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Brisinda D, Merico B, Fenici P, Fenici R. When Manual Analysis of 12-Lead ECG Holter Plays a Critical Role in Discovering Unknown Patterns of Increased Arrhythmogenic Risk: A Case Report of a Patient Treated with Tamoxifen and Subsequent Pneumonia in COVID-19. Cardiovasc Toxicol 2021; 21:687-694. [PMID: 34018126 PMCID: PMC8136377 DOI: 10.1007/s12012-021-09659-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/07/2021] [Indexed: 12/04/2022]
Abstract
Several medicines, including cancer therapies, are known to alter the electrophysiological function of ventricular myocytes resulting in abnormal prolongation and dispersion of ventricular repolarization (quantified by multi-lead QTc measurement). This effect could be amplified by other concomitant factors (e.g., combination with other drugs affecting the QT, and/or electrolyte abnormalities, such as especially hypokalemia, hypomagnesaemia, and hypocalcemia). Usually, this condition results in higher risk of torsade de point and other life-threatening arrhythmias, related to unrecognized unpaired cardiac ventricular repolarization reserve (VRR). Being VRR a dynamic phenomenon, QT prolongation might often not be identified during the 10-s standard 12-lead ECG recording at rest, leaving the patient at increased risk for life-threatening event. We report the case of a 49-year woman, undergoing tamoxifen therapy for breast cancer, which alteration of ventricular repolarization reserve, persisting also after correction of concomitant recurrent hypokalemia, was evidenced only after manual measurements of the corrected QT (QTc) interval from selected intervals of the 12-lead ECG Holter monitoring. This otherwise missed finding was fundamental to drive the discontinuation of tamoxifen, shifting to another "safer" therapeutic option, and to avoid the use of potentially arrhythmogenic antibiotics when treating a bilateral pneumonia in recent COVID-19.
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Affiliation(s)
- Donatella Brisinda
- Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Biomagnetism and Clinical Physiology International Center (BACPIC), Viale dell'Astronomia, 12, 00144, Rome, Italy.
| | - Barbara Merico
- Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Peter Fenici
- Biomagnetism and Clinical Physiology International Center (BACPIC), Viale dell'Astronomia, 12, 00144, Rome, Italy
| | - Riccardo Fenici
- Biomagnetism and Clinical Physiology International Center (BACPIC), Viale dell'Astronomia, 12, 00144, Rome, Italy
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Extramiana F, Maison-Blanche P, Badilini F, Beaufils P, Leenhardt A. Individual QT-R-R relationship: average stability over time does not rule out an individual residual variability: implication for the assessment of drug effect on the QT interval. Ann Noninvasive Electrocardiol 2005; 10:169-78. [PMID: 15842429 PMCID: PMC6932095 DOI: 10.1111/j.1542-474x.2005.05615.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Universal QT correction formulae have been shown to under or overcorrect the QT interval duration. Individual QT-R-R modeling has been proposed as a preferable solution for heart rate correction of QT intervals. However, the QT-R-R relationship stability over time needs to be evaluated. METHODS The present report is part of randomized, double-dummy, and placebo-controlled 4-way crossover phase 1 study (48 healthy volunteers). Each randomized period included a run-in placebo day followed the day after by drug administration, with moxifloxacin as a positive control for QT interval measurement. Digital Holter ECG data were analyzed using the "bin" approach. For each period, individual QT-R-R relationship were calculated using two different models (linear and parabolic log-log models). RESULTS The mean intrasubject variability for the alpha coefficient of the linear modeling (SDintra = 0.011 +/- 0.005) reached 28.6 +/- 10.2%. When the parabolic model was considered, the SDintra was 0.026 +/- 0.009 for the alpha coefficient. The QT-R-R relationship variability was in part related to long-term RR changes (R2 = 30%, P < 0.05). However, no significant time effect (ANOVA) was evidenced for QT-R-R coefficients. Moxifloxacin significantly increased the alpha coefficient of the QT-R-R relationship from 0.07 +/- 0.018 to 0.085 +/- 0.019, P < 0.05 (linear model). CONCLUSIONS The individual QT-R-R relationship shows a residual variability in part related to long-term autonomic changes. In addition, the QT-R-R relationship might be modulated by the drug tested. As a consequence, pretherapy QT-R-R relationship obtained in a given patient cannot be used as a fingerprint throughout a drug trial.
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Vaidean GD, Schroeder EB, Whitsel EA, Prineas RJ, Chambless LE, Perhac JS, Heiss G, Rautaharju PM. Short-term repeatability of electrocardiographic spatial T-wave axis and QT interval. J Electrocardiol 2005; 38:139-47. [PMID: 15892024 DOI: 10.1016/j.jelectrocard.2004.09.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although ventricular repolarization abnormalities reflect arrhythmic susceptibility, few reliable tools exist to identify their presence. We investigated the repeatability of the spatial T-wave axis and QT interval from standard 12-lead electrocardiograms in 63 asymptomatic volunteers. Certified technicians used a standardized protocol to digitally record 2 electrocardiograms per participant at each of 2 visits separated by 1 to 2 weeks. Absolute paired differences within and between visits were 0.19 degrees and 0.90 degrees for the T-wave axis and 1.08 and 1.55 milliseconds for the QT interval, respectively. The intraclass correlation coefficients for the T-wave axis and QT interval were 0.87 and 0.86, respectively. The impact of repeated measurements on the precision of the QT-interval measurements was evaluated for a hypothetical clinical trial aimed at detecting a drug-induced QT prolongation. We conclude that the spatial T-wave axis is as repeatable a measure of ventricular repolarization as the QT interval.
