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Nikolic RPA, Virk MK, Buhler KA, Costenbader KH, Choi MY, Weber BN. Hydroxychloroquine and Chloroquine-Induced Cardiac Arrhythmias and Sudden Cardiac Death in Patients With Systemic Autoimmune Rheumatic Diseases: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2024; 84:158-169. [PMID: 38922589 DOI: 10.1097/fjc.0000000000001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 06/27/2024]
Abstract
ABSTRACT Hydroxychloroquine (HCQ) and chloroquine (CQ) are foundational treatments for several systemic autoimmune rheumatic diseases, including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Concerns regarding the risk of cardiac arrhythmia and death have been raised, yet the burden of HCQ and CQ-related cardiac toxicities remains unclear. A systematic literature search was conducted in the MEDLINE and Embase databases for articles published between the earliest date and April 2023 reporting cardiac conduction abnormalities in patients with systemic autoimmune rheumatic diseases taking HCQ or CQ. Meta-analysis was performed to calculate the difference in mean corrected QT (QTc) interval and odds ratio of prolonged QTc interval in those taking HCQ or CQ versus not. Of 2673 unique records, 34 met the inclusion criteria, including 70,609 subjects. Thirty-three studies reported outcomes in HCQ and 9 in CQ. Five studies reported outcomes in RA, 11 in SLE, and 18 in populations with mixed rheumatic diseases. Eleven studies reported mean QTc and OR for prolonged QTc for meta-analysis, all reporting outcomes in HCQ. There was a significant increase in mean QTc (10.29 ms, P = 0.458) among HCQ users compared to non-HCQ users in patients with RA. There was no difference in mean QTc between HCQ and non-HCQ users in other systemic autoimmune rheumatic diseases. When rheumatic diseases were pooled, HCQ users were more likely to have prolonged QTc compared to non-HCQ users (odds ratio 1.57, 95% CI, 1.19, 2.08). The results of this study suggest that clinicians should be aware of potential adverse cardiac events of HCQ and consider QTc monitoring for patients on HCQ for the treatment of systemic autoimmune rheumatic diseases.
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MESH Headings
- Hydroxychloroquine/adverse effects
- Humans
- Antirheumatic Agents/adverse effects
- Arrhythmias, Cardiac/chemically induced
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/mortality
- Arrhythmias, Cardiac/physiopathology
- Chloroquine/adverse effects
- Rheumatic Diseases/drug therapy
- Rheumatic Diseases/mortality
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/epidemiology
- Autoimmune Diseases/chemically induced
- Autoimmune Diseases/diagnosis
- Autoimmune Diseases/mortality
- Autoimmune Diseases/drug therapy
- Risk Assessment
- Male
- Female
- Middle Aged
- Adult
- Risk Factors
- Cardiotoxicity
- Aged
- Heart Rate/drug effects
- Young Adult
- Treatment Outcome
- Action Potentials/drug effects
- Adolescent
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/mortality
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Affiliation(s)
- Roko P A Nikolic
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mansimran K Virk
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Katherine A Buhler
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - May Y Choi
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada ; and
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Ni M, Dadon Z, Ormerod JOM, Saenen J, Hoeksema WF, Antiperovitch P, Tadros R, Christiansen MK, Steinberg C, Arnaud M, Tian S, Sun B, Estillore JP, Wang R, Khan HR, Roston TM, Mazzanti A, Giudicessi JR, Siontis KC, Alak A, Acosta JG, Divakara Menon SM, Tan NS, van der Werf C, Nazer B, Vivekanantham H, Pandya T, Cunningham J, Gula LJ, Wong JA, Amit G, Scheinman MM, Krahn AD, Ackerman MJ, Priori SG, Gollob MH, Healey JS, Sacher F, Nof E, Glikson M, Wilde AAM, Watkins H, Jensen HK, Postema PG, Belhassen B, Chen SRW, Roberts JD. A Clinical Diagnostic Test for Calcium Release Deficiency Syndrome. JAMA 2024; 332:204-213. [PMID: 38900490 PMCID: PMC11190834 DOI: 10.1001/jama.2024.8599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/23/2024] [Indexed: 06/21/2024]
Abstract
Importance Sudden death and cardiac arrest frequently occur without explanation, even after a thorough clinical evaluation. Calcium release deficiency syndrome (CRDS), a life-threatening genetic arrhythmia syndrome, is undetectable with standard testing and leads to unexplained cardiac arrest. Objective To explore the cardiac repolarization response on an electrocardiogram after brief tachycardia and a pause as a clinical diagnostic test for CRDS. Design, Setting, and Participants An international, multicenter, case-control study including individual cases of CRDS, 3 patient control groups (individuals with suspected supraventricular tachycardia; survivors of unexplained cardiac arrest [UCA]; and individuals with genotype-positive catecholaminergic polymorphic ventricular tachycardia [CPVT]), and genetic mouse models (CRDS, wild type, and CPVT were used to define the cellular mechanism) conducted at 10 centers in 7 countries. Patient tracings were recorded between June 2005 and December 2023, and the analyses were performed from April 2023 to December 2023. Intervention Brief tachycardia and a subsequent pause (either spontaneous or mediated through cardiac pacing). Main Outcomes and Measures Change in QT interval and change in T-wave amplitude (defined as the difference between their absolute values on the postpause sinus beat and the last beat prior to tachycardia). Results Among 10 case patients with CRDS, 45 control patients with suspected supraventricular tachycardia, 10 control patients who experienced UCA, and 3 control patients with genotype-positive CPVT, the median change in T-wave amplitude on the postpause sinus beat (after brief ventricular tachycardia at ≥150 beats/min) was higher in patients with CRDS (P < .001). The smallest change in T-wave amplitude was 0.250 mV for a CRDS case patient compared with the largest change in T-wave amplitude of 0.160 mV for a control patient, indicating 100% discrimination. Although the median change in QT interval was longer in CRDS cases (P = .002), an overlap between the cases and controls was present. The genetic mouse models recapitulated the findings observed in humans and suggested the repolarization response was secondary to a pathologically large systolic release of calcium from the sarcoplasmic reticulum. Conclusions and Relevance There is a unique repolarization response on an electrocardiogram after provocation with brief tachycardia and a subsequent pause in CRDS cases and mouse models, which is absent from the controls. If these findings are confirmed in larger studies, this easy to perform maneuver may serve as an effective clinical diagnostic test for CRDS and become an important part of the evaluation of cardiac arrest.
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Affiliation(s)
- Mingke Ni
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Ziv Dadon
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Jesselson Integrated Heart Center, Eisenberg R&D Authority, Shaare Zedek Medical Center, and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Julian O. M. Ormerod
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, England
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, England
| | - Johan Saenen
- Department of Cardiology, Faculty of Medicine and Health Sciences, Antwerp University Hospital, Antwerp, Belgium
- Cardiovascular Research, Departments of Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Wiert F. Hoeksema
- Department of Clinical Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Pavel Antiperovitch
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Rafik Tadros
- Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | | | - Christian Steinberg
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Marine Arnaud
- Department of Cardiac Pacing and Electrophysiology, Hopital Cardiologique du Haut-Leveque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | - Shanshan Tian
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Bo Sun
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - John Paul Estillore
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Ruiwu Wang
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Habib R. Khan
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Thomas M. Roston
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Andrea Mazzanti
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
- Department of Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - John R. Giudicessi
- Windland Smith Rice Genetic Heart Rhythm Clinic, Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Aiman Alak
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - J. Gabriel Acosta
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Syamkumar M. Divakara Menon
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Nigel S. Tan
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Christian van der Werf
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
- Department of Clinical Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Babak Nazer
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Washington Medical Center, Seattle
| | - Hari Vivekanantham
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Tanvi Pandya
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Cunningham
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lorne J. Gula
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Jorge A. Wong
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Guy Amit
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Melvin M. Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Andrew D. Krahn
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Michael J. Ackerman
- Windland Smith Rice Genetic Heart Rhythm Clinic, Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Silvia G. Priori
- Department of Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Michael H. Gollob
- Inherited Arrhythmia and Cardiomyopathy Program, Arrhythmia Service, Division of Cardiology, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jeff S. Healey
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Frederic Sacher
- Department of Cardiac Pacing and Electrophysiology, Hopital Cardiologique du Haut-Leveque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | - Eyal Nof
- Leviev Heart Institute, Chaim Sheba Medical Center, Ramat Gan, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Eisenberg R&D Authority, Shaare Zedek Medical Center, and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Arthur A. M. Wilde
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
- Department of Clinical Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hugh Watkins
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, England
- Oxford Biomedical Research Centre and Wellcome Centre for Human Genetics, University of Oxford, Oxford, England
| | - Henrik K. Jensen
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Pieter G. Postema
- Member of the European Reference Network for Rare, Low Prevalence, and Complex Diseases of the Heart (ERN GUARD-Heart)
- Department of Clinical Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Bernard Belhassen
- Tel Aviv University, Tel Aviv, Israel
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - S. R. Wayne Chen
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Jason D. Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Rohatgi RK, Tseng AS, Sugrue AM, Lee AT, Scott CG, Wackel PL, Cannon BC, Bos JM, Ackerman MJ. Utilizing median and maximum QTc values improves prediction of breakthrough cardiac events in pediatric long QT syndrome. J Cardiovasc Electrophysiol 2024; 35:1370-1381. [PMID: 38725227 DOI: 10.1111/jce.16293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Although prior studies indicate that a QTc > 500 ms on a single baseline 12-lead electrocardiogram (ECG) is associated with significantly increased risk of arrhythmic events in long QT syndrome (LQTS), less is known about the risk of persistent QT prolongation. We sought to determine QTc persistence and its prognostic effect on breakthrough cardiac events (BCEs) among pediatric patients treated for LQTS. METHODS We performed a retrospective analysis of 433 patients with LQTS evaluated, risk-stratified, and undergoing active guideline-based LQTS treatment between 1999 and 2019. BCEs were defined as arrhythmogenic syncope/seizure, sudden cardiac arrest (SCA), appropriate VF-terminating ICD shock, and sudden cardiac death (SCD). RESULTS During the median follow-up of 5.5 years (interquartile range [IQR] = 3-9), 32 (7%) patients experienced a total of 129 BCEs. A maximum QTc threshold of 520 ms and median QTc threshold of 490 ms were determined to be strong predictors for BCEs. A landmark analysis controlling for age, sex, genotype, and symptomatic status demonstrated models utilizing both the median QTc and maximum QTc demonstrated the highest discriminatory value (c-statistic = 0.93-0.95). Patients in the high-risk group (median QTc > 490 ms and maximum QTc > 520 ms) had a significantly lower BCE free survival (70%-81%) when compared to patients in both medium-risk (93%-97%) and low-risk (98%-99%) groups. CONCLUSIONS The risk of BCE among patients treated for LQTS increases not only based upon their maximum QTc, but also their median QTc (persistence of QTc prolongation). Patients with a maximum QTc > 520 ms and median QTc > 490 ms over serial 12-lead ECGs are at the highest risk of BCE while on guideline-directed medical therapy.
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Affiliation(s)
- Ram K Rohatgi
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology/Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew S Tseng
- Department of Cardiovascular Medicine/Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Alan M Sugrue
- Department of Cardiovascular Medicine/Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander T Lee
- Department of Health Sciences Research/Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher G Scott
- Department of Health Sciences Research/Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip L Wackel
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology/Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryan C Cannon
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology/Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - J Martijn Bos
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology/Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine/Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Ackerman
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology/Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine/Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
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Robinson KM, Eum S, Desta Z, Tyndale RF, Gaedigk A, Crist RC, Haidar CE, Myers AL, Samer CF, Somogyi AA, Zubiaur P, Iwuchukwu OF, Whirl-Carrillo M, Klein TE, Caudle KE, Donnelly RS, Kharasch ED. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2B6 Genotype and Methadone Therapy. Clin Pharmacol Ther 2024. [PMID: 38863207 DOI: 10.1002/cpt.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/22/2024] [Indexed: 06/13/2024]
Abstract
Methadone is a mu (μ) opioid receptor agonist used clinically in adults and children to manage opioid use disorder, neonatal abstinence syndrome, and acute and chronic pain. It is typically marketed as a racemic mixture of R- and S-enantiomers. R-methadone has 30-to 50-fold higher analgesic potency than S-methadone, and S-methadone has a greater adverse effect (prolongation) on the cardiac QTc interval. Methadone undergoes stereoselective metabolism. CYP2B6 is the primary enzyme responsible for catalyzing the metabolism of both enantiomers to the inactive metabolites, S- and R-2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (S- and R-EDDP). Genetic variation in the CYP2B6 gene has been investigated in the context of implications for methadone pharmacokinetics, dose, and clinical outcomes. Most CYP2B6 variants result in diminished or loss of CYP2B6 enzyme activity, which can lead to higher plasma methadone concentrations (affecting S- more than R-methadone). However, the data do not consistently indicate that CYP2B6-based metabolic variability has a clinically significant effect on methadone dose, efficacy, or QTc prolongation. Expert analysis of the published literature does not support a change from standard methadone prescribing based on CYP2B6 genotype (updates at www.cpicpgx.org).
