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Nham T, Garcia MC, Tsang KLJ, Silva JM, Schneider T, Deng J, Lohit S, Mbuagbaw L, Holbrook A. Proarrhythmic major adverse cardiac events with donepezil: A systematic review with meta-analysis. J Am Geriatr Soc 2024. [PMID: 38580328 DOI: 10.1111/jgs.18909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 02/05/2024] [Accepted: 03/16/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) are regularly used in Alzheimer's disease. Of the three ChEIs approved for dementia, donepezil is among the most prescribed drugs in the United States with nearly 6 million prescriptions in 2020; however, it is classified as a "known risk" QT interval-prolonging medication (QTPmed). Given this claim is derived from observational data including single case reports, we aimed to evaluate high-quality literature on the frequency and nature of proarrhythmic major adverse cardiac events (MACE) associated with donepezil. METHODS We searched Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Central from 1996 onwards for randomized controlled trials (RCTs) involving patients age ≥18 years comparing donepezil to placebo. The MACE composite included mortality, sudden cardiac death, non-fatal cardiac arrest, Torsades de pointes, ventricular tachyarrhythmia, seizure or syncope. Random-effects meta-analyses were performed with a treatment-arm continuity correction for single and double zero event studies. RESULTS Sixty RCTs (n = 12,463) were included. Twenty-five of 60 trials (n = 5886) investigated participants with Alzheimer's disease and 33 trials monitored electrocardiogram data. The mean follow-up duration was 31 weeks (SD = 36). Mortality was the most commonly reported MACE (252/331, 75.8% events), the remainder were syncope or seizures, with no arrhythmia events. There was no increased risk of MACE with exposure to donepezil compared to placebo (risk ratio [RR] 1.08, 95% CI 0.88-1.33, I2 = 0%) and this was consistent in the subgroup analysis of trials including participants with cardiovascular morbidities (RR 1.14, 95% CI 0.88-1.47). Subgroup analysis suggested a trend toward more events with donepezil with follow-up ≥52 weeks (RR: 1.32, 0.98-1.79). CONCLUSIONS This systematic review with meta-analysis found donepezil may not be arrhythmogenic. Donepezil was not associated with mortality, ventricular arrhythmias, seizure or syncope, although longer durations of therapy need more study. Further research to clarify actual clinical outcomes related to QTPmed is important to inform prescribing practices.
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Affiliation(s)
- Tina Nham
- Division of Geriatrics, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Cristian Garcia
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kai La Jennifer Tsang
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queens University, Kingston, Ontario, Canada
| | - Jessyca Matos Silva
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tyler Schneider
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simran Lohit
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Mahardika T NQ, Qauli AI, Marcellinus A, Lim KM. Evaluation of cardiac pro-arrhythmic risks using the artificial neural network with ToR-ORd in silico model output. Front Physiol 2024; 15:1374355. [PMID: 38638275 PMCID: PMC11024991 DOI: 10.3389/fphys.2024.1374355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
Torsades de pointes (TdP) is a type of ventricular arrhythmia that can lead to sudden cardiac death. Drug-induced TdP has been an important concern for researchers and international regulatory boards. The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative was proposed that integrates in vitro testing and computational models of cardiac ion channels and human cardiomyocyte cells to evaluate the proarrhythmic risk of drugs. The TdP risk classification performance using only a single TdP metric may require some improvements because of information limitations and the instability of generalizing results. This study evaluates the performance of TdP metrics from the in silico simulations of the Tomek-O'Hara Rudy (ToR-ORd) ventricular cell model for classifying the TdP risk of drugs. We utilized these metrics as an input to an artificial neural network (ANN)-based classifier. The ANN model was optimized through hyperparameter tuning using the grid search (GS) method to find the optimal model. The study outcomes show an area under the curve (AUC) value of 0.979 for the high-risk category, 0.791 for the intermediate-risk category, and 0.937 for the low-risk category. Therefore, this study successfully demonstrates the capability of the ToR-ORd ventricular cell model in classifying the TdP risk into three risk categories, providing new insights into TdP risk prediction methods.
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Affiliation(s)
- Nurul Qashri Mahardika T
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
| | - Ali Ikhsanul Qauli
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Department of Engineering, Faculty of Advanced Technology and Multidiscipline, Universitas Airlangga, Surabaya, Jawa Timur, Indonesia
| | - Aroli Marcellinus
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
| | - Ki Moo Lim
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Computational Medicine Lab, Department of Medical IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Meta Heart Co Ltd., Gumi, Republic of Korea
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Boulay E, Troncy E, Jacquemet V, Huang H, Pugsley MK, Downey AM, Venegas Baca R, Authier S. In Silico Human Cardiomyocyte Action Potential Modeling: Exploring Ion Channel Input Combinations. Int J Toxicol 2024:10915818241237988. [PMID: 38477622 DOI: 10.1177/10915818241237988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
In silico modeling offers an opportunity to supplement and accelerate cardiac safety testing. With in silico modeling, computational simulation methods are used to predict electrophysiological interactions and pharmacological effects of novel drugs on critical physiological processes. The O'Hara-Rudy's model was developed to predict the response to different ion channel inhibition levels on cardiac action potential duration (APD) which is known to directly correlate with the QT interval. APD data at 30% 60% and 90% inhibition were derived from the model to delineate possible ventricular arrhythmia scenarios and the marginal contribution of each ion channel to the model. Action potential values were calculated for epicardial, myocardial, and endocardial cells, with action potential curve modeling. This study assessed cardiac ion channel inhibition data combinations to consider when undertaking in silico modeling of proarrhythmic effects as stipulated in the Comprehensive in Vitro Proarrhythmia Assay (CiPA). As expected, our data highlight the importance of the delayed rectifier potassium channel (IKr) as the most impactful channel for APD prolongation. The impact of the transient outward potassium channel (Ito) inhibition on APD was minimal while the inward rectifier (IK1) and slow component of the delayed rectifier potassium channel (IKs) also had limited APD effects. In contrast, the contribution of fast sodium channel (INa) and/or L-type calcium channel (ICa) inhibition resulted in substantial APD alterations supporting the pharmacological relevance of in silico modeling using input from a limited number of cardiac ion channels including IKr, INa, and ICa, at least at an early stage of drug development.
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Affiliation(s)
- Emmanuel Boulay
- GREPAQ (Groupe de Recherche en Pharmacologie Animale du Québec), Université de Montréal, Saint-Hyacinthe, QC, Canada
- Charles River Laboratories, Laval, QC, Canada
| | - Eric Troncy
- GREPAQ (Groupe de Recherche en Pharmacologie Animale du Québec), Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Vincent Jacquemet
- Département de Pharmacologie et Physiologie, Université de Montréal, Faculté de Médecine, Montréal, QC, Canada
- Centre de Recherche, Hôpital du Sacré-Cœur, Montréal, QC, Canada
- Institut de Génie Biomédical, Université de Montréal, Montréal, QC, Canada
| | - Hai Huang
- Charles River Laboratories, Laval, QC, Canada
| | - Michael K Pugsley
- Toxicology & Safety Pharmacology, Cytokinetics, San Francisco, CA, USA
| | | | | | - Simon Authier
- GREPAQ (Groupe de Recherche en Pharmacologie Animale du Québec), Université de Montréal, Saint-Hyacinthe, QC, Canada
- Charles River Laboratories, Laval, QC, Canada
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Compagnone M, Marinelli A, Dall'Ara G, Ziacchi M, Grotti S, Ciurlanti L, Tarantino FF, Potena L, Biffi M, Galvani M. Prolactin Inhibition to Treat Postpartum Arrhythmic Storm. JACC Case Rep 2024; 29:102211. [PMID: 38379650 PMCID: PMC10874977 DOI: 10.1016/j.jaccas.2023.102211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 02/22/2024]
Abstract
Postpartum electrical storm due to torsade de pointes is a rare but life-threatening condition. The uniqueness of this case lies in the use of cabergoline to suppress postpartum ventricular arrhythmias in absence of heart disease. Timely multidisciplinary management is crucial to achieve final diagnosis, deliver proper treatment and improve prognosis.
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Affiliation(s)
| | | | | | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S. Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Simone Grotti
- Cardiology Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Leonardo Ciurlanti
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S. Orsola University Hospital, University of Bologna, Bologna, Italy
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, S. Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Mauro Biffi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S. Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Marcello Galvani
- Cardiology Unit, Morgagni Pierantoni Hospital, Forlì, Italy
- Department of Medicine and Surgery of University of Bologna, Bologna, Italy
- Cardiovascular Research Unit, Fondazione Cardiologica M.Z. Sacco, Forlì, Italy
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Lopez-Medina AI, Campos-Staffico AM, A Chahal CA, Volkers I, Jacoby JP, Berenfeld O, Luzum JA. Genetic risk factors for drug-induced long QT syndrome: findings from a large real-world case-control study. Pharmacogenomics 2024; 25:117-131. [PMID: 38506312 DOI: 10.2217/pgs-2023-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Aim: Drug-induced long QT syndrome (diLQTS), an adverse effect of many drugs, can lead to sudden cardiac death. Candidate genetic variants in cardiac ion channels have been associated with diLQTS, but several limitations of previous studies hamper clinical utility. Materials & methods: Thus, the purpose of this study was to assess the associations of KCNE1-D85N, KCNE2-I57T and SCN5A-G615E with diLQTS in a large observational case-control study (6,083 self-reported white patients treated with 27 different high-risk QT-prolonging medications; 12.0% with diLQTS). Results: KCNE1-D85N significantly associated with diLQTS (adjusted odds ratio: 2.24 [95% CI: 1.35-3.58]; p = 0.001). Given low minor allele frequencies, the study had insufficient power to analyze KCNE2-I57T and SCN5A-G615E. Conclusion: KCNE1-D85N is a risk factor for diLQTS that should be considered in future clinical practice guidelines.
