1
|
Bertrand É, Caru M, Harvey A, Andelfinger G, Laverdiere C, Krajinovic M, Sinnett D, Jacquemet V, Curnier D. QTc intervals at rest and during exercise assessed by group correction formulas in survivors of childhood acute lymphoblastic leukemia. J Electrocardiol 2024; 83:80-94. [PMID: 38382343 DOI: 10.1016/j.jelectrocard.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/07/2023] [Accepted: 01/28/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Early signs of subclinical cardiac damage must be identified before they turn into clinical manifestations. Tailoring a formula is relevant for precise QTc evaluation in childhood acute lymphoblastic leukemia (ALL) survivors considering they are at risk of long-term cardiac problems. Therefore, we aim to develop group heart rate correction formulas for QT intervals in childhood ALL survivors at rest and during exercise, and to assess the applicability of these methods across a variety of risk groups exposed to diverse chemotherapy dosages. METHODS Two hundred and fifty childhood ALL survivors in the PETALE study were classified into 3 groups depending on their prognostic risk group. ECG measurements (QT and RR intervals) were made at rest and during a cardiopulmonary exercise test. QT correction for heart rate was applied using 5 different formulas, which included 2 previously published formulas and 3 group-specific formulas for each sex. RESULTS The QT/RR relation showed 2 different curves between rest and during exercise, which was worse for females. Group-specific QTc formulas allowed adequate heart rate-corrected QT interval, independently of the cumulative dose of doxorubicin received during treatment. Group-specific formulas showed significantly shorter QTc intervals than QTc from Bazett's formula. QTc (Bazett's formula) values surpassed the established clinical norm in 22 males (11%) and 22 females (11%), with a majority occurring during exercise, affecting 15 males (7.5%) and 10 females (5%). CONCLUSION This study shows the applicability of personalized group correction of QT/RR data in childhood ALL survivors. Our comprehensive assessments (spanning rest, exercise, and recovery) is an effective approach for risk stratification of cardiac complications in childhood ALL survivors.
Collapse
Affiliation(s)
- Émilie Bertrand
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada
| | - Maxime Caru
- Department of Pediatrics, Division of Hematology and Oncology, Department of Public Health Sciences, Pennsylvania State Health Children's Hospital, Hershey, PA, USA
| | - Audrey Harvey
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada
| | - Gregor Andelfinger
- Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada; Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Caroline Laverdiere
- Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada; Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Maja Krajinovic
- Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada; Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Daniel Sinnett
- Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada; Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Vincent Jacquemet
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Daniel Curnier
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Sainte-Justine University Health Center, Research Center, Montreal, Quebec, Canada.
| |
Collapse
|
2
|
Brooks L, Dolton M, Langenhorst J, Yoshida K, Lien YTK, Malhi V, Li C, Perez-Moreno P, Bond J, Chen YC, Yu J. Concentration QTc analysis of giredestrant: Overcoming QT/heart rate confounding in the presence of drug-induced heart rate changes. Clin Transl Sci 2023; 16:823-834. [PMID: 36772881 PMCID: PMC10175970 DOI: 10.1111/cts.13491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/12/2023] Open
Abstract
Concentration-QTc (C-QTc) analysis has become a common approach for evaluating proarrhythmic risk and delayed cardiac repolarization of oncology drug candidates. Significant heart rate (HR) change has been associated with certain classes of oncology drugs and can result in over- or underestimation of the true QT prolongation risk. Because oncology early clinical trials typically lack a placebo control arm or time-matched, treatment-free baseline electrocardiogram collection, significant HR change brings additional challenges to C-QTc analysis in the oncology setting. In this work, a spline-based correction method (QTcSPL) was explored to mitigate the impact of HR changes in giredestrant C-QTc analysis. Giredestrant is a selective estrogen receptor degrader being developed for the treatment of patients with estrogen receptor-positive (ER+) breast cancer. A dose-related HR decrease has been observed in patients under giredestrant treatment, with significant reductions (>10 bpm) observed at supratherapeutic doses. The QTcSPL method demonstrated superior functionality to reduce the correlation between QTc and HR as compared with the Fridericia correction (QTcF). The effect of giredestrant exposure on QTc was evaluated at the clinical dose of 30 mg and supratherapeutic dose of 100 mg based on a prespecified linear mixed effect model. The upper 90% confidence interval of ΔQTcSPL and ΔQTcF were below the 10 ms at both clinical and supratherapeutic exposures, suggesting giredestrant has a low risk of QT prolongation at clinically relevant concentrations. This work demonstrated the use case of QTcSPL to address HR confounding challenges in the context of oncology drug development for the first time.