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Affiliation(s)
- Katherine M Robinson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Seenae Eum
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel F Tyndale
- Department of Pharmacology & Toxicology, and Psychiatry, The Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Richard C Crist
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Alan L Myers
- Department of Diagnostic & Biomedical Sciences, The University of Texas Health Science Center, Houston, Texas, USA
| | - Caroline F Samer
- Department of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Pablo Zubiaur
- Department of Clinical Pharmacology, Hospital Universitario de la Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Otito F Iwuchukwu
- Department of Pharmaceutical Sciences, School of Pharmacy and Health Sciences, Farleigh Dickinson University, Florham Park, New Jersey, USA
| | | | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Roseann S Donnelly
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine | Bermaride LLC, Durham, North Carolina, USA
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Metcalfe JZ, Economou T, Naufal F, Kucukosmanoglu M, Kleiman R, Phillips PPJ, Conradie F. Validation of a Handheld 6-Lead Device for QT Interval Monitoring in Resource-Limited Settings. JAMA Netw Open 2024; 7:e2415576. [PMID: 38848063 PMCID: PMC11161846 DOI: 10.1001/jamanetworkopen.2024.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/08/2024] [Indexed: 06/10/2024] Open
Abstract
Importance Rifampin-resistant tuberculosis treatment regimens require electrocardiographic (ECG) monitoring due to the use of multiple QTc-prolonging agents. Formal 12-lead ECG devices represent a significant burden in resource-constrained clinics worldwide and a potential barrier to treatment scale-up in some settings. Objective To evaluate the diagnostic accuracy of a handheld 6-lead ECG device within resource-constrained clinics. Design, Setting, and Participants This diagnostic study was performed within a multicenter, pragmatic (broad eligibility criteria with no exclusions for randomized participants), phase 3 rifampin-resistant tuberculosis treatment trial (BEAT Tuberculosis [Building Evidence for Advancing New Treatment for Tuberculosis]) in South Africa. A total of 192 consecutive trial participants were assessed, and 191 were recruited for this substudy between January 21, 2021, and March 27, 2023. A low proportion (3 of 432 [0.7%]) of all screened trial participants were excluded due to a QTc interval greater than 450 milliseconds. Triplicate reference standard 12-lead ECG results were human calibrated with readers blinded to 6-lead ECG results. Main Outcomes and Measures Diagnostic accuracy, repeatability, and feasibility of a 6-lead ECG device. Results A total of 191 participants (median age, 36 years [IQR, 28-45 years]; 81 female participants [42.4%]; 91 participants [47.6%] living with HIV) with a median of 4 clinic visits (IQR, 3-4 visits) contributed 2070 and 2015 12-lead and 6-lead ECG assessments, respectively. Across 170 participants attending 489 total clinic visits where valid triplicate QTc measurements were available for both devices, the mean 12-lead QTc measurement was 418 milliseconds (range, 321-519 milliseconds), and the mean 6-lead QTc measurement was 422 milliseconds (range, 288-574 milliseconds; proportion of variation explained, R2 = 0.4; P < .001). At a QTc interval threshold of 500 milliseconds, the 6-lead ECG device had a negative predictive value of 99.8% (95% CI, 98.8%-99.9%) and a positive predictive value of 16.7% (95% CI, 0.4%-64.1%). The normal expected range of within-individual variability of the 6-lead ECG device was high (±50.2 milliseconds [coefficient of variation, 6.0%]) relative to the 12-lead ECG device (±22.0 milliseconds [coefficient of variation, 2.7%]). The mean (SD) increase in the 12-lead QTc measurement during treatment was 10.1 (25.8) milliseconds, with 0.8% of clinic visits (4 of 489) having a QTc interval of 500 milliseconds or more. Conclusions and Relevance This study suggests that simplified, handheld 6-lead ECG devices are effective triage tests that could reduce the need to perform 12-lead ECG monitoring in resource-constrained settings.
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Affiliation(s)
- John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Tamsin Economou
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Fahd Naufal
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Patrick P. J. Phillips
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Francesca Conradie
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Leung HT, Kwok SY, Kwong KY, Shih FY, Tsao S, Chung BHY. Prioritize Variant Reclassification in Pediatric Long QT Syndrome-Time to Revisit. Pediatr Cardiol 2024; 45:1023-1035. [PMID: 38565666 DOI: 10.1007/s00246-024-03461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Abstract
Congenital long QT syndrome (LQTS) is an inherited arrhythmia syndrome associated with sudden cardiac death. Accurate interpretation and classification of genetic variants in LQTS patients are crucial for effective management. All patients with LQTS with a positive genetic test over the past 18 years (2002-2020) in our single tertiary pediatric cardiac center were identified. Reevaluation of the reported variants in LQTS genes was conducted using the American College of Genetics and Genomics (ACMG) guideline after refinement by the US ClinGen SVI working group and guideline by Walsh et al. on genetic variant reclassification, under multidisciplinary input. Among the 59 variants identified. 18 variants (30.5%) were reclassified. A significant larger portion of variants of unknown significance (VUS) were reclassified compared to likely pathogenic (LP)/pathogenic (P) variants (57.7% vs 9.1%, p < 0.001). The rate of reclassification was significantly higher in the limited/disputed evidence group compared to the definite/moderate evidence group (p = 0.0006). All LP/P variants were downgraded in the limited/disputed evidence group (p = 0.0057). VUS upgrades are associated with VUS located in genes within the definite/moderate evidence group (p = 0.0403) and with VUS present in patients exhibiting higher corrected QT intervals (QTc) (p = 0.0445). A significant number of pediatric LQTS variants were reclassified, particularly for VUS. The strength of the gene-disease association of the genes influences the reclassification performance. The study provides important insights and guidance for pediatricians to seek for reclassification of "outdated variants" in order to facilitate contemporary precision medicine.
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Affiliation(s)
- Hei-To Leung
- Department of Paediatrics & Adolescent Medicine, Hong Kong Children's Hospital, 1 Shing Cheong Rd, Ngau Tau Kok, Hong Kong SAR, China
| | - Sit-Yee Kwok
- Department of Paediatrics & Adolescent Medicine, Hong Kong Children's Hospital, 1 Shing Cheong Rd, Ngau Tau Kok, Hong Kong SAR, China.
| | - Ka-Yee Kwong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Fong-Ying Shih
- Clinical Genetics Service Unit, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR, China
| | - Sabrina Tsao
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Brian Hon-Yin Chung
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
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Bene Watts S, Gauthier B, Erickson AC, Morrison J, Sebastian M, Gillman L, McIntosh S, Ens C, Sherwin E, McCormick R, Sanatani S, Arbour L. A mild phenotype associated with KCNQ1 p.V205M mediated long QT syndrome in First Nations children of Northern British Columbia: effect of additional variants and considerations for management. Front Pediatr 2024; 12:1394105. [PMID: 38884101 PMCID: PMC11176454 DOI: 10.3389/fped.2024.1394105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Congenital Long QT Syndrome (LQTS) is common in a First Nations community in Northern British Columbia due to the founder variant KCNQ1 p.V205M. Although well characterized molecularly and clinically in adults, no data have been previously reported on the pediatric population. The phenotype in adults has been shown to be modified by a splice site variant in KCNQ1 (p.L353L). The CPT1A p.P479L metabolic variant, also common in Northern Indigenous populations, is associated with hypoglycemia and infant death. Since hypoglycemia can affect the corrected QT interval (QTc) and may confer risk for seizures (also associated with LQTS), we sought to determine the effect of all three variants on the LQTS phenotype in children within our First Nations cohort. Methods As part of a larger study assessing those with LQTS and their relatives in a Northern BC First Nation, we assessed those entering the study from birth to age 18 years. We compared the corrected peak QTc and potential cardiac events (syncope/seizures) of 186 children from birth to 18 years, with and without the KCNQ1 (p.V205M and p.L353L) and CPT1A variants, alone and in combination. Linear and logistic regression and student t-tests were applied as appropriate. Results Only the KCNQ1 p.V205M variant conferred a significant increase in peak QTc 23.8 ms (p < 0.001) above baseline, with females increased by 30.1 ms (p < 0.001) and males by 18.9 ms (p < 0.01). There was no evidence of interaction effects with the other two variants studied. Although the p.V205M variant was not significantly associated with syncope/seizures, the odds of having a seizure/syncope were significantly increased for those homozygous for CPT1A p.P479L compared to homozygous wild type (Odds Ratio [OR]3.0 [95% confidence interval (CI) 1.2-7.7]; p = 0.019). Conclusion While the KCNQ1 p.V205M variant prolongs the peak QTc, especially in females, the CPT1A p.P479L variant is more strongly associated with loss of consciousness events. These findings suggest that effect of the KCNQ1 p.V205M variant is mild in this cohort, which may have implications for standard management. Our findings also suggest the CPT1A p.P479L variant is a risk factor for seizures and possibly syncope, which may mimic a long QT phenotype.
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Affiliation(s)
- Simona Bene Watts
- Island Medical Program, University of British Columbia, Victoria, BC, Canada
| | - Barbara Gauthier
- Epidemiology and Surveillance Unit, Interior Health Authority, Kelowna, BC, Canada
| | | | | | | | - Lawrence Gillman
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Sarah McIntosh
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Connie Ens
- Department of Pediatrics, Division of Cardiology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Elizabeth Sherwin
- Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Rod McCormick
- Department of Education and Social Work, Thompson Rivers University, Kamloops, BC, Canada
| | - Shubhayan Sanatani
- Department of Pediatrics, Division of Cardiology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Laura Arbour
- Island Medical Program, University of British Columbia, Victoria, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
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8
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Chen P, Zampawala Z, Wang H, Wang L. Exploring the impact of a KCNH2 missense variant on Long QT syndrome: insights into a novel gender-selective, incomplete penetrance inheritance mode. Front Genet 2024; 15:1409459. [PMID: 38873110 PMCID: PMC11169575 DOI: 10.3389/fgene.2024.1409459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024] Open
Abstract
Background Long QT syndrome (LQTS) is an inherited malignant arrhythmia syndrome that poses a risk of sudden death. Variants in the Potassium Voltage-Gated Channel Subfamily H Member 2 (KCNH2) gene are known to cause Long QT syndrome through an autosomal dominant inheritance pattern. However, as of now, there have been no reports of any KCNH2 variant leading to Long QT syndrome exhibiting incomplete penetrance that is influenced by gender. Methods Whole-exome sequencing (WES) was conducted on the proband to identify pathogenic variants. Subsequently, Sanger sequencing was employed to validate the identified likely pathogenic variants in all family members. Results We analyzed a pedigree spanning three-generations afflicted by Long QT syndrome. WES revealed a novel KCNH2 missense variant (p.Val630Gly, c.1889 T>G) as the causative factor for the family's phenotype. Within this family, all three male carriers of the KCNH2 variant carriers exhibited the Long QT syndrome phenotype: one experienced sudden death during sleep, another received an implantable cardioverter defibrillator (ICD), and a younger man displayed a prolonged QTc interval without any instances of syncope or malignant arrhythmia to date. Interestingly, the middle-aged female carrier showed no Long QT Syndrome phenotype. However, her offspring, diagnosed with Turner syndrome (45, X) and also a carrier of this variant, experienced frequent syncope starting at 12 years old and was diagnosed with Long QT syndrome, leading to an ICD implantation when she was 15 years old. These observations suggest that the manifestation of Long QT syndrome associated with this KCNH2 variant exhibits incomplete penetrance influenced by gender within this family, indicating potential protective mechanisms against the syndrome in females affected by this variant. Conclusion Our investigation has led to the identification of a novel pathogenic KCNH2 variant responsible for Long QT syndrome within a familial context characterized by gender-selective, incomplete penetrance. This discovery highlights a unique pathogenic inheritance pattern for the KCNH2 gene associated with Long QT syndrome, and could potentially shed light on the distinct penetrance behaviors and patterns of the KCNH2 gene. This discovery broadens our exploration of the KCNH2 gene in cardiac arrhythmias, highlighting the intricate genetic dynamics behind Long QT syndrome.
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Affiliation(s)
- Peng Chen
- Division of Cardiology, Departments of Internal Medicine and Genetic Diagnosis Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiological Disorders, Wuhan, China
| | - Zainul Zampawala
- Division of Cardiology, Departments of Internal Medicine and Genetic Diagnosis Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Wang
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiological Disorders, Wuhan, China
| | - Luyun Wang
- Division of Cardiology, Departments of Internal Medicine and Genetic Diagnosis Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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9
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John CJ, Engler M, Zaki H, Crooker A, Cabrera M, Golden C, Whitehill R, Xiang Y, Liu K, Fundora MP. The effect of antipsychotic medications on QTc and delirium in paediatric cardiac patients with ICU delirium. Cardiol Young 2024:1-5. [PMID: 38783397 DOI: 10.1017/s1047951124025162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Children with prolonged hospital admissions for CHD often develop delirium. Antipsychotic medications (APMs) have been used to treat delirium but are known to prolong the QTc duration. There is concern for prolongation of the QTc interval in cardiac patients who may be more vulnerable to electrocardiogram (ECG) changes and may have postoperative QTc prolongation already. The goal of this study was to determine the effect of APM on QTc duration in postoperative paediatric cardiac patients and determine the effect of quetiapine and risperidone in treating delirium and QTc prolongation. DESIGN Retrospective study, July 1, 2017-May 31, 2022. SETTING Tertiary children's hospital. PATIENTS Included were patients admitted to the paediatric cardiac ICU at Children's Healthcare of Atlanta. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ECGs, delirium scores, and drug information were collected. Delirium was defined as Cornell Assessment of Pediatric Delirium (CAPD) score >9. Mixed effect models were performed to evaluate the effect of surgery on QTc change and the effect of antipsychotics on QTc and CAPD changes. There were 139 children, 55% male and 67% surgical admissions. Median age was 5.9 months. Mean QTc increased after cardiac surgery by 18 ms (p = 0.014, 95% CI 3.65-32.4). There was no significant change in QTc after antipsychotic administration (p = 0.064). The mean CAPD score decreased (12.5-7.2; p < 0.001). Quetiapine had the most improvement in delirium, and risperidone had the least improvement (77.8%, n = 14; 37.8%, n = 34, respectively; p = 0.002). CONCLUSIONS The QTc interval did not have a statistically significant change after the administration of antipsychotics, while there was improvement in the CAPD score. APMs may be administered safely without significant prolongation of the QTc and are an effective treatment for delirium.
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Affiliation(s)
- Carol J John
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Meghan Engler
- Department of Pediatrics, Children's Healthcare of Atlanta Cardiology, Emory University, Atlanta, GA, USA
| | - Hania Zaki
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Anna Crooker
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Maria Cabrera
- Department of Pediatrics, Children's Healthcare of Atlanta Cardiology, Emory University, Atlanta, GA, USA
| | | | - Robert Whitehill
- Department of Pediatrics, Children's Healthcare of Atlanta Cardiology, Emory University, Atlanta, GA, USA
| | - Yijin Xiang
- Biostatistics Core, Emory University, Atlanta, GA, USA
| | - Katie Liu
- Biostatistics Core, Emory University, Atlanta, GA, USA
| | - Michael P Fundora
- Department of Pediatrics, Children's Healthcare of Atlanta Cardiology, Emory University, Atlanta, GA, USA
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10
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Balestra E, Bobbo M, Cittar M, Chicco D, D’Agata Mottolese B, Barbi E, Caiffa T. Congenital Long QT Syndrome in Children and Adolescents: A General Overview. CHILDREN (BASEL, SWITZERLAND) 2024; 11:582. [PMID: 38790576 PMCID: PMC11119491 DOI: 10.3390/children11050582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/24/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Congenital long QT syndrome (LQTS) represents a disorder of myocardial repolarization characterized by a prolongation of QTc interval on ECG, which can degenerate into fast polymorphic ventricular arrhythmias. The typical symptoms of LQTS are syncope and palpitations, mainly triggered by adrenergic stimuli, but it can also manifest with cardiac arrest. At least 17 genotypes have been associated with LQTS, with a specific genotype-phenotype relationship described for the three most common subtypes (LQTS1, -2, and -3). β-Blockers are the first-line therapy for LQTS, even if the choice of the appropriate patients needing to be treated may be challenging. In specific cases, interventional measures, such as an implantable cardioverter-defibrillator (ICD) or left cardiac sympathetic denervation (LCSD), are useful. The aim of this review is to highlight the current state-of-the-art knowledge on LQTS, providing an updated picture of possible diagnostic algorithms and therapeutic management.