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Grants
- F32 HL162231, K08 HL146990, R01-HL156961, R21-EB032661, R21-HL153694, T32 TR004371 CSR NIH HHS
- F32 HL162231, K08 HL146990, R01-HL156961, R21-EB032661, R21-HL153694, T32 TR004371 CSR NIH HHS
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Affiliation(s)
- Ana I Lopez-Medina
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Choudhary Anwar A Chahal
- Center for Inherited Cardiovascular Diseases, WellSpan Health, Lancaster, PA, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Isabella Volkers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Juliet P Jacoby
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Omer Berenfeld
- Center for Arrhythmia Research, Departments of Internal Medicine - Cardiology, Biomedical Engineering, & Applied Physics, University of Michigan, Ann Arbor, MI, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Al-Azayzih A, Al-Qerem W, Al-Azzam S, Muflih S, Al-Husein BA, Kharaba Z, Kanaan RJ, Rahhal D. Prevalence of Medication Associated with QTc Prolongation Used Among Critically Ill Patients. Vasc Health Risk Manag 2024; 20:27-37. [PMID: 38318252 PMCID: PMC10840412 DOI: 10.2147/vhrm.s438899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/19/2024] [Indexed: 02/07/2024] Open
Abstract
Background Acquired prolonged corrected QT (QTc) interval can lead to life-threatening Torsade de Pointes (TdP) arrhythmia. Multiple risk factors including medications, comorbidities, and electrolyte imbalances contribute significantly to acquired manifestations of the QTc prolongation. Critically ill patients are particularly more vulnerable to TdP due to complex medical conditions, aging, and polypharmacy. Objective This study aimed to assess the prevalence of TdP-associated medication prescribing, identify risk factors for QTc prolongation and TdP, and determine primary predictors of high TdP medication usage in critically ill patients in Jordan. Methods We conducted a retrospective cross-sectional analysis of electronic medical records for patients from King Abdullah University Hospital who were admitted to Intensive Care Unit (ICU) between (July 2012-July 2022). We collected data on patients' demographics, clinical characteristics, comorbidities, laboratory results, and prescribed medications. Medications were categorized into three TdP risk levels according to CredibleMeds® assessment tool. Data were analyzed using descriptive statistics and a binary logistic regression model. Results Of the 13,300 patients (58.2% male, median age 62 years). Prescribing prevalence for medications with known TdP risk was 19%, possible risk (24.7%), conditional risk (21.6%), and confirmed conditional risk (8.3%). Common comorbidities included hypertension (40.9%), diabetes (33.3%), and cancer (15.4%). Drugs with known TdP risk included citalopram, amiodarone, clarithromycin, and ciprofloxacin. A binary regression model revealed that as age increased, the odds of TdP associated medication prescribing decreased (OR = 0.989, p < 0.001), while patients on more than five medications had higher odds (OR = 4.281, p < 0.001). Conclusion The study identified a notable prevalence of prescribing for medications with QTc prolongation/TdP risk in critically ill patients. Healthcare providers in the ICU should exercise caution to minimize the inadvertent prescription of TdP associated medications especially among older patients and those with polypharmacy.
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Affiliation(s)
- Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Walid Al-Qerem
- Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, Jordan
| | - Sayer Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Suhaib Muflih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Belal A Al-Husein
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Zelal Kharaba
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
- Honorary Associate Lecturer, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Roaa J Kanaan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Dania Rahhal
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Li D, Chai S, Wang H, Dong J, Qin C, Du D, Wang Y, Du Q, Liu S. Drug-induced QT prolongation and torsade de pointes: a real-world pharmacovigilance study using the FDA Adverse Event Reporting System database. Front Pharmacol 2023; 14:1259611. [PMID: 38186652 PMCID: PMC10771307 DOI: 10.3389/fphar.2023.1259611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction: Drug-induced QT prolongation and (or) Torsade de Pointes (TdP) is a well-known serious adverse reaction (ADR) for some drugs, but the widely recognized comprehensive landscape of culprit-drug of QT prolongation and TdP is currently lacking. Aim: To identify the top drugs reported in association with QT prolongation and TdP and provide information for clinical practice. Method: We reviewed the reports related to QT prolongation and TdP in the FDA Adverse Event Reporting System (FAERS) database from January 1, 2004 to December 31, 2022, and summarized a potential causative drug list accordingly. Based on this drug list, the most frequently reported causative drugs and drug classes of QT prolongation and TdP were counted, and the disproportionality analysis for all the drugs was conducted to in detect ADR signal. Furthermore, according to the positive-negative distribution of ADR signal, we integrated the risk characteristic of QT prolongation and TdP in different drugs and drug class. Results: A total of 42,713 reports in FAERS database were considered to be associated with QT prolongation and TdP from 2004 to 2022, in which 1,088 drugs were reported as potential culprit-drugs, and the largest number of drugs belonged to antineoplastics. On the whole, furosemide was the most frequently reported drugs followed by acetylsalicylic acid, quetiapine, citalopram, metoprolol. In terms of drug classes, psycholeptics was the most frequently reported drug classes followed by psychoanaleptics, analgesics, beta blocking agents, drugs for acid related disorders. In disproportionality analysis, 612 drugs showed at least one positive ADR signals, while citalopram, ondansetron, escitalopram, loperamide, and promethazine were the drug with the maximum number of positive ADR signals. However, the positive-negative distribution of ADR signals between different drug classes showed great differences, representing the overall risk difference of different drug classes. Conclusion: Our study provided a real-world overview of QT prolongation and TdP to drugs, and the presentation of the potential culprit-drug list, the proportion of reports, the detection results of ADR signals, and the distribution characteristics of ADR signals may help understand the safety profile of drugs and optimize clinical practice.
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Affiliation(s)
- Dongxuan Li
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Chai
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongli Wang
- Department of Pharmacy, The Affiliated Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Dong
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chunmeng Qin
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
- College of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Dan Du
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yalan Wang
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
- College of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Qian Du
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Songqing Liu
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Fuadah YN, Qauli AI, Marcellinus A, Pramudito MA, Lim KM. Machine learning approach to evaluate TdP risk of drugs using cardiac electrophysiological model including inter-individual variability. Front Physiol 2023; 14:1266084. [PMID: 37860622 PMCID: PMC10584148 DOI: 10.3389/fphys.2023.1266084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/20/2023] [Indexed: 10/21/2023] Open
Abstract
Introduction: Predicting ventricular arrhythmia Torsade de Pointes (TdP) caused by drug-induced cardiotoxicity is essential in drug development. Several studies used single biomarkers such as qNet and Repolarization Abnormality (RA) in a single cardiac cell model to evaluate TdP risk. However, a single biomarker may not encompass the full range of factors contributing to TdP risk, leading to divergent TdP risk prediction outcomes, mainly when evaluated using unseen data. We addressed this issue by utilizing multi-in silico features from a population of human ventricular cell models that could capture a representation of the underlying mechanisms contributing to TdP risk to provide a more reliable assessment of drug-induced cardiotoxicity. Method: We generated a virtual population of human ventricular cell models using a modified O'Hara-Rudy model, allowing inter-individual variation. IC 50 and Hill coefficients from 67 drugs were used as input to simulate drug effects on cardiac cells. Fourteen features (dVm dt repol , dVm dt max , Vm peak , Vm resting , APD tri , APD 90 , APD 50 , Ca peak , Ca diastole , Ca tri , CaD 90 , CaD 50 , qNet, qInward) could be generated from the simulation and used as input to several machine learning models, including k-nearest neighbor (KNN), Random Forest (RF), XGBoost, and Artificial Neural Networks (ANN). Optimization of the machine learning model was performed using a grid search to select the best parameter of the proposed model. We applied five-fold cross-validation while training the model with 42 drugs and evaluated the model's performance with test data from 25 drugs. Result: The proposed ANN model showed the highest performance in predicting the TdP risk of drugs by providing an accuracy of 0.923 (0.908-0.937), sensitivity of 0.926 (0.909-0.942), specificity of 0.921 (0.906-0.935), and AUC score of 0.964 (0.954-0.975). Discussion and conclusion: According to the performance results, combining the electrophysiological model including inter-individual variation and optimization of machine learning showed good generalization ability when evaluated using the unseen dataset and produced a reliable drug-induced TdP risk prediction system.
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Affiliation(s)
- Yunendah Nur Fuadah
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- School of Electrical Engineering, Telkom University, Bandung, Indonesia
| | - Ali Ikhsanul Qauli
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Department of Engineering, Faculty of Advanced Technology and Multidiscipline, Universitas Airlangga, Surabaya, Jawa Timur, Indonesia
| | - Aroli Marcellinus
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
| | - Muhammad Adnan Pramudito
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
| | - Ki Moo Lim
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Computational Medicine Lab, Department of Medical IT Convergence Engineering, Kumoh National Institute of Technology, Gumi, Republic of Korea
- Meta Heart Co., Ltd., Gumi, Republic of Korea
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Kuchimanchi M, Dabrowski C, Lu S, Melhem M. Dostarlimab, an anti-programmed death-1 monoclonal antibody, does not cause QT prolongation in patients with solid tumours: A concentration-QT analysis. Br J Clin Pharmacol 2023; 89:2272-2282. [PMID: 36823349 DOI: 10.1111/bcp.15700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS Patients with solid tumours were treated with the anti-PD-1 antibody dostarlimab in the Phase I GARNET trial. This study aimed to examine dostarlimab's effect on corrected QT (QTc) interval and the systemic concentration-QTc interval relationship. METHODS In GARNET Part 2B, patients received 500 mg dostarlimab every 3 weeks (Q3W) for four cycles, then 1000 mg Q6W. Triplicate 12-lead ECGs were recorded and time-matched pharmacokinetic (PK) samples collected at screening, on Day 1 of Cycles 1, 4, 5, 8, 12 (pre-dose and 0.5 h after infusion end), and at treatment end. Concentration-change from baseline QTcF (ΔQTcF) analysis using a linear mixed effects model, summary statistics, incidence of clinically noteworthy ECG values and rhythm abnormalities were evaluated. RESULTS A total of 377 patients were considered for evaluation (n = 15 excluded from concentration-ΔQTcF). There was a non-significant concentration-ΔQTcF relationship (0.001589 ms/μg/mL; P = .5906). Mean ΔQTcF increase was <6 ms (upper-bound two-sided 90% confidence interval [CI], <10 ms at all post-dose timepoints). Highest geometric mean concentration was 414.1 μg/mL (Cycle 5 Day 1, 0.5 h) with predicted mean ∆QTcF of 3.064 ms (upper-bound two-sided 90% CI: 5.071). Mean QTcF prolongation (all concentrations) was 2.4 ms. QTcF prolongation ≥500 ms occurred in five patients (1.3%); 51 (13.6%) and nine patients (2.4%) had ΔQTcF ≥30 ms and ≥60 ms, respectively. Ten patients (2.7%) reported rhythm abnormalities. No U-wave abnormalities, torsades de pointes, ventricular tachycardia or ventricular fibrillation/flutter were observed. CONCLUSIONS Dostarlimab does not cause clinically significant QTcF prolongation exceeding the regulatory concern threshold.