Collapse
Affiliation(s)
- Logan Brooks
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Michael Dolton
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | | | - Kenta Yoshida
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Yi Ting Kayla Lien
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Vikram Malhi
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Chunze Li
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Pablo Perez-Moreno
- Product Development Oncology, Genentech, Inc., South San Francisco, California, USA
| | - John Bond
- Product Development Oncology, Genentech, Inc., South San Francisco, California, USA
| | - Ya-Chi Chen
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Jiajie Yu
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| |
Collapse
|
3
|
QT interval measurement in ventricular pacing: Implications for assessment of drug effects and pro-arrhythmia risk. J Electrocardiol 2021; 70:13-18. [PMID: 34826635 DOI: 10.1016/j.jelectrocard.2021.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
QT interval prolongation is a known risk factor for development of malignant ventricular arrhythmias. Measurement of the QT interval is difficult in the setting of ventricular pacing (VP), which can prolong depolarization and increase the QT interval, overestimating repolarization time. VP and cardiac resynchronization therapies have become commonplace in modern cardiac care and may contribute to repolarization heterogeneity and subsequent increased risk for ventricular arrhythmias including Torsades de Pointes. It is imperative for the clinician caring for acutely ill cardiac patients to understand the relationship between QT interval prolongation, both drug-induced and pacing-induced, and repolarization changes with subsequent ventricular arrhythmia risk. In this review, we discuss the components of QT interval assessment for arrhythmogenic risk including arrhythmogenic QT prolongation, methods for adjusting the QT interval to identify repolarization changes, methods to adjust for heart rate, and propose a framework for medication management to assess for drug-induced long QT syndrome in patients with VP.
Collapse
|
4
|
Rabkin SW, Tang JKK. The Short QTc Is a Marker for the Development of Atrial Flutter and Atrial Fibrillation. Cardiol Res Pract 2020; 2020:2858149. [PMID: 33224525 PMCID: PMC7669358 DOI: 10.1155/2020/2858149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/23/2020] [Indexed: 11/18/2022] Open
Abstract
A short QT interval has been difficult to define, and there is debate whether it exists outside of an extremely small group of individuals with inherited channelopathies and whether it predicts cardiac arrhythmias. The objective was to identify cases with short QT and their consequences. Our hospital ECG database was screened for cases with a QTc based on the Bazett formula (QTcBZT) of less than 340 ms. The QTc was recalculated using the spline (QTcRBK) formula, which more accurately adjusts for the heart rate and identifies cases based on percentile distribution of the QT interval. The exclusion criteria were presence of bundle branch block, arrhythmias, or electronic pacemakers. An age- and sex-matched cohort was obtained from individuals with normal QT intervals with the same exclusion criteria. There were 28 cases with a short QTc (QTcRBK < 380 ms). The age was 69.6 ± 14.6 years (mean ± SD) (50% males). The QT interval was 305.7 ± 61.1 ms with QTcRBK 308.4 ± 31.4 ms. Subsequent ECGs showed atrial flutter in 21%, atrial fibrillation in 18%, and atrial tachycardia in 4% of cases. Thus, atrial arrhythmias occurred in 43% of cases. This incidence was significantly (p < 0.0001) greater than the incidence of atrial arrhythmias in age- and sex-matched controls. In conclusion, a short QT interval can be readily identified based on the first percentile of the new QTc formula. A short QTc is an important marker for the development of atrial arrhythmias, including atrial flutter and atrial fibrillation, with the former predominating. It should be part of patient assessment and warrants consideration to develop strategies for detection and prevention of atrial arrhythmias.
Collapse
Affiliation(s)
- Simon W. Rabkin
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Jacky K. K. Tang
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| |
Collapse
|
5
|
Tang JKK, Bennett MT, Rabkin SW. Assessment of QT interval in ventricular paced rhythm: Derivation of a novel formula. J Electrocardiol 2019; 57:55-62. [PMID: 31499424 DOI: 10.1016/j.jelectrocard.2019.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/26/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of the study was to determine the optimal formula to estimate QT interval adjusting for QRS prolongation during right ventricular (RV) pacing. METHODS This observational study included individuals (n = 43) with a newly implanted permanent ventricular pacemaker, who had a narrow QRS complex before pacemaker insertion. QT interval with RV pacing was related to QT interval before pacemaker implantation. The validation cohort (n = 442) had permanent RV pacing in DDD mode. RESULTS A new QTc formula was derived utilizing the constants from the relationship between the spline heart rate QT correction (QTcRBK) before and after pacing; specifically, QTcRBKPACED = QTcRBK × 0.86. The JT interval from paced complexes was highly heart rate (HR) dependent and was not accurate for QT assessment. Previous, QTc formula for paced complexes were not highly correlated with QT before pacing unless a robust HR correction is added. Formulae subtracting a fixed amount from QTcPACED markedly overestimated QTc before pacing. CONCLUSION We proposed a new, simple formula for QT estimation in RV pacing. JT interval in paced complexes is highly HR dependent and is not accurate for QT assessment. The new spline approach for HR correction for the QT, once incorporated into some previously proposed formulae, blunts HR dependency and improves prediction of QT before pacing. QTcRBKPACED*0.86 and QTcRBKPACED - (QRS*0.5) demonstrated the best balance of relatively strong correlation to QTc before pacing and accurate QTc prolongation identification. Abnormal QT for QTcRBKPACED*0.86 as defined by the 97.5th and 99th percentile are 469 and 479 ms respectively.
Collapse
Affiliation(s)
- Jacky K K Tang
- University of British Columbia, Division of Cardiology, Vancouver, B.C., Canada
| | - Matthew T Bennett
- University of British Columbia, Division of Cardiology, Vancouver, B.C., Canada
| | - Simon W Rabkin
- University of British Columbia, Division of Cardiology, Vancouver, B.C., Canada.
| |
Collapse
|