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Affiliation(s)
- Elia Balestra
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Marco Bobbo
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34127 Trieste, Italy; (M.B.); (D.C.); (B.D.M.); (T.C.)
| | - Marco Cittar
- Cardiovascular Department, Centre for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Integrata di Trieste, University of Trieste, 34127 Trieste, Italy;
| | - Daniela Chicco
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34127 Trieste, Italy; (M.B.); (D.C.); (B.D.M.); (T.C.)
| | - Biancamaria D’Agata Mottolese
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34127 Trieste, Italy; (M.B.); (D.C.); (B.D.M.); (T.C.)
| | - Egidio Barbi
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy;
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34127 Trieste, Italy; (M.B.); (D.C.); (B.D.M.); (T.C.)
| | - Thomas Caiffa
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34127 Trieste, Italy; (M.B.); (D.C.); (B.D.M.); (T.C.)
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11
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Inbaraj LR, Manesh A, Ponnuraja C, Bhaskar A, Srinivasalu VA, Daniel BD. Comparative evaluation of intensified short course regimen and standard regimen for adults TB meningitis: a protocol for an open label, multi-center, parallel arms, randomized controlled superiority trial (INSHORT trial). Trials 2024; 25:294. [PMID: 38693583 PMCID: PMC11064413 DOI: 10.1186/s13063-024-08133-6] [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: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite several incremental improvements in the management of tuberculous meningitis (TBM), the mortality rates remain high. In spite of national and international guidelines, variation in the choice, dose, and duration of drugs exist between countries and clinicians. We propose to evaluate a shorter and more effective regimen containing agents with augmented intracerebral drug exposure and anti-inflammatory approaches to improve disability-free survival among patients with TBM. Our strategy incorporates the various developments in the field of TBM over the last two decades and only few trials have evaluated a composite of these strategies in the overall outcomes of TBM. METHODS An open label, parallel arms, randomized controlled superiority trial will be conducted among 372 participants across 6 sites in India. Eligible participants will be randomly allocated in 1:1:1 ratio into one of the three arms. The intervention arm consists of 2 months of high-dose rifampicin (25 mg/kg), moxifloxacin (400 mg), pyrazinamide, isoniazid, aspirin (150 mg), and steroids followed by rifampicin, isoniazid, and pyrazinamide for 4 months. The second intervention arm includes all the drugs as per the first arm except aspirin and the patients in the control arm will receive treatment according to the National TB Elimination Program guidelines. All participants will be followed up for 1 year after the treatment. DISCUSSION: Current WHO regimens have agents with poor central nervous system drug exposure and is too long. It does not reflect the accumulating evidence in the field. We propose a comprehensive clinical trial incorporating the emerging evidence accrued over the last two decades to shorten the duration and improve the treatment outcomes. This multi-centric trial may generate crucial evidence with policy and practice implications in the treatment of TBM. TRIAL REGISTRATION Clinical Trial Registry India CTRI/2023/05/053314. Registered on 31 May 2023 ( https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=ODYzMzg=&Enc=&userName=CTRI/2023/05/053314 ). CLINICALTRIALS gov NCT05917340. Registered on 6 August 2023 ( https://classic. CLINICALTRIALS gov/ct2/show/NCT05917340 ). PROTOCOL VERSION Version 1.3 dated 12 July 2023.
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Affiliation(s)
- Leeberk Raja Inbaraj
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - C Ponnuraja
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Adhin Bhaskar
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Vignes Anand Srinivasalu
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Bella Devaleenal Daniel
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
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12
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Rebolledo‐Del Toro M, Carvajalino‐Galeano AB, Pinto‐Brito C, Muñoz‐Velandia OM, García‐Peña ÁA. Use of portable single-lead electrocardiogram device as an alternative for QTc monitoring in critically ill patients. Ann Noninvasive Electrocardiol 2024; 29:e13116. [PMID: 38627955 PMCID: PMC11021801 DOI: 10.1111/anec.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE Acquired QT prolongation is frequent and leads to a higher mortality rate in critically ill patients. KardiaMobile 1L® (KM1L) is a portable, user-friendly single lead, mobile alternative to conventional 12-lead electrocardiogram (12-L ECG) that could be more readily available, potentially facilitating more frequent QTc assessments in intensive care units (ICU); however, there is currently no evidence to validate this potential use. METHODS We conducted a prospective diagnostic test study comparing QT interval measurement using KM1L with conventional 12-L ECG ordered for any reason in patients admitted to an ICU. We compared the mean difference using a paired t-test, agreement using Bland-Altman analysis, and Lin's concordance coefficient, numerical precision (proportion of QT measurements with <10 ms difference between KM1L and conventional 12-L ECG), and clinical precision (concordance for adequate discrimination of prolonged QTc). RESULTS We included 114 patients (61.4% men, 60% cardiovascular etiology of hospitalization) with 131 12-L ECG traces. We found no statistical difference between corrected QT measurements (427 ms vs. 428 ms, p = .308). Lin's concordance coefficient was 0.848 (95% CI 0.801-0.894, p = .001). Clinical precision was excellent in males and substantial in females (Kappa 0.837 and 0.781, respectively). Numerical precision was lower in patients with vasoactive drugs (-13.99 ms), QT-prolonging drugs (13.84 ms), antiarrhythmic drugs (-12.87 ms), and a heart rate (HR) difference of ≥5 beats per minute (bpm) between devices (-11.26 ms). CONCLUSION Our study validates the clinical viability of KM1L, a single-lead mobile ECG device, for identifying prolonged QT intervals in ICU patients. Caution is warranted in patients with certain medical conditions that may affect numerical precision.
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Affiliation(s)
- Martin Rebolledo‐Del Toro
- Division of CardiologyHospital Universitario San IgnacioBogotaColombia
- Department of Internal MedicinePontificia Universidad JaverianaBogotaColombia
| | | | | | - Oscar Mauricio Muñoz‐Velandia
- Department of Internal MedicinePontificia Universidad JaverianaBogotaColombia
- Department of Internal MedicineHospital Universitario San IgnacioBogotaColombia
| | - Ángel Alberto García‐Peña
- Division of CardiologyHospital Universitario San IgnacioBogotaColombia
- Department of Internal MedicinePontificia Universidad JaverianaBogotaColombia
- Department of Internal MedicineHospital Universitario San IgnacioBogotaColombia
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13
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Ibrahim AOKZ, Prabhakar AP, Lopez-Candales A. QTc Interval: A Frequently Unrecognized Electrocardiographic Interval. Am J Med Sci 2024:S0002-9629(24)01212-6. [PMID: 38701971 DOI: 10.1016/j.amjms.2024.04.020] [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: 03/14/2023] [Revised: 02/19/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024]
Abstract
The QT interval, an electrocardiographic temporal representation of the ventricular depolarization and repolarization, is an integral parameter that must be carefully evaluated to gather critical information regarding electrical instability that may cause malignant ventricular dysrhythmias or sudden cardiac death. The QT interval is affected by several inheritable and acquired factors, such as genetic mutations, electrolyte disturbances, and medication interactions. We strongly believe that prompt and accurate recognition of any QT interval abnormalities is critical in many clinical settings. This concise review article highlights the importance of accurate measurement of the QT interval, enhances understanding of the most prevalent factors yielding abnormalities within the QT interval and the prognostic value of the QT interval, as well as provides several key practical reminders for healthcare professionals to strengthen our clinical practice.
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Affiliation(s)
- Ali Osama Kamal Zaki Ibrahim
- Department of Medicine, University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, Missouri
| | - Akruti Patel Prabhakar
- Department of Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Angel Lopez-Candales
- Cardiology Section, Department of Medicine at Wright State University Boonshoft School of Medicine, Dayton, Ohio.
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14
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Delinière A, Bessière F, Placide L, Pasquié JL, Haddad C, Tirel S, Mokhtar H, Morel E, Gardey K, Dulac A, Ditac G, Sacher F, Denjoy I, Chevalier P. Wearable electrocardiogram devices in patients with congenital long QT syndrome: The SMART-QT study. Arch Cardiovasc Dis 2024; 117:313-320. [PMID: 38704288 DOI: 10.1016/j.acvd.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND In patients with congenital long QT syndrome (LQTS), the risk of ventricular arrhythmia is correlated with the duration of the corrected QT interval and the changes in the ST-T wave pattern on the 12-lead surface electrocardiogram (12L-ECG). Remote monitoring of these variables could be useful. AIM To evaluate the abilities of two wearable electrocardiogram devices (Apple Watch and KardiaMobile 6L) to provide reliable electrocardiograms in terms of corrected QT interval and ST-T wave patterns in patients with LQTS. METHODS In a prospective multicentre study (ClinicalTrials.gov identifier: NCT04728100), a 12L-ECG, a 6-lead KardiaMobile 6L electrocardiogram and two single-lead Apple Watch electrocardiograms were recorded in patients with LQTS. The corrected QT interval and ST-T wave patterns were evaluated manually. RESULTS Overall, 98 patients with LQTS were included; 12.2% were children and 92.8% had a pathogenic variant in an LQTS gene. The main genotypes were LQTS type 1 (40.8%), LQTS type 2 (36.7%) and LQTS type 3 (7.1%); rarer genotypes were also represented. When comparing the ST-T wave patterns obtained with the 12L-ECG, the level of agreement was moderate with the Apple Watch (k=0.593) and substantial with the KardiaMobile 6L (k=0.651). Regarding the corrected QT interval, the correlation with 12L-ECG was strong for the Apple Watch (r=0.703 in lead II) and moderate for the KardiaMobile 6L (r=0.593). There was a slight overestimation of corrected QT interval with the Apple Watch and a subtle underestimation with the KardiaMobile 6L. CONCLUSIONS In patients with LQTS, the corrected QT interval and ST-T wave patterns obtained with the Apple Watch and the KardiaMobile 6L correlated with the 12L-ECG. Although wearable electrocardiogram devices cannot replace the 12L-ECG for the follow-up of these patients, they could be interesting additional monitoring tools.
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Affiliation(s)
- Antoine Delinière
- National Reference Centre for Inherited Arrhythmia of Lyon (CERA), Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Université Claude-Bernard Lyon-1, MeLiS, CNRS UMR 5284, INSERM U1314, Institut NeuroMyoGène, 69008 Lyon, France; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Francis Bessière
- Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Paediatric and Congenital Heart Disease Medico-Surgical Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Université Claude-Bernard Lyon-1, LabTau, Inserm, 69003 Lyon, France
| | - Leslie Placide
- Service de Cardiologie, Centre de Compétence des Troubles du Rythme Cardiaque d'Origine Héréditaire, Hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 34295 Montpellier, France
| | - Jean-Luc Pasquié
- Service de Cardiologie, Centre de Compétence des Troubles du Rythme Cardiaque d'Origine Héréditaire, Hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 34295 Montpellier, France; CNRS UMR9214, Inserm U1046, PHYMEDEXP, Université de Montpellier, 34295 Montpellier, France
| | - Christelle Haddad
- Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Solenn Tirel
- National Reference Centre for Inherited Arrhythmia of Lyon (CERA), Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Hajira Mokhtar
- National Reference Centre for Inherited Arrhythmia of Lyon (CERA), Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Elodie Morel
- National Reference Centre for Inherited Arrhythmia of Lyon (CERA), Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Kevin Gardey
- Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Arnaud Dulac
- Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Geoffroy Ditac
- Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France
| | - Frédéric Sacher
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); Institut LIRYC, Centre de référence des MAladies RYthmiques héréditaire (CMARY), Bordeaux University Hospital, 33000 Bordeaux, France; Université de Bordeaux, Inserm, CRCTB, U1045, 33000 Bordeaux, France
| | - Isabelle Denjoy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); Service de Cardiologie, Centre de Référence des Troubles du Rythme Cardiaque d'Origine Héréditaire, Hôpital Bichat-Claude-Bernard, AP-HP, 75018 Paris, France
| | - Philippe Chevalier
- National Reference Centre for Inherited Arrhythmia of Lyon (CERA), Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Electrophysiology Unit, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, 69500 Bron, France; Université Claude-Bernard Lyon-1, MeLiS, CNRS UMR 5284, INSERM U1314, Institut NeuroMyoGène, 69008 Lyon, France; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart).
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15
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Havig SM, Berg-Pedersen RM, Krabseth HM, Müller LD, Haugaa K, Zare HK, Gjesdal K, Krajci P, Opdal MS. Effect on QTc interval by switching from methadone to equipotent R-methadone dose in methadone maintenance treatment patients. Basic Clin Pharmacol Toxicol 2024; 134:519-530. [PMID: 38308508 DOI: 10.1111/bcpt.13982] [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: 10/10/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/04/2024]
Abstract
Methadone (R,S-methadone) can prolong the QT interval. R-methadone inhibits cardiac potassium channel function less than S-methadone. We tested if switching from methadone to R-methadone would reduce corrected QT (QTc) intervals in methadone maintenance treatment (MMT) patients. Nine patients, with automatically read QTc intervals ≥450 ms, were required to detect a 20 ms (clinically relevant) reduction in QTc intervals with 15 ms standard deviation (SD) and 90% power. Nine stabilized MMT patients, using median (range) 70 (40-120) mg methadone, were included. Data (ECG recordings, serum samples, and withdrawal symptoms) were collected both before drug intake (Cmin ) and at 3 h after drug intake (Cmax ), and were collected on the day before the switch from methadone to equipotent R-methadone dose and at 14 and 28 days after the switch. A cardiologist calculated QTc intervals retrospectively. Serum electrolytes and methadone concentrations were measured. Mean QTc intervals at Cmin were 472 ms and 422 ms on methadone (automatically and manually read) and 414 ms on R-methadone (manually read). Mean (SD) change in QTc intervals was -8 (10) ms (p = 0.047) at Cmin but non-significant at Cmax . R-methadone showed a concentration-dependent relationship with QTc intervals. Switching to R-methadone reduced QTc intervals, but far less than the 20 ms considered clinically relevant.