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Affiliation(s)
- Mita Kuchimanchi
- Clinical Pharmacology Modeling and Simulation, GSK, Waltham, Massachusetts, USA
| | | | - Sharon Lu
- Clinical Pharmacology Modeling and Simulation, GSK, Waltham, Massachusetts, USA
| | - Murad Melhem
- Clinical Pharmacology Modeling and Simulation, GSK, Waltham, Massachusetts, USA
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10
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Flore F, Scacciavillani R, Narducci ML, Pelargonio G, Crea F. Takotsubo syndrome and its linkage to neuroendocrinological disorders: a case report. Future Cardiol 2023. [PMID: 37378528 DOI: 10.2217/fca-2022-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Takotsubo syndrome (TTS) is an increasingly diagnosed entity, however the underlying pathophysiological mechanisms and their clinical implications are incompletely understood. An 82-year-old female, diagnosed with pituitary apoplexy, presented with ECG abnormalities and hsTnI levels consistent with an acute coronary syndrome and therefore underwent urgent coronary angiography that showed no significant stenosis and apical ballooning at left ventricle angiogram and therefore a TTS diagnosis was made. Moreover, during catheterization a 20 s Torsade de Pointes was registered. TTS is an entity that can be triggered by numerous conditions. This case of TTS was linked to many neuroendocrinological disorders.
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Affiliation(s)
- Francesco Flore
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Roberto Scacciavillani
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Maria Lucia Narducci
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Gemma Pelargonio
- Istituto di Cardiologia Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Filippo Crea
- Istituto di Cardiologia Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome, 00168, Italy
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11
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Shao H, Shi D, Dai Y. Linezolid and the risk of QT interval prolongation: A pharmacovigilance study of the Food and Drug Administration Adverse Event Reporting System. Br J Clin Pharmacol 2023; 89:1386-1392. [PMID: 36346345 DOI: 10.1111/bcp.15587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Few studies have investigated linezolid (LZD)-associated cardiotoxicity. This study explored the potential association between LZD and QT interval prolongation. METHODS Adverse event reports of QT interval prolongation associated with LZD from the Food and Drug Administration Adverse Event Reporting System from January 2013 to December 2021 were analysed and the reporting odds ratio (ROR) with 95% confidence intervals were calculated. RESULTS A total of 6738 adverse event reports of LZD as the primary and secondary suspected drug were obtained from the database, including 192 reports with electrocardiogram QT prolonged (QTp), and the ROR value was 26.1 (95% CI = 22.6-30.2). There were 8 reports of long QT syndrome, ROR 14.2 (95% CI = 7.1-28.5); 5 reports of torsade de pointes, ROR 3.2 (95% CI = 1.3-7.6); and 5 reports of ventricular tachycardia, ROR 1.9 (95% CI = 0.8-4.5). Subgroup analysis revealed that patients with tuberculosis treated with LZD had a higher reporting rate among all QTp reports, exhibiting an odds ratio of 330.0 (95% CI = 223.1-488.1). The odds ratios of QTp associated with LZD treatments in patients with and without tuberculosis were 4.2 (95% CI = 3.4-5.3) and 1.2 (95% CI = 0.8-1.6), respectively. CONCLUSION The study showed an association between LZD and QT interval prolongation. In the report on patients with tuberculosis, the incidence of QTp was higher when treated with LZD.
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Affiliation(s)
- Haixia Shao
- Department of Pharmacy, Second Affiliated Hospital and Yuying Children's hospital of Wenzhou Medical University, Wenzhou City, China
| | - Dawei Shi
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, China
| | - Ying Dai
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, China
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12
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Abstract
Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.
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Affiliation(s)
| | | | - Helen Melita
- 69106Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
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13
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Delaunois A, Mathy F, Cornet M, Gryshkova V, Korlowski C, Bonfitto F, Koch J, Schlit A, Hebeisen S, Passini E, Rodriguez B, Valentin J. Testing the nonclinical Comprehensive In Vitro Proarrhythmia Assay (CiPA) paradigm with an established anti-seizure medication: Levetiracetam case study. Pharmacol Res Perspect 2023; 11:e01059. [PMID: 36748725 PMCID: PMC9903303 DOI: 10.1002/prp2.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 02/08/2023] Open
Abstract
Levetiracetam (LEV), a well-established anti-seizure medication (ASM), was launched before the original ICH S7B nonclinical guidance assessing QT prolongation potential and the introduction of the Comprehensive In Vitro Proarrhythmia Assay (CiPA) paradigm. No information was available on its effects on cardiac channels. The goal of this work was to "pressure test" the CiPA approach with LEV and check the concordance of nonclinical core and follow-up S7B assays with clinical and post-marketing data. The following experiments were conducted with LEV (0.25-7.5 mM): patch clamp assays on hERG (acute or trafficking effects), NaV 1.5, CaV 1.2, Kir 2.1, KV 7.1/mink, KV 1.5, KV 4.3, and HCN4; in silico electrophysiology modeling (Virtual Assay® software) in control, large-variability, and high-risk human ventricular cell populations; electrophysiology measurements in human induced pluripotent stem cell (hiPSC)-derived cardiomyocytes and dog Purkinje fibers; ECG measurements in conscious telemetered dogs after single oral administration (150, 300, and 600 mg/kg). Except a slight inhibition (<10%) of hERG and KV 7.1/mink at 7.5 mM, that is, 30-fold the free therapeutic plasma concentration (FTPC) at 1500 mg, LEV did not affect any other cardiac channels or hERG trafficking. In both virtual and real human cardiomyocytes, and in dog Purkinje fibers, LEV induced no relevant changes in electrophysiological parameters or arrhythmia. No QTc prolongation was noted up to 2.7 mM unbound plasma levels in conscious dogs, corresponding to 10-fold the FTPC. Nonclinical assessment integrating CiPA assays shows the absence of QT prolongation and proarrhythmic risk of LEV up to at least 10-fold the FTPC and the good concordance with clinical and postmarketing data, although this does not exclude very rare occurrence of QT prolongation cases in patients with underlying risk factors.
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Affiliation(s)
| | | | - Miranda Cornet
- Development SciencesUCB Biopharma SRLBraine‐l'AlleudBelgium
| | | | | | | | - Juliane Koch
- Patient Safety, UCB Biosciences GmbHMonheimGermany
| | | | | | - Elisa Passini
- Department of Computer ScienceUniversity of OxfordOxfordUK
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14
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Izumi-Nakaseko H, Sakamoto K, Goto A, Kambayashi R, Matsumoto A, Takei Y, Takahara A, Sugiyama A. Characterization of pathological remodeling in the chronic atrioventricular block cynomolgus monkey heart. Front Pharmacol 2023; 14:1055031. [PMID: 36744259 PMCID: PMC9892184 DOI: 10.3389/fphar.2023.1055031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
We studied time course of pathological remodeling occurring in the cynomolgus monkey hearts against persistent atrioventricular block condition (n = 10). The atrioventricular block induced the ventricular and atrial dilation followed by the ventricular hypertrophy. Interstitial fibrosis in the ventricle was also observed along with gradual increases in the plasma angiotensin II and aldosterone concentrations. These adaptations were associated with the changes in gene expression profiling reflecting fibrosis and hypertrophy. Atrioventricular block reduced the ventricular rate and cardiac output, but the ejection fraction and stroke volume increased, whereas the cardiac output was gradually restored to its basal level. Systolic/diastolic blood pressure after the atrioventricular block was kept equal to or lower than that before the block, according with lack of increase in the plasma catecholamine levels. Chronic atrioventricular block gradually prolonged the QRS width and JT interval, leading to the QT interval prolongation in conscious state. 10 mg/kg of dl-sotalol hydrochloride induced torsade de pointes (TdP) in 6 out of 10 animals by 15 months. Animals showing longer QTcF under anesthesia after the atrioventricular block developed dl-sotalol-induced TdP earlier. No marked difference was observed in pharmacokinetics of dl-sotalol between 1 and 7 months after the atrioventricular block. Each TdP spontaneously terminated, reflecting a monkey's relatively small "effective size of the heart (=∛(left ventricular weight)/wavelength of reentry)". These fundamental knowledge will help better utilize the chronic atrioventricular block monkeys as an in vivo proarrhythmia model for detecting drug-induced TdP.