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Affiliation(s)
- Georgeta D Vaidean
- Department of Medicine, University of North Carolina schools of Public Health and Medicine, Chapel Hill, NC 27514, USA.
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Jensen BT, Larroude CE, Rasmussen LP, Holstein‐Rathlou N, Hojgaard MV, Agner E, Kanters JK. Beat-to-beat QT dynamics in healthy subjects. Ann Noninvasive Electrocardiol 2004; 9:3-11. [PMID: 14731210 PMCID: PMC6931975 DOI: 10.1111/j.1542-474x.2004.91510.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Measures of QT dynamics express repolarization abnormalities that carry prognostic information, but the reproducibility of beat-to-beat QT dynamics has never been established. The QT interval is prolonged at night, but how the circadian rhythm and heart rate influence the dynamic QT measurements is still unsettled. The aims of the present study were: (1) to describe the reproducibility of beat-to-beat QT dynamics with respect to intrasubject, between-subject, and between-observer variability and (2) to describe the normal range, circadian variation, and heart rate dependence of QT dynamics. METHODS Ambulatory Holter recordings were performed three times on 20 healthy volunteers and were analyzed by two experienced cardiologists. Slope and intercept of the QT/RR regression, the variability of QT and R-R intervals expressed as the standard deviation, and the relation between QT and RR variability expressed as a variability ratio were measured among other QT dynamics. RESULTS The reproducibility of all QT dynamics was good. All QT dynamics showed circadian variation when calculated on an hourly basis. The day/night variation in slope could be explained by the differences in heart rate, whereas the day/night variation in intercept was heart rate independent. CONCLUSION The present study shows that reliable automatic QT measurements could be performed, encouraging further evaluation of the clinical value of QT dynamics in risk stratification of cardiac patients.
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Affiliation(s)
- Berit T. Jensen
- Laboratory of Experimental Cardiology, Department of Medical Physiology, University of Copenhagen, Denmark
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
- Copenhagen Heart Arrhythmia Research Center (CHARC), Copenhagen, Denmark
| | - Charlotte E. Larroude
- Laboratory of Experimental Cardiology, Department of Medical Physiology, University of Copenhagen, Denmark
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
- Copenhagen Heart Arrhythmia Research Center (CHARC), Copenhagen, Denmark
| | - Lars P. Rasmussen
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
| | - Niels‐Henrik Holstein‐Rathlou
- Laboratory of Experimental Cardiology, Department of Medical Physiology, University of Copenhagen, Denmark
- Copenhagen Heart Arrhythmia Research Center (CHARC), Copenhagen, Denmark
| | - Michael V. Hojgaard
- Laboratory of Experimental Cardiology, Department of Medical Physiology, University of Copenhagen, Denmark
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
| | - Erik Agner
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
| | - Jørgen K. Kanters
- Laboratory of Experimental Cardiology, Department of Medical Physiology, University of Copenhagen, Denmark
- Department of Medicine, Coronary Care Unit, Elsinore Hospital, Helsingør, Denmark
- Copenhagen Heart Arrhythmia Research Center (CHARC), Copenhagen, Denmark
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Faber TS, Grom A, Schöpflin M, Brunner M, Bode C, Zehender M. Beat-to-beat assessment of QT/RR interval ratio in severe heart failure and overt myocardial ischemia: a measure of electrical integrity in diseased hearts. Pacing Clin Electrophysiol 2003; 26:836-42. [PMID: 12715843 DOI: 10.1046/j.1460-9592.2003.t01-1-00147.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The study was designed to assess the beat-to-beat variation of ventricular repolarization in patients with myocardial ischemia, hear failure, and in normal subjects. Autonomic tone may alter the dynamic QT/RR interval relation and thus may be involved in ventricular arrhythmia development, especially in the diseased heart. The study included 145 patients (age 16-86 years) with CHF (LVEF < or = 0.30) or unstable angina pectoris (LVEF > 0.60). The control group consisted of healthy volunteers giving physiological baseline measures for the evaluated parameters: cycle length, QT interval, and QT/RR interval ratio during three time periods. In patients with myocardial ischemia (LVEF > 0.60) and healthy subjects the QT/RR interval ratio did not reveal significant differences between both groups (QT/RR(CAD) = 0.36 +/- 0.77 vs QT/RR(controls) = 0.28 +/- 0.83; NS). In sharp contrast, in patients with severe heart failure, RR dependent instantaneous variation of the QT interval was almost missing and regression line analysis disclosed a QT/RR interval slope substantially enhanced by 196% (compared to normal subjects) and 131% (compared to CAD patients; P < 0.05) with a complete loss of circadian modulation (QT/RR(CHF) = 0.83 +/- 0.71 vs QT/RR(CAD) = 0.36 +/- 0.77 vs QT/RR(controls) = 0.28 +/- 0.83; P < 0.05). Beat-to-beat QT interval assessment provides a dynamic parameter of physiological and altered repolarization in defined study groups. Compared to other groups (preserved LVEF), patients with left ventricular impairment exhibited a significantly increased sensitivity of repolarization to cycle length (enhanced QT/RR interval ratio) and a blunted circadian modulation of the QT interval. This is consistent with concept that increased repolarization disparity may be deleterious being a potential pathophysiological basis for enhanced arrhythmic risk.