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Affiliation(s)
| | | | | | | | - Kristina Haugaa
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Knut Gjesdal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Krajci
- Department of Substance Use Disorder Treatment, Oslo University Hospital, Oslo, Norway
| | - Mimi Stokke Opdal
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Jiang R, Cheung CC, Garcia-Montero M, Davies B, Cao J, Redfearn D, Laksman ZM, Grondin S, Atallah J, Escudero CA, Cadrin-Tourigny J, Sanatani S, Steinberg C, Joza J, Avram R, Tadros R, Krahn AD. Deep Learning-Augmented ECG Analysis for Screening and Genotype Prediction of Congenital Long QT Syndrome. JAMA Cardiol 2024; 9:377-384. [PMID: 38446445 PMCID: PMC10918571 DOI: 10.1001/jamacardio.2024.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/07/2024] [Indexed: 03/07/2024]
Abstract
Importance Congenital long QT syndrome (LQTS) is associated with syncope, ventricular arrhythmias, and sudden death. Half of patients with LQTS have a normal or borderline-normal QT interval despite LQTS often being detected by QT prolongation on resting electrocardiography (ECG). Objective To develop a deep learning-based neural network for identification of LQTS and differentiation of genotypes (LQTS1 and LQTS2) using 12-lead ECG. Design, Setting, and Participants This diagnostic accuracy study used ECGs from patients with suspected inherited arrhythmia enrolled in the Hearts in Rhythm Organization Registry (HiRO) from August 2012 to December 2021. The internal dataset was derived at 2 sites and an external validation dataset at 4 sites within the HiRO Registry; an additional cross-sectional validation dataset was from the Montreal Heart Institute. The cohort with LQTS included probands and relatives with pathogenic or likely pathogenic variants in KCNQ1 or KCNH2 genes with normal or prolonged corrected QT (QTc) intervals. Exposures Convolutional neural network (CNN) discrimination between LQTS1, LQTS2, and negative genetic test results. Main Outcomes and Measures The main outcomes were area under the curve (AUC), F1 scores, and sensitivity for detecting LQTS and differentiating genotypes using a CNN method compared with QTc-based detection. Results A total of 4521 ECGs from 990 patients (mean [SD] age, 42 [18] years; 589 [59.5%] female) were analyzed. External validation within the national registry (101 patients) demonstrated the CNN's high diagnostic capacity for LQTS detection (AUC, 0.93; 95% CI, 0.89-0.96) and genotype differentiation (AUC, 0.91; 95% CI, 0.86-0.96). This surpassed expert-measured QTc intervals in detecting LQTS (F1 score, 0.84 [95% CI, 0.78-0.90] vs 0.22 [95% CI, 0.13-0.31]; sensitivity, 0.90 [95% CI, 0.86-0.94] vs 0.36 [95% CI, 0.23-0.47]), including in patients with normal or borderline QTc intervals (F1 score, 0.70 [95% CI, 0.40-1.00]; sensitivity, 0.78 [95% CI, 0.53-0.95]). In further validation in a cross-sectional cohort (406 patients) of high-risk patients and genotype-negative controls, the CNN detected LQTS with an AUC of 0.81 (95% CI, 0.80-0.85), which was better than QTc interval-based detection (AUC, 0.74; 95% CI, 0.69-0.78). Conclusions and Relevance The deep learning model improved detection of congenital LQTS from resting ECGs and allowed for differentiation between the 2 most common genetic subtypes. Broader validation over an unselected general population may support application of this model to patients with suspected LQTS.
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Affiliation(s)
- River Jiang
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Marta Garcia-Montero
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Brianna Davies
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Cao
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Damian Redfearn
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Zachary M. Laksman
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steffany Grondin
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Julia Cadrin-Tourigny
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Shubhayan Sanatani
- Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Christian Steinberg
- Institut Universitaire de Cardiologie et Pneumologie de Quebec, Laval University, Quebec City, Quebec, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Avram
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Rafik Tadros
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Andrew D. Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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17
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Asatryan B, Murray B, Gasperetti A, McClellan R, Barth AS. Unraveling Complexities in Genetically Elusive Long QT Syndrome. Circ Arrhythm Electrophysiol 2024; 17:e012356. [PMID: 38264885 DOI: 10.1161/circep.123.012356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Genetic testing has become standard of care for patients with long QT syndrome (LQTS), providing diagnostic, prognostic, and therapeutic information for both probands and their family members. However, up to a quarter of patients with LQTS do not have identifiable Mendelian pathogenic variants in the currently known LQTS-associated genes. This absence of genetic confirmation, intriguingly, does not lessen the severity of LQTS, with the prognosis in these gene-elusive patients with unequivocal LQTS mirroring genotype-positive patients in the limited data available. Such a conundrum instigates an exploration into the causes of corrected QT interval (QTc) prolongation in these cases, unveiling a broad spectrum of potential scenarios and mechanisms. These include multiple environmental influences on QTc prolongation, exercise-induced repolarization abnormalities, and the profound implications of the constantly evolving nature of genetic testing and variant interpretation. In addition, the rapid advances in genetics have the potential to uncover new causal genes, and polygenic risk factors may aid in the diagnosis of high-risk patients. Navigating this multifaceted landscape requires a systematic approach and expert knowledge, integrating the dynamic nature of genetics and patient-specific influences for accurate diagnosis, management, and counseling of patients. The role of a subspecialized expert cardiogenetic clinic is paramount in evaluation to navigate this complexity. Amid these intricate aspects, this review outlines potential causes of gene-elusive LQTS. It also provides an outline for the evaluation of patients with negative and inconclusive genetic test results and underscores the need for ongoing adaptation and reassessment in our understanding of LQTS, as the complexities of gene-elusive LQTS are increasingly deciphered.
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Affiliation(s)
- Babken Asatryan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alessio Gasperetti
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca McClellan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andreas S Barth
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Duman D, Tunca Sahin G, Stuart G, Walsh M, Caputo M, Parry A, Beattie B, Conner C, Uzun O. Influence of improved antenatal detection on the outcomes of complete atrioventricular block diagnosed in fetal-neonatal life and childhood periods - a single-centre experience in South Wales for 55 years. Cardiol Young 2024; 34:412-420. [PMID: 38149337 DOI: 10.1017/s1047951123003967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
OBJECTIVE This study aimed to analyse the influence of improved antenatal detection on the course, contemporary outcomes, and mortality risk factors of the complete atrioventricular block during fetal-neonatal and childhood periods in South Wales. METHODS The clinical characteristics and outcomes of complete atrioventricular block in patients without structural heart disease at the University Hospital of Wales from January 1966 to April 2021 were studied. Patients were divided into two groups according to their age at diagnosis: I-fetal-neonatal and II-childhood. Contemporary outcomes during the post-2001 era were compared with historical data preceding fetal service development and hence earlier detection. RESULTS There were 64 patients: 26 were identified in the fetal-neonatal period and the remaining 38 in the childhood period. Maternal antibodies/systemic lupus erythematosus disease (anti-Ro/Sjögren's-syndrome-related Antigen A and/or anti-La/Sjögren's-syndrome-related Antigen B) were present in 15 (57.7%) of the fetal-neonatal. Fetal/neonatal and early diagnosis increased after 2001 with an incidence of 1:25000 pregnancies. Pacemaker implantation was required in 34 patients, of whom 13 were diagnosed in the fetal-neonatal group. Survival rates in cases identified before 2001 were at 96.3% (26/27), whereas it was 83.8% (31/37) in patients diagnosed after 2001 (P > 0.05). Other mortality risk factors comprised a lower gestational week at birth, maternal antibodies, and an average ventricular heart rate of < 55 bpm. CONCLUSIONS Fetal diagnosis of complete atrioventricular block is still portends high fetal and neonatal mortality and morbidity despite significantly improved antenatal detection after 2001. Pacemaker intervention is needed earlier in the fetal-neonatal group. Whether routine antenatal medical treatment might alter this outcome calls for further prospective multicentre studies.
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Affiliation(s)
| | | | | | - Mark Walsh
- Bristol Royal Children's Hospital, Bristol, UK
| | | | | | | | | | - Orhan Uzun
- University Hospital of Wales, Cardiff, UK
- Cardiff University, School of Medicine, Cardiff, UK
- Swansea University, School of Engineering and Sport Sciences, Swansea, UK
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19
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Khorgami MR, Rezaei Y, Tabib A, Ghavidel AA, Omrani G, Mohebbi A, Peighambari MM, Emkanjoo Z, Oveisi M, Hajianfar G, Kazemborji B, Hosseini S, Samiei N. Prevalence of electrocardiographic abnormalities among Iranian children and adolescents and associations with blood pressure and obesity: findings from the SHED LIGHT study. Cardiol Young 2024:1-9. [PMID: 38234002 DOI: 10.1017/s1047951123004304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND There are few studies for detecting rhythm abnormalities among healthy children and adolescents. The aim of the study was to investigate the prevalence of abnormal electrocardiographic findings in the young Iranian population and its association with blood pressure and obesity. METHODS A total of 15084 children and adolescents were examined in a randomly selected population of Tehran city, Iran, between October 2017 and December 2018. Anthropometric values and blood pressure measurements were also assessed. A standard 12-lead electrocardiogram was recorded by a unique recorder, and those were examined by electrophysiologists. RESULTS All students mean age was 12.3 ± 3.1 years (6-18 years), and 52% were boys. A total of 2900 students (192.2/1000 persons; 95% confidence interval 186-198.6) had electrocardiographic abnormalities. The rate of electrocardiographic abnormalities was higher in boys than girls (p < 0.001). Electrocardiographic abnormalities were significantly higher in thin than obese students (p < 0.001), and there was a trend towards hypertensive individuals to have more electrocardiographic abnormalities compared to normotensive individuals (p = 0.063). Based on the multivariable analysis, individuals with electrocardiographic abnormalities were less likely to be girls (odds ratio 0.745, 95% confidence interval 0.682-0.814) and had a lower body mass index (odds ratio 0.961, 95% confidence interval 0.944-0.979). CONCLUSIONS In this large-scale study, there was a high prevalence of electrocardiographic abnormalities among young population. In addition, electrocardiographic findings were significantly influenced by increasing age, sex, obesity, and blood pressure levels. This community-based study revealed the implications of electrocardiographic screening to improve the care delivery by early detection.
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Affiliation(s)
- Mohammad Rafie Khorgami
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Avisa Tabib
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza A Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Omrani
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Mohebbi
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Peighambari
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Emkanjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular, Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Oveisi
- Faculty of Life Sciences & Medicine, Comprehensive Cancer Centre, School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Ghasem Hajianfar
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahareh Kazemborji
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Niloufar Samiei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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20
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Postema PG. Editorial commentary: Precision therapy in congenital Long QT syndrome: The future is today. Trends Cardiovasc Med 2024; 34:48-49. [PMID: 35788048 DOI: 10.1016/j.tcm.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Pieter G Postema
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, the Netherlands.
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21
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Liu H, Naser JA, Lin G, Lee SS. Cardiomyopathy in cirrhosis: From pathophysiology to clinical care. JHEP Rep 2024; 6:100911. [PMID: 38089549 PMCID: PMC10711481 DOI: 10.1016/j.jhepr.2023.100911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 01/12/2024] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as systolic or diastolic dysfunction in the absence of prior heart disease or another identifiable cause in patients with cirrhosis, in whom it is an important determinant of outcome. Its underlying pathogenic/pathophysiological mechanisms are rooted in two distinct pathways: 1) factors associated with portal hypertension, hyperdynamic circulation, gut bacterial/endotoxin translocation and the resultant inflammatory phenotype; 2) hepatocellular insufficiency with altered synthesis or metabolism of substances such as proteins, lipids, carbohydrates, bile acids and hormones. Different criteria have been proposed to diagnose CCM; the first in 2005 by the World Congress of Gastroenterology, and more recently in 2019 by the Cirrhotic Cardiomyopathy Consortium. These criteria mainly utilised echocardiographic evaluation, with the latter refining the evaluation of diastolic function and integrating global longitudinal strain into the evaluation of systolic function, an important addition since the haemodynamic changes that occur in advanced cirrhosis may lead to overestimation of systolic function by left ventricular ejection fraction. Advances in cardiac imaging, such as cardiac magnetic resonance imaging and the incorporation of an exercise challenge, may help further refine the diagnosis of CCM. Over recent years, CCM has been shown to contribute to increased mortality and morbidity after major interventions, such as liver transplantation and transjugular intrahepatic portosystemic shunt insertion, and to play a pathophysiologic role in the genesis of hepatorenal syndrome. In this review, we discuss the pathogenesis/pathophysiology of CCM, its clinical implications, and the role of cardiac imaging modalities including MRI. We also compare diagnostic criteria and review the potential diagnostic role of electrocardiographic QT prolongation. At present, no definitive medical therapy exists, but some promising potential treatment strategies for CCM are reviewed.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Jwan A. Naser
- Division of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Grace Lin
- Division of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Samuel S. Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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22
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Abrahams T, Davies B, Laksman Z, Sy RW, Postema PG, Wilde AAM, Krahn AD, Han HC. Provocation testing in congenital long QT syndrome: A practical guide. Heart Rhythm 2023; 20:1570-1582. [PMID: 37481219 DOI: 10.1016/j.hrthm.2023.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/01/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
Congenital long QT syndrome (LQTS) is a hereditary cardiac channelopathy with an estimated prevalence of 1 in 2500. A prolonged resting QT interval corrected for heart rate (QTc interval) remains a key diagnostic component; however, the QTc value may be normal in up to 40% of patients with genotype-positive LQTS and borderline in a further 30%. Provocation of QTc prolongation and T-wave changes may be pivotal to unmasking the diagnosis and useful in predicting genotype. LQTS provocation testing involves assessment of repolarization during and after exercise, in response to changes in heart rate or autonomic tone, with patients with LQTS exhibiting a maladaptive repolarization response. We review the utility and strengths and limitations of 4 forms of provocation testing-stand-up test, exercise stress test, epinephrine challenge, and mental stress test-in diagnosing LQTS and provide some practical guidance for performing provocation testing. Ultimately, exercise testing, when feasible, is the most useful form of provocation testing when considering diagnostic sensitivity and specificity.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia
| | - Brianna Davies
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hui-Chen Han
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia.
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23
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Ho K, Ganesh GK, Prasad S, Hoffmann TJ, Larsen A, Sandoval C, Berger S, Schell-Chaple H, Badilini F, Mackin LA, Pelter MM. Agreement of Computerized QT and QTc Interval Measurements Between Both Bedside and Expert Nurses Using Electronic Calipers. J Cardiovasc Nurs 2023:00005082-990000000-00138. [PMID: 37787695 DOI: 10.1097/jcn.0000000000001048] [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: 10/04/2023]
Abstract
BACKGROUND In hospitalized patients, QT/QTc (heart rate corrected) prolongation on the electrocardiogram (ECG) increases the risk of torsade de pointes. Manual measurements are time-consuming and often inaccurate. Some bedside monitors automatically and continuously measure QT/QTc; however, the agreement between computerized versus nurse-measured values has not been evaluated. OBJECTIVE The aim of this study was to examine the agreement between computerized QT/QTc and bedside and expert nurses who used electronic calipers. METHODS This was a prospective observational study in 3 intensive care units. Up to 2 QT/QTc measurements (milliseconds) per patient were collected. Bland-Altman test was used to analyze measurement agreement. RESULTS A total of 54 QT/QTc measurements from 34 patients admitted to the ICU were included. The mean difference (bias) for QT comparisons was as follows: computerized versus expert nurses, -11.04 ± 4.45 milliseconds (95% confidence interval [CI], -2.3 to -19.8; P = .016), and computerized versus bedside nurses, -13.72 ± 6.70 (95% CI, -0.70 to -26.8; P = .044). The mean bias for QTc comparisons was as follows: computerized versus expert nurses, -12.46 ± 5.80 (95% CI, -1.1 to -23.8; P = .035), and computerized versus bedside nurses, -18.49 ± 7.90 (95% CI, -3.0 to -33.9; P = .022). CONCLUSION Computerized QT/QTc measurements calculated by bedside monitor software and measurements performed by nurses were in close agreement; statistically significant differences were found, but differences were less than 20 milliseconds (on-half of a small box), indicating no clinical significance. Computerized measurements may be a suitable alternative to nurse-measured QT/QTc. This could reduce inaccuracies and nurse burden while increasing adherence to practice recommendations. Further research comparing computerized QT/QTc from bedside monitoring to standard 12-lead electrocardiogram in a larger sample, including non-ICU patients, is needed.