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Affiliation(s)
| | | | - Ai Goto
- Department of Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Ryuichi Kambayashi
- Department of Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Akio Matsumoto
- Department of Aging Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoshinori Takei
- Department of Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Akira Takahara
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Atsushi Sugiyama
- Department of Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan,Department of Aging Pharmacology, Faculty of Medicine, Toho University, Tokyo, Japan,*Correspondence: Atsushi Sugiyama,
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Muacevic A, Adler JR, Briggs RP, Weaver KR. Severe Hypokalemia Causing Ventricular Tachycardia: A Case Report. Cureus 2023; 15:e34043. [PMID: 36814750 PMCID: PMC9940904 DOI: 10.7759/cureus.34043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/21/2023] [Indexed: 01/22/2023] Open
Abstract
Hypokalemia and hyperosmolar hyperglycemic syndrome (HHS) are two reversible but potentially fatal disorders that are important to identify and treat urgently. A 43-year-old patient presented to the ED with altered mental status and slurred speech, difficulty communicating, left-sided facial droop, and stool incontinence according to emergency medical services. This was preceded by 1.5 weeks of nausea, vomiting, polydipsia, and weight loss. On presentation, the patient was found tachycardic and tachypneic, with uncertain neurological deficits on physical exam, hyperglycemia, and electrocardiogram (EKG) abnormalities. Lab data were consistent with hyperosmolar hyperglycemic nonketotic coma. This case provides two important clinical scenarios in which cardiac EKG abnormalities and focal neurological deficits are the product of hyperosmolality and electrolyte abnormalities. Hypokalemia with EKG abnormalities consistent with a potential ischemic disease can progress into wide complex tachycardia and ventricular fibrillation. Hyperosmolar hyperglycemia may manifest with focal neurological deficits and without the classical presentation of a coma. Careful consideration of EKG and lab values in the context of clinical presentation may provide clues to resolvable etiologies. We report a case of a patient who presented to the ED with hypokalemia and HHS, both reversible but potentially fatal disorders that are important to identify and urgently treat.
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17
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Yuan Y, Wang C, Yao H. A case report of sudden cardiac arrest and torsade de pointes induced by the second-generation tyrosine kinase inhibitor dasatinib combined with fluconazole. Front Cardiovasc Med 2023; 10:984572. [PMID: 36873392 PMCID: PMC9975254 DOI: 10.3389/fcvm.2023.984572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
A-41-year-old man diagnosed with acute myeloid leukemia (AML) survived dasatinib + fluconazole drug-induced long QT syndrome, sudden cardiac arrest, and torsade de pointes. Drug features and interaction jointly contributed to the whole process. Therefore, appropriate attention to drug interaction and close ECG monitoring are highly recommended for hospitalized patients, especially for those undergoing multi-drug regimens.
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Affiliation(s)
- Yuting Yuan
- Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Chunjian Wang
- Department of Hematology, Peking University International Hospital, Beijing, China
| | - Hongying Yao
- Department of Cardiology, Peking University International Hospital, Beijing, China
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18
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Pan D, Li B, Wang S. Establishment and validation of a torsade de pointes prediction model based on human iPSC‑derived cardiomyocytes. Exp Ther Med 2022; 25:61. [PMID: 36588805 PMCID: PMC9780517 DOI: 10.3892/etm.2022.11760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022] Open
Abstract
Drug-induced cardiotoxicity is one of the main causes of drug failure, which leads to subsequent withdrawal from pharmaceutical development. Therefore, identifying the potential toxic candidate in the early stages of drug development is important. Human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) are a useful tool for assessing candidate compounds for arrhythmias. However, a suitable model using hiPSC-CMs to predict the risk of torsade de pointes (TdP) has not been fully established. The present study aimed to establish a predictive TdP model based on hiPSC-CMs. In the current study, 28 compounds recommended by the Comprehensive in vitro Proarrhythmia Assay (CiPA) were used as training set and models were established in different risk groups, high- and intermediate-risk versus low-risk groups. Subsequently, six endpoints of electrophysiological responses were used as potential model predictors. Accuracy, sensitivity and area under the curve (AUC) were used as evaluation indices of the models and seven compounds with known TdP risk were used to verify model differentiation and calibration. The results showed that among the seven models, the AUC of logistic regression and AdaBoost model was higher and had little difference in both training and test sets, which indicated that the discriminative ability and model stability was good and excellent, respectively. Therefore, these two models were taken as submodels, similar weight was configured and a new TdP risk prediction model was constructed using a soft voting strategy. The classification accuracy, sensitivity and AUC of the new model were 0.93, 0.95 and 0.92 on the training set, respectively and all 1.00 on the test set, which indicated good discrimination ability on both training and test sets. The risk threshold was defined as 0.50 and the consistency between the predicted and observed results were 92.8 and 100% on the training and test sets, respectively. Overall, the present study established a risk prediction model for TdP based on hiPSC-CMs which could be an effective predictive tool for compound-induced arrhythmias.
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Affiliation(s)
- Dongsheng Pan
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China,National Center for Safety Evaluation of Drugs, National Institutes for Food and Drug Control, Beijing 100176, P.R. China
| | - Bo Li
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China,National Center for Safety Evaluation of Drugs, National Institutes for Food and Drug Control, Beijing 100176, P.R. China
| | - Sanlong Wang
- National Center for Safety Evaluation of Drugs, National Institutes for Food and Drug Control, Beijing 100176, P.R. China,Correspondence to: Professor Sanlong Wang, National Center for Safety Evaluation of Drugs, National Institutes for Food and Drug Control, A8 Hongda Middle Street, Beijing Economic-Technological Development Area, Beijing 100176, P.R. China
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19
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Yu M, Sun L, Yang HL, Sun H, Wang C, Yao S, Yang P. A rare endocrine cause of ventricular tachycardia: a case series of two patients and a literature review. Cardiovasc J Afr 2022; 33:277-281. [PMID: 36162825 PMCID: PMC9887437 DOI: 10.5830/cvja-2022-043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 08/15/2022] [Indexed: 10/08/2023] Open
Abstract
Sheehan's syndrome is a type of hypopituitarism caused by massive uterine bleeding and hypovolaemic shock after or during delivery. Heart involvement has been documented sporadically among the various clinical manifestations of Sheehan's syndrome but life-threatening arrhythmias are infrequent. Here, we report on two rare cases of ventricular tachycardia caused by Sheehan's syndrome. Both female patients were diagnosed with Sheehan's syndrome 30 years previously, due to massive postpartum bleeding. Both of them terminated hormone replacement therapy recently. Both patients presented with torsade de pointes. The electrocardiogram showed prolonged QT interval. In addition to potassium supplementation and anti-arrhythmia therapy, steroids and thyroid hormone replacement therapy were employed, QT-interval prolongation and T-wave inversion were normalised, and implantable cardioverter defibrillator implantation was avoided. One of the patients was recovering well at the one-year follow up and the other patient was in a coma at the time of this report. We also review the literature for cases of Sheehan's syndrome presenting with ventricular tachycardia.
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Affiliation(s)
- Ming Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Lin Sun
- Department of Endocrinology, The First Hospital of Jilin University, Changchun, China
| | - Hong-Liang Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Huan Sun
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Chang Wang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Shuai Yao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China.
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20
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Goto A, Sakamoto K, Kambayashi R, Izumi-Nakaseko H, Kawai S, Takei Y, Matsumoto A, Kanda Y, Sugiyama A. Validation of risk-stratification method for the chronic atrioventricular block cynomolgus monkey model and its mechanistic interpretation using 6 drugs with pharmacologically-distinct profile. Toxicol Sci 2022; 190:99-109. [PMID: 35993620 DOI: 10.1093/toxsci/kfac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Validation of risk-stratification method for the chronic atrioventricular block cynomolgus monkey model and its mechanistic interpretation were performed using 6 pharmacologically-distinct drugs. The following drugs were orally administered in conscious state, astemizole: 1, 5 and 10 mg/kg (n = 6); haloperidol: 1, 10 and 30 mg/kg (n = 5); amiodarone: 30 mg/kg (n = 4); famotidine: 10 mg/kg (n = 4); levofloxacin: 100 mg/kg (n = 4); and tolterodine: 0.2, 1 and 4.5 mg/kg (n = 4). Astemizole of 5 and 10 mg/kg significantly prolonged ΔΔQTcF, whereas no significant change was observed by the others. Torsade de pointes (TdP) was induced by astemizole of 5 and 10 mg/kg in 3/6 and 6/6, and by haloperidol of 10 and 30 mg/kg in 1/5 and 1/5, respectively, which was not observed in the others. Torsadogenic risk of the drugs was quantified using the criteria for the monkey model specified in our previous study. Namely, high-risk drugs induced TdP at ≤ 3times of their maximum clinical daily dose. Intermediate-risk drugs did not induce TdP at this dose range, but induced it at higher doses. Low/no-risk drugs never induced TdP at any dose tested. The magnitude of risk was intermediate for astemizole and haloperidol, and low/no risk for the others. The pre-specified, risk-stratification method for the monkey model may solve the issue existing between non-clinical models and patients with labile repolarization, which can reinforce the regulatory decision-making and labelling at time of marketing application of non-double-negative drug candidate (hERG assay positive and/or in vivo QT study positive).
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Affiliation(s)
- Ai Goto
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kengo Sakamoto
- Ina Research Inc, 2148-188 Nishiminowa, Ina-shi, Nagano, 399-4501, Japan
| | - Ryuichi Kambayashi
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Hiroko Izumi-Nakaseko
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Shinichi Kawai
- Department of Inflammation & Pain Control Research, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yoshinori Takei
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Akio Matsumoto
- Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yasunari Kanda
- Division of Pharmacology, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki-ku, Kawasaki, Kanagawa, 210-9501, Japan
| | - Atsushi Sugiyama
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Inflammation & Pain Control Research, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
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21
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Hammond BH, El Assaad I, Herber JM, Saarel EV, Cantillon D, Aziz PF. Contemporary Maternal and Fetal Outcomes in Treatment of LQTS during Pregnancy: Is Nadolol Bad for the Fetus? Heart Rhythm 2022; 19:1516-1521. [PMID: 35525421 DOI: 10.1016/j.hrthm.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Beta blocker therapy, specifically nadolol, is the recommended treatment for long QT syndrome (LQTS). Previous studies assessing maternal and fetal outcomes were published prior to nadolol era. OBJECTIVES The purpose of this study was to examine contemporary maternal and fetal outcomes in treatment of LQTS during pregnancy. METHODS We queried the Inherited Arrhythmia Database at Cleveland Clinic and identified all pregnant LQTS patients from January 2001 to January 2020. Collected data included use and timing of beta-blockers, maternal arrhythmia events, fetal growth restriction, neonatal hypoglycemia and bradycardia. RESULTS Among 68 live-birth pregnancies in 31 women with LQTS (mean age 29 ± 5.9 years, mean QTc 468 ± 39 ms), there were 5 arrhythmia events in 4 mothers. All arrhythmia events occurred in the post-partum period and there were no arrhythmia events in patients taking beta blockers. In diagnosed LQTS patients treated with beta blockers (n=27, 41%), nadolol was the most commonly prescribed agent throughout pregnancy and postpartum period (n=16, 60%). The rate of intrauterine growth restriction (IUGR) was not significantly different in fetuses exposed to beta blockers vs. unexposed (p=0.08). In the postnatal period, hypoglycemia was not seen and one patient in the exposure group had bradycardia. CONCLUSIONS Arrhythmia events were only seen in the post-partum period in those not treated with beta blockers. Events occurred as late as 9 months postpartum. Beta blocker therapy, specifically nadolol, was not associated with higher incidence of IUGR. Moreover, neonatal bradycardia was rare and hypoglycemia was not observed.