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Affiliation(s)
- Thomas S Faber
- Department of Cardiology, University Hospital of Freiburg, Freiburg, Germany
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Extramiana F, Maison-Blanche P, Tavernier R, Jordaens L, Leenhardt A, Coumel P. Cardiac effects of chronic oral beta-blockade: lack of agreement between heart rate and QT interval changes. Ann Noninvasive Electrocardiol 2002; 7:379-88. [PMID: 12431318 PMCID: PMC7027610 DOI: 10.1111/j.1542-474x.2002.tb00189.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although well established on the sinus node, the effects of beta-blockade on ventricular repolarization are still conflicting. The aim of the study was to investigate the effects of a chronic beta-blockade on sinus node and repolarization parameters and their relationship. METHODS Sixteen healthy volunteers (10 males, mean age: 40 +/- 6.7 years) were randomized to placebo or atenolol (100 mg). After 7 days, subjects were crossed over. Heart rate (HR) and HRV indices were calculated from long-term ECG recordings separately during the day and at night, together with ventricular repolarization parameters (QT interval duration and QT rate-dependence). RESULTS Mean R-R intervals were significantly and consistently increased after atenolol (Day: 916 +/- 103 ms vs. 712 +/- 89 ms, and Night: 1149 +/- 93 vs. 996 +/- 125 ms). HRV changes under atenolol were also consistent, with a significant decrease in sympathovagal ratio. In contrast, atenolol only lowered diurnal QT rate-dependence (0.123 +/- 0.032 vs. 0.190 +/- 0.065 on placebo, P < 0.001), but not the nocturnal pattern. After multivariate analysis QT rate-dependence changes induced by atenolol were correlated with pretreatment QT/RR relation (r = 0.65, P < 0.01) but not with any HR or HRV parameters. CONCLUSIONS In healthy subjects, repolarization changes following chronic beta-blockade cannot be predicted by HR or HRV changes, but are dependent on pretreatment rate-dependence.
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Affiliation(s)
- Fabrice Extramiana
- Hôpital Lariboisière, Service de Cardiologie, 2 rue Ambroise Paré, 75010 Paris, France.
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Valensi PE, Johnson NB, Maison-Blanche P, Extramania F, Motte G, Coumel P. Influence of cardiac autonomic neuropathy on heart rate dependence of ventricular repolarization in diabetic patients. Diabetes Care 2002; 25:918-23. [PMID: 11978691 DOI: 10.2337/diacare.25.5.918] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Prolongation of the QT interval and increased QT dispersion are associated with a poor cardiac prognosis. The goal of this study was to assess the long-term influence of the autonomic nervous system on the heart rate dependence of ventricular repolarization in patients with diabetic autonomic neuropathy (DAN). RESEARCH DESIGN AND METHODS We studied 27 subjects (mean age 51.8 years) divided into three age- and sex-matched groups: nine control subjects, nine diabetic subjects with DAN (mostly at a mild stage; DAN+), and nine diabetic subjects without DAN (DAN-). DAN was assessed on heart rate variations during standard maneuvers (Valsalva, deep-breathing, and lying-to-standing maneuvers). No subject had coronary artery disease or left ventricular dysfunction or hypertrophy, and no subject was taking any drugs known to prolong the QT interval. All subjects underwent electrocardiogram and 24-h Holter recordings for heart rate variations (time and frequency domain) and QT analysis (selective beat averaging QT/RR relation, nocturnal QT lengthening). RESULTS Rate-corrected QT intervals (Bazett formula) did not differ significantly between the three groups. The diurnal and nocturnal levels of low frequency/high frequency, an index of sympathovagal balance, were significantly reduced in DAN+ subjects. Using the selective beat-averaging technique, a day-night modulation of the QT/RR relation was evidenced in control and DAN- subjects. This long-term modulation was significantly different in DAN+ subjects, with a reversed day-night pattern and an increased nocturnal QT rate dependence. CONCLUSIONS In diabetic patients with mild parasympathetic denervation, QT heart rate dependence was found to be impaired, as determined by noninvasive assessment using Holter data. Analysis of ventricular repolarization could represent a sensitive index of the progression of neuropathy. The potential prognostic impact of a reversed day-night pattern with steep nocturnal QT/RR relation still remains to be defined.
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