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24
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Davies RA, Ladouceur VB, Green MS, Joza J, Juurlink DN, Krahn AD, McMurtry MS, Roberts JD, Roston TM, Sanatani S, Steinberg C, MacIntyre C. The 2023 Canadian Cardiovascular Society Clinical Practice Update on Management of the Patient With a Prolonged QT Interval. Can J Cardiol 2023; 39:1285-1301. [PMID: 37827588 DOI: 10.1016/j.cjca.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 10/14/2023] Open
Abstract
A prolonged QT interval on the electrocardiogram is associated with an increased risk of the torsades de pointes form of ventricular arrhythmia resulting in syncope, sudden cardiac arrest or death, or misdiagnosis as a seizure disorder. The cause of QT prolongation can be congenital and inherited as an autosomal dominant variant, or it can be transient and acquired, often because of QT-prolonging drugs or electrolyte abnormalities. Automated measurement of the QT interval can be inaccurate, especially when the baseline electrocardiogram is abnormal, and manual verification is recommended. In this clinical practice update we provide practical tips about measurement of the QT interval, diagnosis, and management of congenital long QT syndrome and acquired prolongation of the QT interval. For congenital long QT syndrome, certain β-adrenergic-blocking drugs are highly effective, and implantable defibrillators are infrequently required. Many commonly prescribed drugs such as antidepressants and antibiotics can prolong the QT interval, and recommendations are provided on their safe use.
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Affiliation(s)
- Ross A Davies
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | | | - Martin S Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - David N Juurlink
- University of Toronto, ICES, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jason D Roberts
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Thomas M Roston
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shubhayan Sanatani
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christian Steinberg
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec, Québec, Canada
| | - Ciorsti MacIntyre
- Dalhousie University, Halifax, Nova Scotia, Canada; Mayo Clinic, Rochester, Minnesota, USA
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25
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Schäfer M, Mitchell MB, Brateng C, Ivy DD, Hunter KS, Nash DB, von Alvensleben JC. Extraction and Digitization of ECG Signals from Standard Clinical Portable Document Format Files for the Principal Component Analysis of T-wave Morphology. Cardiovasc Eng Technol 2023; 14:631-639. [PMID: 37491551 DOI: 10.1007/s13239-023-00673-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION T-wave analysis from standard electrocardiogram (ECG) remains one of the most available clinical and research methods for evaluating myocardial repolarization. T-wave morphology was recently evaluated to aid with diagnosis and characterization of diastolic dysfunction. Unfortunately, PDF stored ECG datasets limit additional numerical post-processing of ECG waveforms. In this study, we apply a simple custom process pipeline to extract and re-digitize T-wave signals and subject them to principal component analysis (PCA) to define primary T-wave shape variations. METHODS We propose simple pre-processing and digitization algorithms programmable as a MATLAB tool using standard thresholding functions without the need for advanced signal analysis. To validate digitized datasets, we compared clinically standard measurements in 20 different ECGs with the original ECG machine interpreted values as a gold standard. Afterwards, we analyzed 212 individual ECGs for T-wave shape analysis using PCA. RESULTS The re-digitized signal was shown to preserve the original information as evidenced by excellent agreement between original - machine interpreted and re-digitized clinical variables including heart rate: bias ~ 1 bpm (95% CI: -1.0 to 3.5), QT interval: bias ~ 0.000 ms (95% CI: -0.012 to 0.012), PR interval: bias = -0.015 ms (95% CI: -0.015 to 0.003), and QRS duration: bias = -0.001 ms (95% CI: -0.007 to 0.006). PCA revealed that the first principal component universally modulates the T-wave height or amount of repolarization voltage regardless of the investigated ECG lead. The second and third principal components described variation in the T-wave peak onset and the T-wave peak morphology, respectively. CONCLUSION This study presents a straightforward method for re-digitizing ECGs stored in the PDF format utilized in many academic electronic medical record systems. This process can yield re-digitized lead specific signals which can be retrospectively analyzed using advanced custom post-processing numerical analysis independent of commercially available platforms.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, 13123 E 16th Ave, Anschutz Medical Campus, Aurora, CO, 80045-2560, USA.
| | - Max B Mitchell
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Caitlin Brateng
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, 13123 E 16th Ave, Anschutz Medical Campus, Aurora, CO, 80045-2560, USA
- Division of Cardiology, Section of Electrophysiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, 13123 E 16th Ave, Anschutz Medical Campus, Aurora, CO, 80045-2560, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Dustin B Nash
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, 13123 E 16th Ave, Anschutz Medical Campus, Aurora, CO, 80045-2560, USA
- Division of Cardiology, Section of Electrophysiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Johannes C von Alvensleben
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, 13123 E 16th Ave, Anschutz Medical Campus, Aurora, CO, 80045-2560, USA
- Division of Cardiology, Section of Electrophysiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Section of Adult Congenital Heart Disease, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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Ke Z, Li C, Bai G, Tan L, Wang J, Zhou M, Zhou J, Chen SY, Dong X. KCNH2 mutation c.3099_3112del causes congenital long QT syndrome type 2 with gender differences. Clinics (Sao Paulo) 2023; 78:100285. [PMID: 37783170 PMCID: PMC10562146 DOI: 10.1016/j.clinsp.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Long QT Syndrome (LQTS) is an inherited disease with an abnormal electrical conduction system in the heart that can cause sudden death as a result of QT prolongation. LQT2 is the second most common subtype of LQTS caused by loss of function mutations in the potassium voltage-gated channel subfamily H member 2 (KCNH2) gene. Although more than 900 mutations are associated with the LQTS, many of these mutations are not validated or characterized. METHODS AND RESULTS Sequencing analyses of genomic DNA of a family with LQT2 identified a putative mutation. i.e., KCNH2(NM_000238.3): c.3099_3112del, in KCNH2 gene which appeared to be a definite pathogenic mutation. The family pedigree information showed a gender difference in clinical features and T-wave morphology between male and female patients. The female with mutation exhibited recurring ventricular arrhythmia and syncope, while two male carriers did not show any symptoms. In addition, T-wave in females was much flatter than in males. The female proband showed a positive reaction to the lidocaine test. Lidocaine injection almost completely blocked ventricular arrhythmia and shortened the QT interval by ≥30 ms. Treatment with propranolol, mexiletine, and implantation of cardioverter-defibrillators prevented the sustained ventricular tachycardia, ventricular fibrillation, and syncope, as assessed by a 3-year follow-up evaluation. CONCLUSIONS A putative mutation c.3099_3112del in the KCNH2 gene causes LQT2 syndrome, and the pathogenic mutation mainly causes symptoms in female progeny.
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Affiliation(s)
- ZunPing Ke
- School of Public Health, Hubei University of Medicine, China
| | - Chao Li
- Children's Medical Center, Taihe Hospital, Hubei University of Medicine, China
| | - Gang Bai
- Department of Ultrasonics, Taihe Hospital, Hubei University of Medicine, China
| | - Li Tan
- Cardiovascular Center, Taihe Hospital, Hubei University of Medicine, China
| | - JunFeng Wang
- Cardiovascular Center, Taihe Hospital, Hubei University of Medicine, China
| | - Ming Zhou
- Cardiovascular Center, Taihe Hospital, Hubei University of Medicine, China
| | - JianHua Zhou
- Cardiovascular Center, Taihe Hospital, Hubei University of Medicine, China
| | - Shi-You Chen
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Xiao Dong
- Cardiovascular Center, Taihe Hospital, Hubei University of Medicine, China; Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
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Mahendran S, Gupta I, Davis J, Davis AJ, Orchard JW, Orchard JJ. Comparison of methods for correcting QT interval in athletes and young people: A systematic review. Clin Cardiol 2023; 46:1106-1115. [PMID: 37470093 PMCID: PMC10540007 DOI: 10.1002/clc.24093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/18/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023] Open
Abstract
Screening elite athletes for conditions associated with sudden cardiac death is recommended by numerous international guidelines. Current athlete electrocardiogram interpretation criteria recommend the Bazett formula (QTcB) for correcting QT interval. However, other formulae may perform better at lower and higher heart rates (HR). This review aimed to examine the literature on various QT correction methods in athletes and young people aged 14-35 years and determine the most accurate method of calculating QTc in this population. A systematic review of MEDLINE, EMBASE, Scopus, and SportDiscus was performed. Papers comparing at least two different methods of QT interval correction in athletes or young people were included. Quality and risk of bias were assessed using a standardized tool. The search strategy identified 545 papers, of which 10 met the criteria and were included. Nine of these studies concluded that QTcB was least reliable for removing the effect of HR and was inaccurate at both high (>90 beats per min [BPM]) and low (<60 BPM) HRs. No studies supported the use of QTcB in athletes and young people. Alternative QT correction algorithms such as Fridericia (QTcF) produce more accurate correction of QT interval at HRs seen in athletes and young people. QTcB is less accurate at lower and higher HRs. QTcF has been shown to be more accurate in these HR ranges and may be preferred to QTcB for QTc calculation in athletes and young people. However, accurate QTc reference values for discrete HRs using alternative algorithms are not well established and require further research.
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Affiliation(s)
- Shehane Mahendran
- Sydney School of Public HealthThe University of SydneySydneyAustralia
| | - Ishita Gupta
- Sydney School of Public HealthThe University of SydneySydneyAustralia
| | - Jason Davis
- Sydney School of Public HealthThe University of SydneySydneyAustralia
- Royal Brisbane and Women's HospitalBrisbaneAustralia
- School of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Angus J. Davis
- Sydney School of Public HealthThe University of SydneySydneyAustralia
| | - John W. Orchard
- Sydney School of Public HealthThe University of SydneySydneyAustralia
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28
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Neumann B, Vink AS, Hermans BJM, Lieve KVV, Cömert D, Beckmann BM, Clur SAB, Blom NA, Delhaas T, Wilde AAM, Kääb S, Postema PG, Sinner MF. Manual vs. automatic assessment of the QT-interval and corrected QT. Europace 2023; 25:euad213. [PMID: 37470430 PMCID: PMC10469369 DOI: 10.1093/europace/euad213] [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: 04/10/2023] [Revised: 05/29/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
AIMS Sudden cardiac death (SCD) is challenging to predict. Electrocardiogram (ECG)-derived heart rate-corrected QT-interval (QTc) is used for SCD-risk assessment. QTc is preferably determined manually, but vendor-provided automatic results from ECG recorders are convenient. Agreement between manual and automatic assessments is unclear for populations with aberrant QTc. We aimed to systematically assess pairwise agreement of automatic and manual QT-intervals and QTc. METHODS AND RESULTS A multi-centre cohort enriching aberrant QTc comprised ECGs of healthy controls and long-QT syndrome (LQTS) patients. Manual QT-intervals and QTc were determined by the tangent and threshold methods and compared to automatically generated, vendor-provided values. We assessed agreement globally by intra-class correlation coefficients and pairwise by Bland-Altman analyses and 95% limits of agreement (LoA). Further, manual results were compared to a novel automatic QT-interval algorithm. ECGs of 1263 participants (720 LQTS patients; 543 controls) were available [median age 34 (inter-quartile range 35) years, 55% women]. Comparing cohort means, automatic and manual QT-intervals and QTc were similar. However, pairwise Bland-Altman-based agreement was highly discrepant. For QT-interval, LoAs spanned 95 (tangent) and 92 ms (threshold), respectively. For QTc, the spread was 108 and 105 ms, respectively. LQTS patients exhibited more pronounced differences. For automatic QTc results from 440-540 ms (tangent) and 430-530 ms (threshold), misassessment risk was highest. Novel automatic QT-interval algorithms may narrow this range. CONCLUSION Pairwise vendor-provided automatic and manual QT-interval and QTc results can be highly discrepant. Novel automatic algorithms may improve agreement. Within the above ranges, automatic QT-interval and QTc results require manual confirmation, particularly if T-wave morphology is challenging.
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Affiliation(s)
- Benjamin Neumann
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - A Suzanne Vink
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ben J M Hermans
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Krystien V V Lieve
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Didem Cömert
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Britt-Maria Beckmann
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Legal Medicine, Goethe Univeristy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sally-Ann B Clur
- Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Princess Al-Jawhara Al-Brahim Center of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Stefan Kääb
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Moritz F Sinner
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
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29
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Vink AS, Hermans BJM, Hooglugt JLQ, Peltenburg PJ, Meijborg VMF, Hofman N, Clur SAB, Blom NA, Delhaas T, Wilde AAM, Postema PG. Diagnostic Accuracy of the Standing Test in Adults Suspected for Congenital Long-QT Syndrome. J Am Heart Assoc 2023:e026419. [PMID: 37421262 PMCID: PMC10382089 DOI: 10.1161/jaha.122.026419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/08/2023] [Indexed: 07/10/2023]
Abstract
Background An elegant bedside provocation test has been shown to aid the diagnosis of long-QT syndrome (LQTS) in a retrospective cohort by evaluation of QT intervals and T-wave morphology changes resulting from the brief tachycardia provoked by standing. We aimed to prospectively determine the potential diagnostic value of the standing test for LQTS. Methods and Results In adults suspected for LQTS who had a standing test, the QT interval was assessed manually and automated. In addition, T-wave morphology changes were determined. A total of 167 controls and 131 genetically confirmed patients with LQTS were included. A prolonged heart rate-corrected QT interval (QTc) (men ≥430 ms, women ≥450 ms) at baseline before standing yielded a sensitivity of 61% (95% CI, 47-74) in men and 54% (95% CI, 42-66) in women, with a specificity of 90% (95% CI, 80-96) and 89% (95% CI, 81-95), respectively. In both men and women, QTc≥460 ms after standing increased sensitivity (89% [95% CI, 83-94]) but decreased specificity (49% [95% CI, 41-57]). Sensitivity further increased (P<0.01) when a prolonged baseline QTc was accompanied by a QTc≥460 ms after standing in both men (93% [95% CI, 84-98]) and women (90% [95% CI, 81-96]). However, the area under the curve did not improve. T-wave abnormalities after standing did not further increase the sensitivity or the area under the curve significantly. Conclusions Despite earlier retrospective studies, a baseline ECG and the standing test in a prospective evaluation displayed a different diagnostic profile for congenital LQTS but no unequivocal synergism or advantage. This suggests that there is markedly reduced penetrance and incomplete expression in genetically confirmed LQTS with retention of repolarization reserve in response to the brief tachycardia provoked by standing.