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Affiliation(s)
- Benjamin H Hammond
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH
| | - Iqbal El Assaad
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH
| | - Joshua M Herber
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH; Department of Pediatric Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Elizabeth V Saarel
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH; Department of Pediatric Cardiology, St. Luke's Health System, Boise, ID
| | - Daniel Cantillon
- Department of Electrophysiology, Cleveland Clinic, Cleveland, OH
| | - Peter F Aziz
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH.
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22
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Mar PL, Horbal P, Chung MK, Dukes JW, Ezekowitz M, Lakkireddy D, Lip GYH, Miletello M, Noseworthy PA, Reiffel JA, Tisdale JE, Olshansky B, Gopinathannair R. Drug Interactions Affecting Antiarrhythmic Drug Use. Circ Arrhythm Electrophysiol 2022; 15:e007955. [PMID: 35491871 DOI: 10.1161/circep.121.007955] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiarrhythmic drugs (AAD) play an important role in the management of arrhythmias. Drug interactions involving AAD are common in clinical practice. As AADs have a narrow therapeutic window, both pharmacokinetic as well as pharmacodynamic interactions involving AAD can result in serious adverse drug reactions ranging from arrhythmia recurrence, failure of device-based therapy, and heart failure, to death. Pharmacokinetic drug interactions frequently involve the inhibition of key metabolic pathways, resulting in accumulation of a substrate drug. Additionally, over the past 2 decades, the P-gp (permeability glycoprotein) has been increasingly cited as a significant source of drug interactions. Pharmacodynamic drug interactions involving AADs commonly involve additive QT prolongation. Amiodarone, quinidine, and dofetilide are AADs with numerous and clinically significant drug interactions. Recent studies have also demonstrated increased morbidity and mortality with the use of digoxin and other AAD which interact with P-gp. QT prolongation is an important pharmacodynamic interaction involving mainly Vaughan-Williams class III AAD as many commonly used drug classes, such as macrolide antibiotics, fluoroquinolone antibiotics, antipsychotics, and antiemetics prolong the QT interval. Whenever possible, serious drug-drug interactions involving AAD should be avoided. If unavoidable, patients will require closer monitoring and the concomitant use of interacting agents should be minimized. Increasing awareness of drug interactions among clinicians will significantly improve patient safety for patients with arrhythmias.
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Affiliation(s)
- Philip L Mar
- Department of Medicine, Division of Cardiology, St. Louis University, St. Louis, MO (P.L.M., P.H.)
| | - Piotr Horbal
- Department of Medicine, Division of Cardiology, St. Louis University, St. Louis, MO (P.L.M., P.H.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute (M.K.C.), Cleveland Clinic, OH
| | | | - Michael Ezekowitz
- Lankenau Heart Institute, Bryn Mawr Hospital & Sidney Kimmel Medical College (M.E.)
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, United Kingdom (G.Y.H.L.).,Department of Clinical Medicine, Aalborg, Denmark (G.Y.H.L.)
| | | | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N.)
| | - James A Reiffel
- Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.A.R.)
| | - James E Tisdale
- College of Pharmacy, Purdue University (J.E.T.).,School of Medicine, Indiana University, Indianapolis (J.E.T.)
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City (B.O.)
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23
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Wang J, Sun Z, Tao S. Torsade de pointes caused by citalopram during the pacemaker battery-depletion phase: A case report. Ann Noninvasive Electrocardiol 2022; 27:e12936. [PMID: 35322503 PMCID: PMC9296796 DOI: 10.1111/anec.12936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 12/02/2022] Open
Abstract
Drug‐induced QT prolongation, primarily antiarrhythmic drugs, is a common cause of torsade de pointes (TdP). Although there have been previous reports of drug‐induced TdP in patients, it has not been well documented when caused by citalopram during the pacemaker battery‐depletion phase. To improve delirium recognition, we report a case of citalopram‐induced TdP during the pacemaker battery‐depletion phase. An 84‐year‐old Chinese female was brought to the hospital presenting recurrent syncope. She lost consciousness and was admitted after her syncope TdP was documented. Her pacemaker was inspected and found to be operating in an extremely ineffective manner. Although she had prolonged QT interval after the pacemaker was replaced, she did not suffer another syncope attack, and ECG monitoring revealed no cardiac arrhythmia or TdP. During her admission, she was treated with citalopram for depression. Citalopram was discontinued when the QT interval shortened progressively. In this study, we described a case of citalopram‐induced TdP during the depletion phase of a pacemaker battery. This case should serve as a cautionary lesson to clinicians to avoid using citalopram during the pacemaker battery‐depletion phase.
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Affiliation(s)
- Junwen Wang
- Department of Cardiology, The Affiliated Hospital of Yunnan University, Kunming, China
| | - Ziyi Sun
- Department Intensive Care Unit, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Siming Tao
- Department of Cardiology, The Affiliated Hospital of Yunnan University, Kunming, China
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24
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Liu J, Hou H, Xu H, Chen Y, Su X. Prolonged ST segment and T-wave alternans with torsade de pointes secondary to hypocalcemia due to hypoparathyroidism: A case report. Ann Noninvasive Electrocardiol 2022; 27:e12939. [PMID: 35146844 PMCID: PMC9296802 DOI: 10.1111/anec.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 11/29/2022] Open
Abstract
Hypoparathyroidism predisposes patients to hypocalcemia. Patients with hypoparathyroidism are thus at risk of electrocardiographic abnormalities, including T-wave alternans. T-wave alternans is poorly understood and lacks uniform diagnostic criteria. Its presence suggests myocardial electrical instability, and it has become an important sign for identifying patients at high risk of malignant arrhythmias and sudden cardiac death. We report a rare case of T-wave alternans with torsade de pointes due to hypocalcemia. The etiology of T-wave alternans may easily be overlooked. It should thus be thoroughly investigated to avoid misdiagnosis and poor outcomes.
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Affiliation(s)
- Jiang Liu
- Department of Cardiac Function, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Hong Hou
- Department of Cardiac Function, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Hui Xu
- Department of Cardiac Function, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Yazhuo Chen
- Department of Cardiac Function, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Xiaoling Su
- Department of Cardiology, Qinghai Provincial People's Hospital, Xining, China
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25
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Takahara A, Kawakami S, Aimoto M, Nagasawa Y. Torsadogenic Potential of HCN Channel Blocker Ivabradine Assessed in the Rabbit Proarrhythmia Model. Biol Pharm Bull 2021; 44:1796-1799. [PMID: 34719656 DOI: 10.1248/bpb.b21-00605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Torsadogenic effects of ivabradine, an inhibitor of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, were assessed in an in vivo proarrhythmia model of acute atrioventricular block rabbit. Ivabradine at 0.01, 0.1, and 1 mg/kg was intravenously administered to isoflurane-anesthetized rabbits (n = 5) in the stable idioventricular rhythm. Ivabradine at 0.01 and 0.1 mg/kg hardly affected the atrial and ventricular automaticity, QT interval, or the monophasic action potential duration of the ventricle. Additionally administred ivabradine at 1 mg/kg decreased the atrial and ventricular rate significantly but increased the QT interval and duration of the monophasic action potential. Meanwhile, torsade de pointes arrhythmias were detected in 1 out of 5 animals and in 2 out of 5 animals after the administration of 0.1 and 1 mg/kg, respectively. Importantly, torsade de pointes arrhythmias could be observed only in 2 rabbits showing more potent suppressive effects on ventricular automaticity. These results suggest that the torsadogenic potential of ivabradine may become evident when its expected bradycardic action appears more excessively.
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Affiliation(s)
- Akira Takahara
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University
| | - Satoshi Kawakami
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University
| | - Megumi Aimoto
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University
| | - Yoshinobu Nagasawa
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University
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26
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Koshino K, Endo A, Watanabe N, Okazaki K, Tanabe K. Hydroxyzine-induced Torsade de Pointes in a Patient with Complete Atrioventricular Block. Intern Med 2021; 60:3257-3260. [PMID: 33896871 PMCID: PMC8580752 DOI: 10.2169/internalmedicine.7382-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An 82-year-old woman was admitted to our hospital because of dyspnea and bradycardia during exertion. Electrocardiography revealed complete atrioventricular block. During pacemaker implantation, a small dose (12.5 mg) of hydroxyzine was injected for sedation, and torsade de pointes (Tdp) occurred. The QT interval was prolonged after administration of hydroxyzine, and Tdp was observed after the R on T phenomenon occurred, indicating that hydroxyzine was capable of prolonging the QT interval and causing Tdp. Therefore, we must be cautious when administering hydroxyzine for sedation during surgery, especially in patients with bradycardia.
