculated (peak to end of T wave, Tpe = QT - QTp). QT, QTp, and Tpe at the same heart rate were compared between the first and last minute of each stage. QT shortened from the first to last minute of exercise in each stage (Stage I: 358 +/- 30 to 346 +/- 25 ms, P < 0.001; Stage II: 342 +/- 27 to 331 +/- 24 ms, P = 0.003; Stage III: 329 +/- 21 to 322 +/- 18 ms, P = 0.03; Stage IV: 313 +/- 22 to 303 +/- 23 ms, P = 0.005). QTp also shortened in each stage, while Tpe was unchanged.

CONCLUSION

QT hysteresis occurs during exercise in normals, and the major determinant is shortening of the first component of the T wave. Terminal repolarization (peak to end of T wave), a surrogate for transmural dispersion of repolarization, does not shorten significantly with exercise.

Understanding drug-induced torsades de pointes: a genetic stance

Drugs may produce a variety of arrhythmias, but drug-induced QT prolongation and the risk of the polymorphic ventricular tachycardia torsades de pointes (drug-induced long QT syndrome) has garnered the most attention. The wide array of drugs with potential for QT prolongation, the correspondingly large number of patients exposed to such drugs, the difficulty in predicting an individual's risk, and the potentially fatal outcome, make drug-induced long QT syndrome an important public health problem for clinicians, researchers, drug development programs, and regulatory agencies. This review focuses on the genetic risk factors and mechanisms underlying QT prolongation and proarrhythmia. The post-genomic era hints at an improved understanding (and prediction) of how the gene-environment interaction produces this particular adverse drug response.

Persistent atrial fibrillation is associated with reduced risk of torsades de pointes in patients with drug-induced long QT syndrome

OBJECTIVES

The goal of this study was to identify markers of torsades de pointes (TdP) in patients with drug-associated long QT syndrome (LQTS).

BACKGROUND

Drug-induced LQTS includes individuals developing marked prolongation of ventricular repolarization on exposure to an offending drug. Under these conditions, TdP develops in some but not all patients.

METHODS

This was a case-control study of 123 adults with drug-associated LQTS. Patients were divided into LQTS only (LQTS; n = 40, QT >500 ms on drug) and LQTS + TdP (TdP; n = 83).

RESULTS

Baseline QT intervals were similar in the 2 groups (381 +/- 38 ms [LQTS] vs. 388 +/- 43 ms [TdP]). Clinical variables associated with risk of TdP included hypokalemia and female gender; by contrast, persistent atrial fibrillation (AF) at the time of drug discontinuation for QT prolongation was protective despite similar heart rates in AF and sinus rhythm (n = 20, 71 +/- 13 beats/min vs. 69 +/- 13 beats/min). Electrocardiographic variables that significantly increased the risk for TdP included absolute and rate-corrected QT intervals (QTc) on drug therapy, the magnitude of QT and QTc interval prolongation, and the change in T(peak) to T(end) (DeltaT(p)-T(e)), a relatively new index of transmural dispersion of repolarization and potential arrhythmogenicity. Multivariable logistic regression analysis revealed that only gender was predictive for TdP, whereas persistent AF at the time of drug discontinuation for QT prolongation (odds ratio 0.14, 95% confidence interval 0.03 to 0.63, p = 0.01) was negatively associated with the arrhythmia.

CONCLUSIONS

This study strongly suggests that despite ongoing rate irregularity, AF reduces the likelihood of developing TdP after the administration of drugs that prolong cardiac repolarization.