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Affiliation(s)
- Arja S Vink
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
- Department of Pediatric Cardiology Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam The Netherlands
| | - Ben J M Hermans
- Department of Biomedical Engineering Maastricht University Maastricht The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Maastricht The Netherlands
| | - Jean-Luc Q Hooglugt
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
- Department of Pediatric Cardiology Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam The Netherlands
| | - Puck J Peltenburg
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
- Department of Pediatric Cardiology Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam The Netherlands
| | - Veronique M F Meijborg
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
| | - Nynke Hofman
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
| | - Sally-Ann B Clur
- Department of Pediatric Cardiology Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam The Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam The Netherlands
- Department of Pediatric Cardiology Leiden University Medical Center Leiden The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering Maastricht University Maastricht The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Maastricht The Netherlands
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
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Zaballos M, Fernández I, Rodríguez L, Orozco S, García A, Juncos M, Alvarez-Zaballos S, Piñeiro P, Hortal J. Feasibility of using KardiaMobile-L6 for QT interval monitoring during the early phase of the COVID-19 pandemic in critical care patients. Sci Rep 2023; 13:10985. [PMID: 37415069 PMCID: PMC10326027 DOI: 10.1038/s41598-023-37688-8] [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: 12/25/2022] [Accepted: 06/26/2023] [Indexed: 07/08/2023] Open
Abstract
The electrocardiogram (ECG) represents an essential tool to determine cardiac electrical abnormalities in COVID-19 patients, the effects of anti-SARS-CoV-2 drugs, and potential drug interactions. Smartphone-based heart monitors have increased the spectrum of ECG monitoring however, we are not aware of its reliability in critically ill COVID-19 patients. We aim to evaluate the feasibility and reliability of nurse-performed smartphone electrocardiography for QT interval monitoring in critically ill COVID-19 patients using KardiaMobile-6L compared with the standard 12-lead ECG. An observational comparative study was conducted comparing consecutive KardiaMobile-6L and 12-lead ECG recordings obtained from 20 patients admitted to the intensive care unit with SARS-CoV-2 infection and on invasive mechanical ventilation. The heart rate-corrected QT (QTc) intervals measured by KardiaMobile-6L and 12-lead ECG were compared. In 60 percent of the recordings, QTc intervals measured by KardiaMobile-6L matched those by 12-lead ECG. The QTc intervals measured by KardiaMobile-6 and 12-lead ECG were 428 ± 45 ms and 425 ± 35 ms (p = 0.82), respectively. The former demonstrated good agreement (bias = 2.9 ms; standard deviation of bias = 29.6 ms) with the latter, using the Bland-Altman method of measurement agreement. In all but one recording, KardiaMobile-6L demonstrated QTc prolongation. QTc interval monitoring with KardiaMobile-6L in critically ill COVID-19 patients was feasible and demonstrated reliability comparable to the standard 12-lead ECG.
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Affiliation(s)
- Matilde Zaballos
- Department of Forensic Medicine, Psychiatry and Pathology, Complutense University, C/ Dr Esquerdo nº46, 28007, Madrid, Spain.
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ignacio Fernández
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Rodríguez
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Silvia Orozco
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Amparo García
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mónica Juncos
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sara Alvarez-Zaballos
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Piñeiro
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Hortal
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Pharmacology, Complutense University, Madrid, Spain
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Wu MJ, Wang WQ, Zhang W, Li JH, Zhang XW. The diagnostic value of electrocardiogram-based machine learning in long QT syndrome: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1172451. [PMID: 37351282 PMCID: PMC10282180 DOI: 10.3389/fcvm.2023.1172451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Introduction To perform a meta-analysis to discover the performance of ML algorithms in identifying Congenital long QT syndrome (LQTS). Methods The searched databases included Cochrane, EMBASE, Web of Science, and PubMed. Our study considered all English-language studies that reported the detection of LQTS using ML algorithms. Quality was assessed using QUADAS-2 and QUADAS-AI tools. The bivariate mixed effects models were used in our study. Based on genotype data for LQTS, we performed a subgroup analysis. Results Out of 536 studies, 8 met all inclusion criteria. The pooled area under the receiving operating curve (SAUROC) for detecting LQTS was 0.95 (95% CI: 0.31-1.00); sensitivity was 0.87 (95% CI: 0.83-0.90), and specificity was 0.91 (95% CI: 0.88-0.93). Additionally, diagnostic odd ratio (DOR) was 65 (95% CI: 39-109). The positive likelihood ratio (PLR) was 9.3 (95% CI: 7.0-12.3) and the negative likelihood ratio (NLR) was 0.14 (95% CI: 0.11-0.20), with very low heterogeneity (I2 = 16%). Discussion We found that machine learning can be used to detect features of rare cardiovascular disease like LQTS, thus increasing our understanding of intelligent interpretation of ECG. To improve ML performance in the classification of LQTS subtypes, further research is required. Systematic Review Registration identifier PROSPERO CRD42022360122.
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Affiliation(s)
- Min-Juan Wu
- School of Nursing, Hangzhou Medical College, Hangzhou, China
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Wen-Qin Wang
- School of Nursing, Hangzhou Normal University, Hangzhou, China
| | - Wei Zhang
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Jun-Hua Li
- School of Nursing, Hangzhou Normal University, Hangzhou, China
| | - Xing-Wei Zhang
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
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32
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Aweimer A, Mügge A, Akin I, El-Battrawy I. [Asymptomatic channelopathies : Risk stratification and primary prophylaxis]. Herzschrittmacherther Elektrophysiol 2023; 34:101-108. [PMID: 37103573 DOI: 10.1007/s00399-023-00937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 04/28/2023]
Abstract
In general, asymptomatic patients with channelopathies are at increased risk of sudden cardiac death (SCD), due to pathogenic variants in genes encoding ion channels that result in pathological ion currents. Channelopathies include long-QT syndrome (LQTS), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and short-QT syndrome (SQTS). In addition to the patient's clinical presentation, history and clinical tests, the main diagnostic tools are electrocardiography and genetic testing to identify known gene mutations. Early and correct diagnosis as well as further risk stratification of affected individuals and their relatives are paramount for prognosis. The recent availability of risk score calculators for LQTS and BrS allows SCD risk to be accurately estimated. The extent to which these improve patient selection for treatment with an implantable cardioverter-defibrillator (ICD) system is currently unknown. In most cases, initiation of basic therapy in asymptomatic patients in the form of avoidance of triggers, which are usually medication or stressful situations, is sufficient and contributes to risk reduction. In addition, there are other risk-reducing prophylactic measures, such as permanent medication with nonselective β‑ blockers (for LQTS and CPVT) or mexiletine for LQTS3. Patients and their family members should be referred to specialized outpatient clinics for individual risk stratification in the sense of primary prophylaxis.
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Affiliation(s)
- Assem Aweimer
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland.
| | - Andreas Mügge
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Ibrahim El-Battrawy
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
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Díez-Escuté N, Arbelo E, Martínez-Barrios E, Cerralbo P, Cesar S, Cruzalegui J, Chipa F, Fiol V, Zschaeck I, Hernández C, Campuzano O, Sarquella-Brugada G. Sex differences in long QT syndrome. Front Cardiovasc Med 2023; 10:1164028. [PMID: 37082456 PMCID: PMC10110834 DOI: 10.3389/fcvm.2023.1164028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Abstract
Long QT Syndrome (LQTS) is a rare, inherited channelopathy characterized by cardiac repolarization dysfunction, leading to a prolonged rate-corrected QT interval in patients who are at risk for malignant ventricular tachyarrhythmias, syncope, and even sudden cardiac death. A complex genetic origin, variable expressivity as well as incomplete penetrance make the diagnosis a clinical challenge. In the last 10 years, there has been a continuous improvement in diagnostic and personalized treatment options. Therefore, several factors such as sex, age diagnosis, QTc interval, and genetic background may contribute to risk stratification of patients, but it still currently remains as a main challenge in LQTS. It is widely accepted that sex is a risk factor itself for some arrhythmias. Female sex has been suggested as a risk factor in the development of malignant arrhythmias associated with LQTS. The existing differences between the sexes are only manifested after puberty, being the hormones the main inducers of arrhythmias. Despite the increased risk in females, no more than 10% of the available publications on LQTS include sex-related data concerning the risk of malignant arrhythmias in females. Therein, the relevance of our review data update concerning women and LQTS.
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Affiliation(s)
- Nuria Díez-Escuté
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- IDIBAPS, Institut d’Investigació August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart, Amsterdam, Netherlands
| | - Estefanía Martínez-Barrios
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Patricia Cerralbo
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Sergi Cesar
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - José Cruzalegui
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Freddy Chipa
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Victoria Fiol
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Irene Zschaeck
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Clara Hernández
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Oscar Campuzano
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Medical Science Department, School of Medicine, University of Girona, Girona, Spain
- Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain
- Correspondence: Oscar Campuzano Georgia Sarquella-Brugada
| | - Georgia Sarquella-Brugada
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart, Amsterdam, Netherlands
- Medical Science Department, School of Medicine, University of Girona, Girona, Spain
- Correspondence: Oscar Campuzano Georgia Sarquella-Brugada
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Cui S, Hayashi K, Kobayashi I, Hosomichi K, Nomura A, Teramoto R, Usuda K, Okada H, Deng Y, Kobayashi-Sun J, Nishikawa T, Furusho H, Saito T, Hirase H, Ohta K, Fujimoto M, Horita Y, Kusayama T, Tsuda T, Tada H, Kato T, Usui S, Sakata K, Fujino N, Tajima A, Yamagishi M, Takamura M. The utility of zebrafish cardiac arrhythmia model to predict the pathogenicity of KCNQ1 variants. J Mol Cell Cardiol 2023; 177:50-61. [PMID: 36898499 DOI: 10.1016/j.yjmcc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
Genetic testing for inherited arrhythmias and discriminating pathogenic or benign variants from variants of unknown significance (VUS) is essential for gene-based medicine. KCNQ1 is a causative gene of type 1 long QT syndrome (LQTS), and approximately 30% of the variants found in type 1 LQTS are classified as VUS. We studied the role of zebrafish cardiac arrhythmia model in determining the clinical significance of KCNQ1 variants. We generated homozygous kcnq1 deletion zebrafish (kcnq1del/del) using the CRISPR/Cas9 and expressed human Kv7.1/MinK channels in kcnq1del/del embryos. We dissected the hearts from the thorax at 48 h post-fertilization and measured the transmembrane potential of the ventricle in the zebrafish heart. Action potential duration was calculated as the time interval between peak maximum upstroke velocity and 90% repolarization (APD90). The APD90 of kcnq1del/del embryos was 280 ± 47 ms, which was significantly shortened by injecting KCNQ1 wild-type (WT) cRNA and KCNE1 cRNA (168 ± 26 ms, P < 0.01 vs. kcnq1del/del). A study of two pathogenic variants (S277L and T587M) and one VUS (R451Q) associated with clinically definite LQTS showed that the APD90 of kcnq1del/del embryos with these mutant Kv7.1/MinK channels was significantly longer than that of Kv7.1 WT/MinK channels. Given the functional results of the zebrafish model, R451Q could be reevaluated physiologically from VUS to likely pathogenic. In conclusion, functional analysis using in vivo zebrafish cardiac arrhythmia model can be useful for determining the pathogenicity of loss-of-function variants in patients with LQTS.
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Affiliation(s)
- Shihe Cui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan; School of Health Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan.
| | - Isao Kobayashi
- Faculty of Biological Science and Technology, Institute of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Kazuyoshi Hosomichi
- Laboratory of Computational Genomics, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Akihiro Nomura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Ryota Teramoto
- Laboratory for Comprehensive Genomic Analysis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Keisuke Usuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hirofumi Okada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yaowen Deng
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Jingjing Kobayashi-Sun
- Faculty of Biological Science and Technology, Institute of Science and Engineering, Kanazawa University, Kanazawa, Japan; Department of Clinical Engineering, Faculty of Health Sciences, Komatsu University, Komatsu, Japan
| | - Tetsuo Nishikawa
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroshi Furusho
- Department of Cardiology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Takekatsu Saito
- Department of Pediatrics, Minamigaoka Hospital, Kanazawa, Japan
| | - Hiroaki Hirase
- Department of Cardiology, Takaoka Minami Heart Center, Takaoka, Japan
| | - Kunio Ohta
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan; Medical Education Research Center, Graduate School of Medical Sciences, Kanazawa University, Japan
| | - Manabu Fujimoto
- Department of Cardiology, Kouseiren Takaoka Hospital, Takaoka, Japan
| | - Yuki Horita
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Takashi Kusayama
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takeshi Kato
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Noboru Fujino
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan; School of Health Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Atsushi Tajima
- Department of Bioinformatics and Genomics, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | | | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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Phenotypes of Overdiagnosed Long QT Syndrome. J Am Coll Cardiol 2023; 81:477-486. [PMID: 36725176 DOI: 10.1016/j.jacc.2022.11.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/18/2022] [Accepted: 11/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long QT syndrome (LQTS) predisposes individuals to arrhythmic syncope or seizure, sudden cardiac arrest, or sudden cardiac death (SCD). Increased physician and public awareness of LQTS-associated warning signs and an increase in electrocardiographic screening programs may contribute to overdiagnosis of LQTS. OBJECTIVES This study sought to identify the diagnostic miscues underlying the continued overdiagnosis of LQTS. METHODS Electronic medical records were reviewed for patients who arrived with an outside diagnosis of LQTS but were dismissed as having normal findings subsequently. Data were abstracted for details on referral, clinical history, and both cardiologic and genetic test results. RESULTS Overall, 290 of 1,841 (16%) patients with original diagnosis of LQTS (174 [60%] female; mean age at first Mayo Clinic evaluation, 22 ± 14 years; mean QTc interval, 427 ± 25 milliseconds) were dismissed as having normal findings. The main cause of LQTS misdiagnosis or overdiagnosis was a prolonged QTc interval secondary to vasovagal syncope (n = 87; 30%), followed by a seemingly positive genetic test result for a variant in 1 of the main LQTS genes (n = 68; 23%) that was ultimately deemed not to be of clinical significance. Furthermore, patients received misdiagnoses because of a positive family history of SCD that was deemed unrelated to LQTS (n = 46; 16%), isolated/transient QT prolongation (n = 44; 15%), or misinterpretation of the QTc interval as a result of inclusion of the U-wave (n = 40, 14%). CONCLUSIONS Knowing the 5 main determinants of discordance between a previously rendered diagnosis of LQTS and full diagnostic reversal or removal (vasovagal syncope, "pseudo"-positive genetic test result in LQTS-causative genes, family history of SCD, transient QT prolongation, and misinterpretation of the QTc interval) increases awareness and provides critical guidance to reduce this burden of overdiagnosed LQTS.