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Affiliation(s)
- Kaito Koshino
- Division of Cardiology, Shimane University Faculty of Medicine, Japan
| | - Akihiro Endo
- Division of Cardiology, Shimane University Faculty of Medicine, Japan
| | - Nobuhide Watanabe
- Division of Cardiology, Shimane University Faculty of Medicine, Japan
| | - Koichi Okazaki
- Division of Cardiology, Shimane University Faculty of Medicine, Japan
| | - Kazuaki Tanabe
- Division of Cardiology, Shimane University Faculty of Medicine, Japan
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27
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Mantri N, Lu M, Zaroff JG, Risch N, Hoffmann T, Oni-Orisan A, Lee C, Iribarren C. Torsade de pointes: A nested case-control study in an integrated healthcare delivery system. Ann Noninvasive Electrocardiol 2021; 27:e12888. [PMID: 34547155 PMCID: PMC8739596 DOI: 10.1111/anec.12888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background TdP is a form of polymorphic ventricular tachycardia which develops in the setting of a prolonged QT interval. There are limited data describing risk factors, treatment, and outcomes of this potentially fatal arrhythmia. Objective Our goals were as follows: (1) to validate cases presenting with Torsade de Pointes (TdP), (2) to identify modifiable risk factors, and (3) to describe the management strategies used for TdP and its prognosis in a real‐world healthcare setting. Methods Case–control study (with 2:1 matching on age, sex, and race/ethnicity) nested within the Genetic Epidemiology Research on Aging (GERA) cohort. Follow‐up of the cohort for case ascertainment was between January 01, 2005 and December 31, 2018. Results A total of 56 cases of TdP were confirmed (incidence rate = 3.6 per 100,000 persons/years). The average (SD) age of the TdP cases was 74 (13) years, 55 percent were female, and 16 percent were non‐white. The independent predictors of TdP were potassium concentration <3.6 mEq/L (OR = 10.6), prior history of atrial fibrillation/flutter (OR = 6.2), QTc >480 ms (OR = 4.4) and prior history of coronary artery disease (OR = 2.6). Exposure to furosemide and amiodarone was significantly greater in cases than in controls. The most common treatment for TdP was IV magnesium (78.6%) and IV potassium repletion (73.2%). The in‐hospital and 1‐year mortality rates for TdP cases were 10.7% and 25.0% percent, respectively. Conclusions These findings may inform quantitative multivariate risk indices for the prediction of TdP and could guide practitioners on which patients may qualify for continuous ECG monitoring and/or electrolyte replacement therapy.
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Affiliation(s)
- Neha Mantri
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meng Lu
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Jonathan G Zaroff
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Neil Risch
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas Hoffmann
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Akinyemi Oni-Orisan
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Catherine Lee
- Division of Research, Kaiser Permanente, Oakland, CA, USA
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28
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Takahashi K, Yamashita M, Sakaue T, Enomoto D, Uemura S, Okura T, Ikeda S, Takemoto M, Utsunomiya Y, Hyodo T, Ochi M, Higuchi S. Premature atrial contractions with multiple patterns of aberrant conduction followed by torsade de pointes in a patient with polymyalgia rheumatica: A case report. Medicine (Baltimore) 2021; 100:e27286. [PMID: 34664888 PMCID: PMC8448026 DOI: 10.1097/md.0000000000027286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/02/2021] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Recent studies have shown that QT interval prolongation is associated with disease severity and predicts mortality in systemic inflammatory diseases, particularly rheumatoid arthritis. Systemic pro-inflammatory cytokines released from synovial tissues in rheumatoid arthritis, such as interleukin (IL)-1β, IL-6, and tumor necrosis factor-α, could have direct effects on cardiac electrophysiology, particularly changes in the expression and function of potassium and calcium channels, resulting in QT interval prolongation on surface electrocardiogram (ECG) and an increased predisposition to develop lethal ventricular arrhythmias. However, reports on torsade de pointes (TdP) due to acquired long QT syndrome in patients with polymyalgia rheumatica (PMR) are limited. PATIENT CONCERNS An 85-year-old Japanese woman with active PMR developed first syncope. DIAGNOSIS Frequent premature atrial contractions (PACs) with multiple patterns of aberrant conduction, QT interval prolongation, and morphological T-U wave variability followed by TdP were documented. PACs were the first beat of TdP. INTERVENTIONS Amiodarone, together with magnesium and potassium, was intravenously administered. However, TdP resulted in a ventricular arrhythmic storm, for which sedation with mechanical ventilatory support, temporary overdrive cardiac pacing, and intravenous landiolol administration in addition to multiple direct current shocks were effective. OUTCOMES Approximately 2 years later, the patient was treated with amiodarone, propranolol, and prednisolone. She did not undergo implantable cardioverter-defibrillator implantation and was quite well, with no recurrence of ventricular tachyarrhythmia. LESSONS IL-6 hyperproduction in inflamed tissues has been widely confirmed in PMR. Frequent PACs with various patterns of aberrant conduction, QT interval prolongation, and morphological T-U wave variability followed by TdP, for which IL-6-mediated enhancement of L-type Ca2+ current and inhibition of the rapid component of the delayed rectifier K+ current are the most likely mechanisms, were documented in an elderly Japanese woman with PMR. ECG may be recorded once in patients with active PMR even when these patients do not complain of palpitation or syncope. If QT interval prolongation or arrhythmia, including even PACs, is observed, follow-up ECG may be warranted, particularly for patients with some risk factors for QT prolongation that could lead to TdP, such as advanced age, female sex, hypopotassemia, and polypharmacy.
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Affiliation(s)
- Koji Takahashi
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Mina Yamashita
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Tomoki Sakaue
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Daijiro Enomoto
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Shigeki Uemura
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Takafumi Okura
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Shuntaro Ikeda
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Masafumi Takemoto
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
| | - Yutaka Utsunomiya
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
| | - Takashi Hyodo
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
| | - Masayuki Ochi
- Department of Geriatric Medicine and Neurology, Ehime University Graduate School of Medicine, Ehime, Japan
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29
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Abstract
Polymorphic ventricular tachyarrhythmias are highly lethal arrhythmias. Several types of polymorphic ventricular tachycardia have similar electrocardiographic characteristics but have different modes of therapy. In fact, medications considered the treatment of choice for one form of polymorphic ventricular tachycardia, are contraindicated for the other. Yet confusion about terminology, and thus diagnosis and therapy, continues. We present an in-depth review of the different forms of polymorphic ventricular tachycardia and propose a practical step-by-step approach for distinguishing these malignant arrhythmias.
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Affiliation(s)
- Sami Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Ehud Chorin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Dana Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Aviram Hochstadt
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Arie Lorin Schwartz
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Raphael Rosso
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
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30
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Goto A, Sakamoto K, Kambayashi R, Nunoi Y, Izumi-Nakaseko H, Kawai S, Takei Y, Matsumoto A, Kanda Y, Sugiyama A. Torsadogenic Action of Cisapride, dl-Sotalol, Bepridil, and Verapamil Analyzed by the Chronic Atrioventricular Block Cynomolgus Monkeys: Comparison With That Reported in the CiPA In Silico Mechanistic Model. Toxicol Sci 2021; 181:125-133. [PMID: 33544870 DOI: 10.1093/toxsci/kfab015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In order to bridge the gap of information between the in silico model and human subjects, we evaluated torsadogenic risk of cisapride, dl-sotalol, bepridil and verapamil selected from 12 training compounds in the comprehensive in vitro proarrhythmia assay using the chronic atrioventricular block monkeys. Cisapride (0, 1, and 5 mg/kg, n = 5 for each dose), dl-sotalol (0, 1, 3, and 10 mg/kg, n = 5 for each dose), bepridil (0, 10, and 100 mg/kg, n = 4 for each dose), verapamil (0, 1.5, 15, and 75 mg/kg, n = 4 for each dose) were orally administered to the monkeys in conscious state. Five mg/kg of cisapride, 1, 3, and 10 mg/kg of dl-sotalol and 100 mg/kg of bepridil prolonged ΔΔQTcF, which was not observed by verapamil. Torsade de pointes was induced by 5 mg/kg of cisapride in 2 out of 5 animals, by 10 mg/kg of dl-sotalol in 5 out of 5 and by 100 mg/kg of bepridil in 2 out of 4, which was not induced by verapamil. These torsadogenic doses were normalized by their maximum clinical daily ones to estimate torsadogenic risk. The order of risk was dl-sotalol >bepridil ≥cisapride >verapamil in our study. Since the order was bepridil ≥dl-sotalol >cisapride >verapamil in comprehensive in vitro proarrhythmia assay (CiPA) in silico mechanistic model validation, sympathetic regulation on the heart may play a pivotal role in the onset of torsade de pointes in vivo.
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Affiliation(s)
- Ai Goto
- Department of Pharmacology, Toho University Graduate School of Medicine, Ota-ku, Tokyo 143-8540, Japan
| | - Kengo Sakamoto
- Safety Research Center Ina Research Inc., Ina-shi, Nagano 399-4501, Japan
| | - Ryuichi Kambayashi
- Department of Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Yoshio Nunoi
- Department of Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Hiroko Izumi-Nakaseko
- Department of Pharmacology, Toho University Graduate School of Medicine, Ota-ku, Tokyo 143-8540, Japan.,Department of Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Shinichi Kawai
- Department of Inflammation & Pain Control Research, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Yoshinori Takei
- Department of Translational Research & Cellular Therapeutics, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Akio Matsumoto
- Department of Aging Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Yasunari Kanda
- Division of Pharmacology, National Institute of Health Sciences, Kawasaki, Kanagawa 210-9501, Japan
| | - Atsushi Sugiyama
- Department of Pharmacology, Toho University Graduate School of Medicine, Ota-ku, Tokyo 143-8540, Japan.,Department of Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan.,Department of Inflammation & Pain Control Research, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan.,Department of Translational Research & Cellular Therapeutics, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan.,Department of Aging Pharmacology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
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31
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Burke J, Haigney MCP, Farasat M, Mehler PS, Krantz MJ. Huffing and twist: Fatal Torsade de pointes associated with Tetrafluoroethane Inhalation and amphetamine use. Clin Case Rep 2021; 9:CCR33838. [PMID: 34466229 PMCID: PMC8385681 DOI: 10.1002/ccr3.3838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/25/2020] [Accepted: 12/24/2020] [Indexed: 11/12/2022] Open
Abstract
Many volatile chemicals inhaled for a recreational high have a chemical structure similar to chloroform and may lead to Ikr blockade and subsequent torsades de pointes. This is one potential mechanism of action for huffing-associated sudden death.