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Janzen ML, Davies B, Laksman ZW, Roberts JD, Sanatani S, Steinberg C, Tadros R, Cadrin-Tourigny J, MacIntyre C, Atallah J, Fournier A, Green MS, Hamilton R, Khan HR, Kimber S, White S, Joza J, Makanjee B, Ilhan E, Lee D, Hansom S, Hadjis A, Arbour L, Leather R, Seifer C, Angaran P, Simpson CS, Healey JS, Gardner M, Talajic M, Krahn AD. Management of Inherited Arrhythmia Syndromes: a HiRO Consensus Handbook on Process of Care. CJC Open 2023; 5:268-284. [PMID: 37124966 PMCID: PMC10140751 DOI: 10.1016/j.cjco.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/14/2023] [Indexed: 02/27/2023] Open
Abstract
Inherited arrhythmia syndromes are rare genetic conditions that predispose seemingly healthy individuals to sudden cardiac arrest and death. The Hearts in Rhythm Organization is a multidisciplinary Canadian network of clinicians, researchers, patients, and families that aims to improve care for patients and families with inherited cardiac conditions, focused on those that confer predisposition to arrhythmia and sudden cardiac arrest and/or death. The field is rapidly evolving as research discoveries increase. A streamlined, practical guide for providers to diagnose and follow pediatric and adult patients with inherited cardiac conditions represents a useful tool to improve health system utilization, clinical management, and research related to these conditions. This review provides consensus care pathways for 7 conditions, including the 4 most common inherited cardiac conditions that confer predisposition to arrhythmia, with scenarios to guide investigation, diagnosis, risk stratification, and management. These conditions include Brugada syndrome, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy and related arrhythmogenic cardiomyopathies, and catecholaminergic polymorphic ventricular tachycardia. In addition, an approach to investigating and managing sudden cardiac arrest, sudden unexpected death, and first-degree family members of affected individuals is provided. Referral to specialized cardiogenetic clinics should be considered in most cases. The intention of this review is to offer a framework for the process of care that is useful for both experts and nonexperts, and related allied disciplines such as hospital management, diagnostic services, coroners, and pathologists, in order to provide high-quality, multidisciplinary, standardized care.
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Hasegawa K, Fukuoka Y, Ohno S, Horie M, Tada H. Computerized misinterpretation of
QT
interval in 12‐lead electrocardiogram and its clinical consequences: A case of recurrent syncope. J Arrhythm 2023; 39:227-230. [PMID: 37021023 PMCID: PMC10068927 DOI: 10.1002/joa3.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 02/01/2023] Open
Abstract
Don't blindly accept the automated assessment of electrocardiogram. It is important to raise long QT syndrome to the differential diagnosis of repeated syncope.
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Affiliation(s)
- Kanae Hasegawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences University of Fukui Fukui Japan
| | - Yoshitomo Fukuoka
- Department of Cardiovascular Medicine, Faculty of Medical Sciences University of Fukui Fukui Japan
| | - Seiko Ohno
- Department of Bioscience and Genetics National Cerebral and Cardiovascular Center, Suita Osaka Japan
| | - Minoru Horie
- Department of Cardiovascular Medicine Shiga University of Medical Science Otsu Shiga Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences University of Fukui Fukui Japan
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38
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Asatryan B, Barth AS. Sex-related differences in incidence, phenotype and risk of sudden cardiac death in inherited arrhythmia syndromes. Front Cardiovasc Med 2023; 9:1010748. [PMID: 36684594 PMCID: PMC9845907 DOI: 10.3389/fcvm.2022.1010748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Inherited Arrhythmia Syndromes (IAS) including long QT and Brugada Syndrome, are characterized by life-threatening arrhythmias in the absence of apparent structural heart disease and are caused by pathogenic variants in genes encoding cardiac ion channels or associated proteins. Studies of large pedigrees of families affected by IAS have demonstrated incomplete penetrance and variable expressivity. Biological sex is one of several factors that have been recognized to modulate disease severity in IAS. There is a growing body of evidence linking sex hormones to the susceptibility to arrhythmias, yet, many sex-specific disease aspects remain underrecognized as female sex and women with IAS are underinvestigated and findings from male-predominant cohorts are often generalized to both sexes with minimal to no consideration of relevant sex-associated differences in prevalence, disease manifestations and outcome. In this review, we highlight current knowledge of sex-related biological differences in normal cardiac electrophysiology and sex-associated factors that influence IAS phenotypes.
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Affiliation(s)
- Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas S. Barth
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Andreas S. Barth ✉
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39
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Viskin S. Long QT begets long QT. J Cardiovasc Electrophysiol 2023; 34:177-179. [PMID: 36335630 DOI: 10.1111/jce.15736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Sami Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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40
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Neira V, Enriquez A, Sheldon R, Hanson MG, Maxey C, Baranchuk A. Impact of bundle branch block morphology on outcomes of patients with syncope and bifascicular block: A SPRITELY (POST 3) substudy. Heart Rhythm 2023; 20:31-36. [PMID: 36184061 DOI: 10.1016/j.hrthm.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Permanent pacing is often considered for patients with syncope and bifascicular block. OBJECTIVE The purpose of this study was to determine whether QRS morphology or other electrocardiographic characteristics can identify patients who may benefit from permanent pacing. METHODS The Syncope: Pacing or Recording in the Later Years (SPRITELY) trial was a multicenter trial that randomized patients with bifascicular block and syncope (n = 115) to empiric pacemaker implantation vs implantable loop recorder (ILR) monitoring. In this SPRITELY subanalysis, baseline 12-lead electrocardiograms were evaluated for bundle branch block (BBB) morphology, QRS width, and PR and QT intervals and their impact on clinical outcomes was assessed. RESULTS There were 41 patients with left BBB (36%), 69 patients with right bundle branch block (RBBB) and left anterior fascicular block (60%), and 5 patients with RBBB and left posterior fascicular block (4%). Pacemaker implant compared with ILR was associated with a significant reduction of major study-related events (MSREs) in both patients with left BBB (23.8% vs 78.9%; P = .001) and those with RBBB (27% vs 72.9%; P < .0001). Similarly, a reduction of MSREs was observed in both patients with trifascicular block (23% vs 84.6%; P < .0001) and those with bifascicular block (26.6% vs 68.9%; P = .002). In the group randomized to ILR monitoring, the type of BBB was not a predictor of recurrent syncope (P = .30), bradycardia requiring pacemaker (P = .15), or MSREs (P = .42). The presence of PR interval prolongation or QRS width in this group did not predict MSREs (P = .22 and P = .96, respectively). CONCLUSION In patients with syncope and bifascicular block, pacemaker implantation reduces adverse events as compared with ILR monitoring, irrespective of the type of BBB or the presence of PR interval prolongation.
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Affiliation(s)
- Victor Neira
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Robert Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Matthew G Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Connor Maxey
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada.
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41
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Del Buono MG, Damonte JI, Moroni F, Ravindra K, Westman P, Chiabrando JG, Bressi E, Li P, Kapoor K, Mao Y, Oakes T, Rodriguez-Miguelez P, Gal TS, Koneru J, Ellenbogen KA, Kron J, Abbate A. QT Prolongation and In-Hospital Ventricular Arrhythmic Complications in Patients With Apical Ballooning Takotsubo Syndrome. JACC Clin Electrophysiol 2022; 8:1500-1510. [PMID: 36543499 DOI: 10.1016/j.jacep.2022.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Takotsubo syndrome is associated with life threatening arrhythmias, and the apical ballooning pattern is characterized by a peculiar QT prolongation and particularly high-risk of arrhythmias. OBJECTIVES The aim of the study was to determine the association of QT interval on electrocardiogram for ventricular arrhythmic complications in patients with apical ballooning Takotsubo syndrome in a diverse population at a large urban hospital in the U.S. METHODS We reviewed 105 cases of apical ballooning Takotsubo syndrome in patients admitted between 2011 and 2017. Two cardiologists reviewed the electrocardiograms to measure QT interval, adjusted for rate using the Fridericia formula (QTCF), and ventricular arrhythmic complications during the hospitalization. Data are reported as median and interquartile range or number and percentage. RESULTS Of the 105 patients, 86 (82%) were female, and 34 (32%) were self-reported Black or African American. The mean age was 65 years (range: 58-72 years). Left ventricular ejection fraction was 25% (range: 25%-35%). Heart rate was 101 beats/min (range: 83-121 beats/min). Ten (11%) patients experienced a ventricular arrhythmic complication and had significantly longer QTCF (470 [range: 422-543] milliseconds) than did those without complications (417 [range: 383-456] milliseconds, P = 0.031). The area under the curve for QTCF was 0.708 (95% CI: 0.536-0.880; P = 0.031). Twenty-eight (27%) patients had a QTCF ≥460 milliseconds and significantly more arrhythmic complications (21% vs 5%, odds ratio 4.997 [95% CI: 1.288-19.237], P = 0.021). QTCF was an independent predictor of ventricular arrhythmias: odds ratio 1.090 for each 10-millisecond increase in QTCF (95% CI: 1.004-1.183; P = 0.040, corrected for sex). CONCLUSIONS In a diverse population of patients with apical ballooning Takotsubo syndrome admitted to a large urban hospital in the United States, QTCF at admission ≥460 milliseconds identifies patients at high risk for in-hospital arrhythmic complications. Further studies are needed to determine strategies aimed at shortening QT interval to potentially prevent life-threatening arrhythmic events.
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Affiliation(s)
- Marco Giuseppe Del Buono
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Juan Ignacio Damonte
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA; Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Francesco Moroni
- Robert M. Berne Cardiovascular Research Center, and Department of Medicine, Division of Cardiovascular Medicine, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia, USA
| | - Krishna Ravindra
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Peter Westman
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Juan G Chiabrando
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA; Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Edoardo Bressi
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Pengyang Li
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kunal Kapoor
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yuxuan Mao
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Travis Oakes
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Paula Rodriguez-Miguelez
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Tamas S Gal
- Department of Biostatistics, Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jayanthi Koneru
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kenneth A Ellenbogen
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jordana Kron
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA; Robert M. Berne Cardiovascular Research Center, and Department of Medicine, Division of Cardiovascular Medicine, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia, USA.
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42
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Räsänen E, Pukkila T, Kanniainen M, Miettinen M, Duda R, Kim J, Solanpää J, Aalto-Setälä K, Potapov I. Accurate QT correction method from transfer entropy. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 4:1-8. [PMID: 36865582 PMCID: PMC9972000 DOI: 10.1016/j.cvdhj.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background The QT interval in the electrocardiogram (ECG) is a fundamental risk measure for arrhythmic adverse cardiac events. However, the QT interval depends on the heart rate and must be corrected accordingly. The present QT correction (QTc) methods are either simple models leading to under- or overcorrection, or impractical in requiring long-term empirical data. In general, there is no consensus on the best QTc method. Objective We introduce a model-free QTc method-AccuQT-that computes QTc by minimizing the information transfer from R-R to QT intervals. The objective is to establish and validate a QTc method that provides superior stability and reliability without models or empirical data. Methods We tested AccuQT against the most commonly used QT correction methods by using long-term ECG recordings of more than 200 healthy subjects from PhysioNet and THEW databases. Results AccuQT overperforms the previously reported correction methods: the proportion of false-positives is reduced from 16% (Bazett) to 3% (AccuQT) for the PhysioNet data. In particular, the QTc variance is significantly reduced and thus the RR-QT stability is increased. Conclusion AccuQT has significant potential to become the QTc method of choice in clinical studies and drug development. The method can be implemented in any device recording R-R and QT intervals.
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Affiliation(s)
- Esa Räsänen
- Computational Physics Laboratory, Tampere University, Tampere, Finland,Address reprint requests and correspondence: Dr Esa Räsänen, Computational Physics Laboratory, Tampere University, P.O. Box 692, FI-33014, Tampere, Finland.
| | - Teemu Pukkila
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Matias Kanniainen
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Minna Miettinen
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Rostislav Duda
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Jiyeong Kim
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Janne Solanpää
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Katriina Aalto-Setälä
- Faculty of Medicine and Health Technology, BioMediTech, Tampere University, Tampere, Finland,Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Ilya Potapov
- Computational Physics Laboratory, Tampere University, Tampere, Finland
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Altuntas E, Cetın S, Karabay KO, Bagırtan B, Celebı F. The relationship between length of stay in intensive care unit and Tpeak‐Tend and Tpeak‐Tend/QTc ratio in COVID 19 patients with acute coronary syndrome. J Arrhythm 2022; 38:1088-1093. [PMCID: PMC9745550 DOI: 10.1002/joa3.12785] [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: 04/10/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 12/15/2022] Open
Abstract
Background Patients with coronavirus disease 2019 (COVID‐19) can develop cardiac injury resulting in cardiac arrhythmias, myocarditis, and acute coronary syndrome (ACS). In this study, we aimed to investigate whether COVID‐19 infection affects ventricular repolarization parameters such as Tpeak‐Tend interval (Tp‐e), QT interval, corrected QT (QTc), Tp‐e/QT, and Tp‐e/cQT in patients with ACS. Methods The study consisted of two groups. The first group included patients with ACS and COVID‐19 (Group 1) (n = 50). Polymerase chain reaction test positive patients were enrolled. The second group included patients with only ACS (Group 2) (n = 100). The risk of ventricular arrhythmias was evaluated on the basis of the measured electrocardiographic Tp‐e and QT interval, and QTc, Tp‐e/QT, and Tp‐e/QTc values. Results Tp‐e interval, QTc, and Tp‐e/QTc were significantly higher in the group1 than group 2 (p < .001, p < .018, and p < .001, respectively). Significant positive correlations were found between Tp‐e, D‐dimer level, and C‐reactive protein (CRP) level in the group1 (p = .002, p = 0 .03, and p = .021, respectively). Univariate and multivariate regression analyses revealed that Tp‐e was one of the independent predictor of length of stay in the intensive care unit (ICU). (B = 1.662, p = .006 and B = 1.804, p = .021, respectively). Conclusions In the patients with ACS, COVID‐19 infection caused increases in QTc, Tp‐e, and Tp‐e/QTc ratio. In addition, age and prolonged Tp‐e were found to be independent predictors of prolonged ICU stay.
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Affiliation(s)
- Emine Altuntas
- Department of CardiologySancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research HospitalIstanbulTurkey
| | - Sükrü Cetın
- Department of CardiologySancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research HospitalIstanbulTurkey
| | - Kanber Ocal Karabay
- Department of CardiologySancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research HospitalIstanbulTurkey
| | - Bayram Bagırtan
- Department of CardiologySancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research HospitalIstanbulTurkey
| | - Filiz Celebı
- Department of CardiologySancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research HospitalIstanbulTurkey
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44
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Yee LA, Han H, Davies B, Pearman CM, Laksman ZWM, Roberts JD, Steinberg C, Tadros R, Cadrin‐Tourigny J, Simpson CS, Gardner M, MacIntyre C, Arbour L, Leather R, Fournier A, Green MS, Kimber S, Angaran P, Sanatani S, Joza J, Khan H, Healey JS, Atallah J, Seifer C, Krahn AD. Sex Differences and Utility of Treadmill Testing in Long‐QT Syndrome. J Am Heart Assoc 2022; 11:e025108. [DOI: 10.1161/jaha.121.025108] [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: 11/16/2022]
Abstract
Background
Diagnosis of congenital long‐QT syndrome (LQTS) is complicated by phenotypic ambiguity, with a frequent normal‐to‐borderline resting QT interval. A 3‐step algorithm based on exercise response of the corrected QT interval (QTc) was previously developed to diagnose patients with LQTS and predict subtype. This study evaluated the 3‐step algorithm in a population that is more representative of the general population with LQTS with milder phenotypes and establishes sex‐specific cutoffs beyond the resting QTc.
Methods and Results
We identified 208 LQTS likely pathogenic or pathogenic
KCNQ1
or
KCNH2
variant carriers in the Canadian NLQTS (National Long‐QT Syndrome) Registry and 215 unaffected controls from the HiRO (Hearts in Rhythm Organization) Registry. Exercise treadmill tests were analyzed across the 5 stages of the Bruce protocol. The predictive value of exercise ECG characteristics was analyzed using receiver operating characteristic curve analysis to identify optimal cutoff values. A total of 78% of male carriers and 74% of female carriers had a resting QTc value in the normal‐to‐borderline range. The 4‐minute recovery QTc demonstrated the best predictive value for carrier status in both sexes, with better LQTS ascertainment in female patients (area under the curve, 0.90 versus 0.82), with greater sensitivity and specificity. The optimal cutoff value for the 4‐minute recovery period was 440 milliseconds for male patients and 450 milliseconds for female patients. The 1‐minute recovery QTc had the best predictive value in female patients for differentiating LQTS1 versus LQTS2 (area under the curve, 0.82), and the peak exercise QTc had a marginally better predictive value in male patients for subtype with (area under the curve, 0.71). The optimal cutoff value for the 1‐minute recovery period was 435 milliseconds for male patients and 455 milliseconds for femal patients.
Conclusions
The 3‐step QT exercise algorithm is a valid tool for the diagnosis of LQTS in a general population with more frequent ambiguity in phenotype. The algorithm is a simple and reliable method for the identification and prediction of the 2 major genotypes of LQTS.
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Affiliation(s)
- Lauren A. Yee
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Hui‐Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Brianna Davies
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Charles M. Pearman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Zachary W. M. Laksman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Jason D. Roberts
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences Hamilton Ontario Canada
| | - Christian Steinberg
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Laval University Quebec City Quebec Canada
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal Montreal Quebec Canada
| | - Julia Cadrin‐Tourigny
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal Montreal Quebec Canada
| | | | - Martin Gardner
- Queen Elizabeth II Health Sciences Center Halifax Nova Scotia Canada
| | - Ciorsti MacIntyre
- Queen Elizabeth II Health Sciences Center Halifax Nova Scotia Canada
| | - Laura Arbour
- Department of Medical Genetics University of British Columbia, and Island Health Victoria British Columbia Canada
| | | | - Anne Fournier
- Centre Hospitalier Universitaire Sainte‐Justine Montréal Quebec Canada
| | | | | | - Paul Angaran
- St. Michael’s Hospital, University of Toronto Toronto Ontario Canada
| | | | - Jacqueline Joza
- McGill University Health Sciences Center Montreal Quebec Canada
| | - Habib Khan
- London Health Sciences Center London Ontario Canada
| | | | | | | | - Andrew D. Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine University of British Columbia Vancouver British Columbia Canada
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45
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Rabkin SW. Assessment of the QT interval in right bundle branch block. Acta Cardiol 2022:1-8. [PMID: 35582918 DOI: 10.1080/00015385.2022.2066778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Identifying prolonged QT interval in RBBB has been problematic. METHODS Four approaches were compared to adjust for the QT prolongation in intermittent RBBB. The implications were assessed in a separate group of 200 persons with established RBBB. RESULTS In 12 individuals, mean age 74.5 years with intermittent RBBB, the presence of RBBB significantly (p < 0.05) increased the QT interval in each of six different heart rate correction formulae by an amount ranging from 35.4 ms in the Hodges formula to 50.2 ms in the Bazett formula. Four different equations were tested to adjust the QT interval and one approach QTcRBBB = 0.945*QTcRBBB - 26 was the best method to adjust for the increased QT in RBBB as it produced a QT value that was not significantly different from the QT interval in the absence of RBBB in intermittent RBBB.Failure to adjust the QT interval in RBBB produces an overestimate of the QT interval which in some heart rate adjustment formulae was marked. For the Bazett heart rate adjustment approach QTc 450 ms was found in 73.9% of men and QTc over 460 ms was found in 60.6% of women. CONCLUSION These data suggest the implementation of a new approach to recalculate the QT intervals in RBBB. QTcRBBB = 0.945*QTcRBBB - 26 with an appropriate heart rate adjustment formula (other than the Bazett formula) accurately predicts the QT interval in the absence of RBBB.
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Affiliation(s)
- Simon W. Rabkin
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, Canada
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46
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Aufiero S, Bleijendaal H, Robyns T, Vandenberk B, Krijger C, Bezzina C, Zwinderman AH, Wilde AAM, Pinto YM. A deep learning approach identifies new ECG features in congenital long QT syndrome. BMC Med 2022; 20:162. [PMID: 35501785 PMCID: PMC9063181 DOI: 10.1186/s12916-022-02350-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/24/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Congenital long QT syndrome (LQTS) is a rare heart disease caused by various underlying mutations. Most general cardiologists do not routinely see patients with congenital LQTS and may not always recognize the accompanying ECG features. In addition, a proportion of disease carriers do not display obvious abnormalities on their ECG. Combined, this can cause underdiagnosing of this potentially life-threatening disease. METHODS This study presents 1D convolutional neural network models trained to identify genotype positive LQTS patients from electrocardiogram as input. The deep learning (DL) models were trained with a large 10-s 12-lead ECGs dataset provided by Amsterdam UMC and externally validated with a dataset provided by University Hospital Leuven. The Amsterdam dataset included ECGs from 10000 controls, 172 LQTS1, 214 LQTS2, and 72 LQTS3 patients. The Leuven dataset included ECGs from 2200 controls, 32 LQTS1, and 80 LQTS2 patients. The performance of the DL models was compared with conventional QTc measurement and with that of an international expert in congenital LQTS (A.A.M.W). Lastly, an explainable artificial intelligence (AI) technique was used to better understand the prediction models. RESULTS Overall, the best performing DL models, across 5-fold cross-validation, achieved on average a sensitivity of 84 ± 2%, 90 ± 2% and 87 ± 6%, specificity of 96 ± 2%, 95 ± 1%, and 92 ± 4%, and AUC of 0.90 ± 0.01, 0.92 ± 0.02, and 0.89 ± 0.03, for LQTS 1, 2, and 3 respectively. The DL models were also shown to perform better than conventional QTc measurements in detecting LQTS patients. Furthermore, the performances held up when the DL models were validated on a novel external cohort and outperformed the expert cardiologist in terms of specificity, while in terms of sensitivity, the DL models and the expert cardiologist in LQTS performed the same. Finally, the explainable AI technique identified the onset of the QRS complex as the most informative region to classify LQTS from non-LQTS patients, a feature previously not associated with this disease. CONCLUSIONS This study suggests that DL models can potentially be used to aid cardiologists in diagnosing LQTS. Furthermore, explainable DL models can be used to possibly identify new features for LQTS on the ECG, thus increasing our understanding of this syndrome.
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Affiliation(s)
- Simona Aufiero
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands. .,Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Hidde Bleijendaal
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bert Vandenberk
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christian Krijger
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Connie Bezzina
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Yigal M Pinto
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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Krahn AD, Laksman Z, Sy RW, Postema PG, Ackerman MJ, Wilde AAM, Han HC. Congenital Long QT Syndrome. JACC Clin Electrophysiol 2022; 8:687-706. [PMID: 35589186 DOI: 10.1016/j.jacep.2022.02.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 12/14/2022]
Abstract
Congenital long QT syndrome (LQTS) encompasses a group of heritable conditions that are associated with cardiac repolarization dysfunction. Since its initial description in 1957, our understanding of LQTS has increased dramatically. The prevalence of LQTS is estimated to be ∼1:2,000, with a slight female predominance. The diagnosis of LQTS is based on clinical, electrocardiogram, and genetic factors. Risk stratification of patients with LQTS aims to identify those who are at increased risk of cardiac arrest or sudden cardiac death. Factors including age, sex, QTc interval, and genetic background all contribute to current risk stratification paradigms. The management of LQTS involves conservative measures such as the avoidance of QT-prolonging drugs, pharmacologic measures with nonselective β-blockers, and interventional approaches such as device therapy or left cardiac sympathetic denervation. In general, most forms of exercise are considered safe in adequately treated patients, and implantable cardioverter-defibrillator therapy is reserved for those at the highest risk. This review summarizes our current understanding of LQTS and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Departments of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart), Academic University Medical Center, Amsterdam, the Netherlands
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada; Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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48
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Jiang A, Gu H, Feng Z, Ding Y, Xu X, Yin G, Zhang W, Shen Z, Li Q. Heart rate-corrected QT interval: A novel diagnostic biomarker for diabetic peripheral neuropathy. J Diabetes Investig 2022; 13:850-857. [PMID: 34932277 PMCID: PMC9077736 DOI: 10.1111/jdi.13738] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION To explore the relationship between heart rate-corrected QT (QTc) interval and diabetic peripheral neuropathy (DPN), and whether QTc interval has diagnostic utility for DPN beyond nerve conduction velocity. MATERIALS AND METHODS A total of 965 patients with diabetes, including 473 patients with DPN and 492 patients without DPN, underwent standard 12-lead electrocardiography and detailed assessments of peripheral neuropathy. RESULTS Patients with DPN had longer QTc intervals than those without. Among participants, from the first to fourth quartile of QTc interval, the proportion of patients with DPN appreciably increased and the nerve conduction velocity obviously decreased (P for trend <0.001). The univariate and multivariate analyses showed that prolonged QTc interval was closely associated with increased risk of DPN (univariable odds ratio 1.112, 95% confidence interval 1.097-1.127, P < 0.001; multivariable odds ratio 1.118, 95% confidence interval 1.099-1.137, P < 0.001). Receiver operating characteristic analysis for the diagnosis of DPN showed a greater area under the curve for QTc interval of 0.894 than the median nerve motor conduction velocity of 0.691, median nerve sensory conduction velocity of 0.664 and peroneal nerve motor conduction velocity of 0.692. The optimal cut-off point of QTc interval for DPN was 428.5 ms with sensitivity of 0.715 and specificity of 0.920 (P < 0.001). The combination of QTc interval and nerve conduction testing increased the area under the curve for the diagnosis of DPN (from 0.736 to 0.916; P < 0.001). CONCLUSIONS QTc interval with 428.5 ms has more reliable diagnostic utility for DPN than nerve conduction velocity, and prolonged QTc interval is closely associated with an increased risk of DPN.
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Affiliation(s)
- Ai‐jun Jiang
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Heng Gu
- Nanjing Medical UniversityNanjingChina
| | - Zhan‐rong Feng
- Department of EndocrinologyShuyang Hospital of Traditional Chinese MedicineSuqianChina
| | - Ying Ding
- Department of EndocrinologyShuyang Hospital of Traditional Chinese MedicineSuqianChina
| | - Xiao‐hua Xu
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Guo‐ping Yin
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Wen‐li Zhang
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Zi‐yang Shen
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Qian Li
- Department of Endocrinology, Nanjing First HospitalNanjing Medical UniversityNanjingChina
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Resdal Dyssekilde J, Frederiksen TC, Christiansen MK, Hasle Sørensen R, Pedersen LN, Loof Møller P, Christensen LS, Larsen JM, Thomsen KK, Lindhardt TB, Böttcher M, Molsted S, Havndrup O, Fischer T, Møller DS, Henriksen FL, Johansen JB, Nielsen JC, Bundgaard H, Nygaard M, Jensen HK. Diagnostic Yield of Genetic Testing in Young Patients With Atrioventricular Block of Unknown Cause. J Am Heart Assoc 2022; 11:e025643. [PMID: 35470684 PMCID: PMC9238593 DOI: 10.1161/jaha.121.025643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background The cause of atrioventricular block (AVB) remains unknown in approximately half of young patients with the diagnosis. Although variants in several genes associated with cardiac conduction diseases have been identified, the contribution of genetic variants in younger patients with AVB is unknown. Methods and Results Using the Danish Pacemaker and Implantable Cardioverter Defibrillator (ICD) Registry, we identified all patients younger than 50 years receiving a pacemaker because of AVB in Denmark in the period from January 1, 1996 to December 31, 2015. From medical records, we identified patients with unknown cause of AVB at time of pacemaker implantation. These patients were invited to a genetic screening using a panel of 102 genes associated with inherited cardiac diseases. We identified 471 living patients with AVB of unknown cause, of whom 226 (48%) accepted participation. Median age at the time of pacemaker implantation was 39 years (interquartile range, 32–45 years), and 123 (54%) were men. We found pathogenic or likely pathogenic variants in genes associated with or possibly associated with AVB in 12 patients (5%). Most variants were found in the LMNA gene (n=5). LMNA variant carriers all had a family history of either AVB and/or sudden cardiac death. Conclusions In young patients with AVB of unknown cause, we found a possible genetic cause in 1 out of 20 participating patients. Variants in the LMNA gene were most common and associated with a family history of AVB and/or sudden cardiac death, suggesting that genetic testing should be a part of the diagnostic workup in these patients to stratify risk and screen family members.
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Affiliation(s)
| | - Tanja Charlotte Frederiksen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Health Aarhus University Aarhus Denmark
| | | | | | | | | | | | | | | | - Tommi Bo Lindhardt
- Department of Cardiology Copenhagen University HospitalHerlev and Gentofte Hospital Hellerup Denmark
| | - Morten Böttcher
- Department of Cardiology Regional Hospital Herning Herning Denmark
| | - Stig Molsted
- Department of Clinical Research North Zealand Hospital Hillerød Denmark
| | - Ole Havndrup
- Department of Cardiology Zealand University Hospital Roskilde Denmark
| | | | | | | | | | - Jens Cosedis Nielsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Health Aarhus University Aarhus Denmark
| | - Henning Bundgaard
- Department of Cardiology The Heart Center Rigshospitalet Copenhagen Denmark.,Department of Clinical Medicine University of Copenhagen Denmark
| | - Mette Nygaard
- Department of Biomedicine Health Aarhus University Aarhus Denmark.,Department of Health Science and Technology Aalborg Denmark
| | - Henrik Kjærulf Jensen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Health Aarhus University Aarhus Denmark
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50
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Bedwetting from the heart: Time for a paradigm shift in the minimal diagnostic evaluation of enuresis. Heart Rhythm 2022; 19:862-865. [DOI: 10.1016/j.hrthm.2022.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/16/2022] [Accepted: 01/22/2022] [Indexed: 01/08/2023]
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