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Affiliation(s)
- Joseph Burke
- Department of MedicineDivision of CardiologyDenver Health and Hospital AuthorityDenverCOUSA
- Department of MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | | | - Morteza Farasat
- Department of MedicineDivision of CardiologyDenver Health and Hospital AuthorityDenverCOUSA
- Department of MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Philip S. Mehler
- Department of MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Mori J. Krantz
- Department of MedicineDivision of CardiologyDenver Health and Hospital AuthorityDenverCOUSA
- Department of MedicineUniversity of Colorado School of MedicineAuroraCOUSA
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32
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Krantz MJ, Palmer RB, Haigney MCP. Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:205-23. [PMID: 33446314 DOI: 10.1016/j.jacc.2020.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022]
Abstract
Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.
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33
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Chikata A, Kato T, Usuda K, Fujita S, Otowa KI, Maruyama M, Hayashi K, Takamura M. Torsade de Pointes Due to QT Prolongation after Pulmonary Vein Isolation for Persistent Atrial Fibrillation. Intern Med 2021; 60:2089-2092. [PMID: 33518578 PMCID: PMC8313932 DOI: 10.2169/internalmedicine.6627-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We herein report a 60-year-old woman with long-standing persistent atrial fibrillation (AF) who developed QT prolongation and torsade de pointes (TdP) after pulmonary vein isolation (PVI). When electrical cardioversion was performed three months before PVI, prominent QT prolongation was not observed. QT prolongation emerged after PVI and was sustained until AF recurrence on the third day after ablation, and TdP disappeared along with AF recurrence. PVI affects the ganglionated plexi around the atrium, leading to modification of the intrinsic cardiac autonomic system. This case indicates that PVI has the potential risk of inducing lethal ventricular arrhythmias due to QT prolongation.
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Affiliation(s)
- Akio Chikata
- Department of Cardiology, Toyama Prefectural Central Hospital, Japan
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Japan
| | - Takeshi Kato
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Japan
| | - Kazuo Usuda
- Department of Cardiology, Toyama Prefectural Central Hospital, Japan
| | - Shuhei Fujita
- Department of Pediatrics, Toyama Prefectural Central Hospital, Japan
| | - Kan-Ichi Otowa
- Department of Cardiology, Toyama Prefectural Central Hospital, Japan
| | - Michiro Maruyama
- Department of Cardiology, Toyama Prefectural Central Hospital, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Japan
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34
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Zayas-Arrabal J, Alquiza A, Tuncay E, Turan B, Gallego M, Casis O. Molecular and Electrophysiological Role of Diabetes-Associated Circulating Inflammatory Factors in Cardiac Arrhythmia Remodeling in a Metabolic-Induced Model of Type 2 Diabetic Rat. Int J Mol Sci 2021; 22:ijms22136827. [PMID: 34202017 PMCID: PMC8268936 DOI: 10.3390/ijms22136827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Diabetic patients have prolonged cardiac repolarization and higher risk of arrhythmia. Besides, diabetes activates the innate immune system, resulting in higher levels of plasmatic cytokines, which are described to prolong ventricular repolarization. Methods: We characterize a metabolic model of type 2 diabetes (T2D) with prolonged cardiac repolarization. Sprague-Dawley rats were fed on a high-fat diet (45% Kcal from fat) for 6 weeks, and a low dose of streptozotozin intraperitoneally injected at week 2. Body weight and fasting blood glucose were measured and electrocardiograms of conscious animals were recorded weekly. Plasmatic lipid profile, insulin, cytokines, and arrhythmia susceptibility were determined at the end of the experimental period. Outward K+ currents and action potentials were recorded in isolated ventricular myocytes by patch-clamp. Results: T2D animals showed insulin resistance, hyperglycemia, and elevated levels of plasma cholesterol, triglycerides, TNFα, and IL-1b. They also developed bradycardia and prolonged QTc-interval duration that resulted in increased susceptibility to severe ventricular tachycardia under cardiac challenge. Action potential duration (APD) was prolonged in control cardiomyocytes incubated 24 h with plasma isolated from diabetic rats. However, adding TNFα and IL-1b receptor blockers to the serum of diabetic animals prevented the increased APD. Conclusions: The elevation of the circulating levels of TNFα and IL-1b are responsible for impaired ventricular repolarization and higher susceptibility to cardiac arrhythmia in our metabolic model of T2D.
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Affiliation(s)
- Julian Zayas-Arrabal
- Departament of Physiology, Facultad de Farmacia, Universidad del País Vasco UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (J.Z.-A.); (A.A.); (M.G.)
| | - Amaia Alquiza
- Departament of Physiology, Facultad de Farmacia, Universidad del País Vasco UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (J.Z.-A.); (A.A.); (M.G.)
| | - Erkan Tuncay
- Department of Biophysics, Faculty of Medicine, Ankara University, 06100 Ankara, Turkey;
| | - Belma Turan
- Department of Biophysics, Faculty of Medicine, Lokman Hekim University, 06510 Ankara, Turkey;
| | - Monica Gallego
- Departament of Physiology, Facultad de Farmacia, Universidad del País Vasco UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (J.Z.-A.); (A.A.); (M.G.)
| | - Oscar Casis
- Departament of Physiology, Facultad de Farmacia, Universidad del País Vasco UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (J.Z.-A.); (A.A.); (M.G.)
- Correspondence: ; Tel.: +34-945013033
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35
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Lazzerini PE, Cartocci A, Qu YS, Saponara S, Furini S, Fusi F, Fabris F, Gamberucci A, El-Sherif N, Cevenini G, Pettini F, Laghi-Pasini F, Acampa M, Bertolozzi I, Capecchi PL, Lazaro D, Boutjdir M. Proton Pump Inhibitors Directly Block hERG-Potassium Channel and Independently Increase the Risk of QTc Prolongation in a Large Cohort of US Veterans. Circ Arrhythm Electrophysiol 2021; 14:e010042. [PMID: 34143643 DOI: 10.1161/circep.121.010042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences (P.E.L., F.L.-P., P.L.C.), University of Siena, Italy
| | - Alessandra Cartocci
- Department of Medical Biotechnologies (A.C., S.F., G.C., F.P.), University of Siena, Italy
| | - Yongxia Sarah Qu
- Research and Development Department, VA New York Harbor Healthcare System, SUNY Downstate Medical Center (Y.S.Q., F.F., N.E.-S., D.L., M.B.).,Department of Cardiology, New York Presbyterian Brooklyn Methodist Hospital (Y.S.Q.)
| | - Simona Saponara
- Department of Life Sciences (S.S.), University of Siena, Italy
| | - Simone Furini
- Department of Medical Biotechnologies (A.C., S.F., G.C., F.P.), University of Siena, Italy
| | - Fabio Fusi
- Department of Biotechnology, Chemistry and Pharmacy (F.F.), University of Siena, Italy
| | | | - Alessandra Gamberucci
- Department of Molecular and Developmental Medicine (A.G.), University of Siena, Italy
| | | | - Gabriele Cevenini
- Department of Medical Biotechnologies (A.C., S.F., G.C., F.P.), University of Siena, Italy.,Research and Development Department, VA New York Harbor Healthcare System, SUNY Downstate Medical Center (Y.S.Q., F.F., N.E.-S., D.L., M.B.)
| | - Francesco Pettini
- Department of Medical Biotechnologies (A.C., S.F., G.C., F.P.), University of Siena, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences (P.E.L., F.L.-P., P.L.C.), University of Siena, Italy
| | - Maurizio Acampa
- Research and Development Department, VA New York Harbor Healthcare System, SUNY Downstate Medical Center (Y.S.Q., F.F., N.E.-S., D.L., M.B.).,Department of Neurological and Sensorineural Sciences, Stroke Unit, University Hospital of Siena, Italy (M.A.)
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit, Department of Internal Medicine, Nuovo Ospedale San Giovanni di Dio, Florence, Italy (I.B.)
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences (P.E.L., F.L.-P., P.L.C.), University of Siena, Italy
| | - Deana Lazaro
- Research and Development Department, VA New York Harbor Healthcare System, SUNY Downstate Medical Center (Y.S.Q., F.F., N.E.-S., D.L., M.B.)
| | - Mohamed Boutjdir
- Research and Development Department, VA New York Harbor Healthcare System, SUNY Downstate Medical Center (Y.S.Q., F.F., N.E.-S., D.L., M.B.).,Department of Medicine, NYU School of Medicine, New York, NY (M.B.)
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36
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Simon M, Rague J. A Case Report of Torsade de Pointes and Brugada Pattern Associated with Loperamide Misuse and Supratherapeutic Loperamide Concentrations. J Emerg Med 2021:S0736-4679(21)00389-9. [PMID: 34127340 DOI: 10.1016/j.jemermed.2021.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Loperamide, commonly sold under the brand name Imodium® (Johnson & Johnson, Fort Washington, PA), is a widely available, over-the-counter antidiarrheal medication that possesses µ-opioid agonist properties and can have catastrophic cardiac events when misused or abused. Since the start of the opioid epidemic in the United States, there has been an increasing number of case reports and deaths linking loperamide abuse with cardiac events such as torsades de pointes (TdP) and Brugada syndrome. CASE REPORT This case report presents a 22-year-old man who presented in cardiac arrest from polymorphic ventricular tachycardia consistent with TdP and a Type 1 Brugada pattern after intentional loperamide abuse. We discuss this patient's management and the proposed pathophysiology of these two cardiotoxicities, of which, to our knowledge, no previously published case report has displayed both in the same patient after a supratherapeutic loperamide ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the prevalence of opioid dependency and misuse has increased, so, too, has the misuse of un-scheduled medications such as loperamide to achieve central nervous system opioid effects. It is important for the emergency physician to know about and understand loperamide-associated cardiotoxicities such as prolongation of the QRS, unmasking of Brugada patterns, QT prolongation, or ventricular dysrhythmias such as TdP to be able to recognize and treat it.
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37
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Takahashi K, Yamashita M, Sakaue T, Enomoto D, Uemura S, Okura T, Ikeda S, Takemoto M, Utsunomiya Y, Hyodo T. Suppression of amiodarone-induced torsade de pointes by landiolol in a patient with atrial fibrillation-mediated cardiomyopathy. Ann Noninvasive Electrocardiol 2021; 26:e12842. [PMID: 33755267 PMCID: PMC8588365 DOI: 10.1111/anec.12842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 12/28/2022] Open
Abstract
An elderly Japanese woman developed acute decompensated heart failure caused by persistent atrial fibrillation (AF) and left ventricular systolic dysfunction. Approximately 6 days after starting intravenous administration of amiodarone (600 mg/day) for maintaining sinus rhythm after cardioversion of AF, electrocardiograms revealed a prolonged QT interval associated with torsade de pointes (TdP). The amiodarone-induced TdP disappeared after intravenous administration of landiolol plus magnesium and potassium, without discontinuation of amiodarone or overdrive cardiac pacing, although the prolonged QT interval persisted. To the best of our knowledge, this is the first report that landiolol could be effective for amiodarone-induced TdP.
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Affiliation(s)
- Koji Takahashi
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan.,Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Mina Yamashita
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Tomoki Sakaue
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan.,Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Daijiro Enomoto
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Shigeki Uemura
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Takafumi Okura
- Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Shuntaro Ikeda
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan.,Department of Cardiology, Yawatahama City General Hospital, Ehime, Japan
| | - Masafumi Takemoto
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
| | - Yutaka Utsunomiya
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
| | - Takashi Hyodo
- Department of Medical Engineering, Yawatahama City General Hospital, Ehime, Japan
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38
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Cicirale C, Jackson J, Gothard D. Safety of Inpatient Dofetilide Initiation per Cardiology Services: A Retrospective Review. J Pharm Pract 2021; 35:593-598. [PMID: 33736527 DOI: 10.1177/08971900211000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Dofetilide is an antiarrhythmic medication that has the potential to cause life threatening arrhythmias, such as Torsade de pointes. The 2014 ACC/AHA/HRS guidelines for the management of patients with atrial fibrillation state that patients need to meet certain criteria to be initiated on dofetilide. Patients who are not initiated on this therapy according to the guideline criteria are likely to be at higher risk of adverse reactions. METHODS This is a single center, retrospective chart review of patients who were initiated on dofetilide from July 2016-December 2019. Patients included in the study were initiated on dofetilide as a new antiarrhythmic and monitored inpatient for 3 days. The primary outcome was a composite of incidence of cardiac arrhythmias, cardiac arrest, cardiac death, and cardiac related hospital readmission. RESULTS There were 224 patients included in the analysis: 190 patients who were initiated on dofetilide inappropriately and 34 that were initiated appropriately. The primary outcome (composite of cardiac arrhythmia, cardiac arrest, cardiac death, and hospital readmission) was statistically significant with more patients experiencing an outcome in the group initiated inappropriately. CONCLUSIONS Patients are placed at a higher risk of adverse reactions when this potentially dangerous antiarrhythmic medication is not used according to the protocol set forth by the guidelines. Practitioners should use caution when prescribing dofetilide. Other antiarrhythmic medications or non-pharmacologic options should be considered due to the incidence of these dangerous adverse reactions.
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39
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Affiliation(s)
- Arja S Vink
- Department of Clinical and Experimental Cardiology Amsterdam University Medical CentersUniversity of AmsterdamHeart Center Amsterdam the Netherlands.,Department of Pediatric Cardiology Emma Children's HospitalAmsterdam University Medical CentersUniversity of Amsterdam Amsterdam the Netherlands
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology Amsterdam University Medical CentersUniversity of AmsterdamHeart Center Amsterdam the Netherlands
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40
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Hasegawa K, Ito H, Kaseno K, Miyazaki S, Shiomi Y, Tama N, Ikeda H, Ishida K, Uzui H, Ohno S, Horie M, Yokoyama O, Tada H. Impact of Medical Castration on Malignant Arrhythmias in Patients With Prostate Cancer. J Am Heart Assoc 2021; 10:e017267. [PMID: 33599136 PMCID: PMC8174268 DOI: 10.1161/jaha.120.017267] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Medical castration, gonadotropin‐releasing hormone agonists, and antiandrogens have been widely applied as a treatment for prostate cancer. Sex steroid hormones influence cardiac ion channels. However, few studies have examined the proarrhythmic properties of medical castration. Methods and Results This study included 149 patients who underwent medical castration using gonadotropin‐releasing hormones with/without antiandrogen for prostate cancer. The changes in the ECG findings during the therapy and associations of the electrocardiographic findings with malignant arrhythmias were studied. The QT and corrected QT (QTc) intervals prolonged during the therapy compared with baseline (QT, 394±32 to 406±39 ms [P<0.001]; QTc, 416±27 to 439±31 ms [P<0.001]). The QTc interval was prolonged in 119 (79.9%) patients during the therapy compared with baseline. In 2 (1.3%) patients who had no structural heart disease, torsade de pointes (TdP) and ventricular fibrillation (VF) occurred ≥6 months after starting the therapy. In patients with TdP/VF, the increase in the QTc interval from the pretreatment value was >80 ms. However, in patients without TdP/VF, the prevalence of an increase in the QTc interval from the pretreatment value of >50 ms was 11%, and an increase in the QTc interval from the pretreatment value >80 ms was found in only 4 (3%) patients. Conclusions Medical castration prolongs the QT/QTc intervals in most patients with prostate cancer, and it could cause TdP/VFs even in patients with no risk of QT prolongation before the therapy. An increase in the QTc interval from the pretreatment value >50 ms might become a predictor of TdP/VF. Much attention should be paid to the QTc interval throughout all periods of medical castration to prevent malignant arrhythmias.
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Affiliation(s)
- Kanae Hasegawa
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hideaki Ito
- Department of Urology Faculty of Medical Science University of Fukui Japan
| | - Kenichi Kaseno
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Yuichiro Shiomi
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Naoto Tama
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hiroyuki Ikeda
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Kentaro Ishida
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Seiko Ohno
- Department of Bioscience and Genetics National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine Shiga University of Medical Science Otsu Japan
| | - Osamu Yokoyama
- Department of Urology Faculty of Medical Science University of Fukui Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
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41
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Coromilas EJ, Kochav S, Goldenthal I, Biviano A, Garan H, Goldbarg S, Kim JH, Yeo I, Tracy C, Ayanian S, Akar J, Singh A, Jain S, Zimerman L, Pimentel M, Osswald S, Twerenbold R, Schaerli N, Crotti L, Fabbri D, Parati G, Li Y, Atienza F, Zatarain E, Tse G, Leung KSK, Guevara-Valdivia ME, Rivera-Santiago CA, Soejima K, De Filippo P, Ferrari P, Malanchini G, Kanagaratnam P, Khawaja S, Mikhail GW, Scanavacca M, Abrahão Hajjar L, Rizerio B, Sacilotto L, Mollazadeh R, Eslami M, Laleh Far V, Mattioli AV, Boriani G, Migliore F, Cipriani A, Donato F, Compagnucci P, Casella M, Dello Russo A, Coromilas J, Aboyme A, O'Brien CG, Rodriguez F, Wang PJ, Naniwadekar A, Moey M, Kow CS, Cheah WK, Auricchio A, Conte G, Hwang J, Han S, Lazzerini PE, Franchi F, Santoro A, Capecchi PL, Joglar JA, Rosenblatt AG, Zardini M, Bricoli S, Bonura R, Echarte-Morales J, Benito-González T, Minguito-Carazo C, Fernández-Vázquez F, Wan EY. Worldwide Survey of COVID-19-Associated Arrhythmias. Circ Arrhythm Electrophysiol 2021; 14:e009458. [PMID: 33554620 PMCID: PMC7982128 DOI: 10.1161/circep.120.009458] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Supplemental Digital Content is available in the text. Coronavirus disease 2019 (COVID-19) has led to over 1 million deaths worldwide and has been associated with cardiac complications including cardiac arrhythmias. The incidence and pathophysiology of these manifestations remain elusive. In this worldwide survey of patients hospitalized with COVID-19 who developed cardiac arrhythmias, we describe clinical characteristics associated with various arrhythmias, as well as global differences in modulations of routine electrophysiology practice during the pandemic.
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Affiliation(s)
- Ellie J Coromilas
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
| | - Stephanie Kochav
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
| | - Isaac Goldenthal
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
| | - Angelo Biviano
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
| | - Seth Goldbarg
- New York Presbyterian Queens, Weill Medical College (S.G., J.-H.K., I.Y.)
| | - Joon-Hyuk Kim
- New York Presbyterian Queens, Weill Medical College (S.G., J.-H.K., I.Y.)
| | - Ilhwan Yeo
- New York Presbyterian Queens, Weill Medical College (S.G., J.-H.K., I.Y.)
| | - Cynthia Tracy
- The George Washington University School of Medicine & Health Sciences, The GW Medical Faculty Associates, Washington, DC (C.T., S.A.)
| | - Shant Ayanian
- The George Washington University School of Medicine & Health Sciences, The GW Medical Faculty Associates, Washington, DC (C.T., S.A.)
| | - Joseph Akar
- Section of Cardiovascular Disease, Yale University School of Medicine, New Haven, CT (J.A., A. Singh, S.J.)
| | - Avinainder Singh
- Section of Cardiovascular Disease, Yale University School of Medicine, New Haven, CT (J.A., A. Singh, S.J.)
| | - Shashank Jain
- Section of Cardiovascular Disease, Yale University School of Medicine, New Haven, CT (J.A., A. Singh, S.J.)
| | - Leandro Zimerman
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil (L.Z., M.P.)
| | - Maurício Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil (L.Z., M.P.)
| | - Stefan Osswald
- Department of Cardiology & Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland (S.O., R.T., N.S.)
| | - Raphael Twerenbold
- Department of Cardiology & Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland (S.O., R.T., N.S.)
| | - Nicolas Schaerli
- Department of Cardiology & Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland (S.O., R.T., N.S.)
| | - Lia Crotti
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural & Metabolic Sciences, San Luca Hospital, Milan, Italy (L.C., D.F., G.P.).,Department of Medicine & Surgery, University of Milano-Bicocca, Milan, Italy (L.C., D.F., G.P.)
| | - Daniele Fabbri
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural & Metabolic Sciences, San Luca Hospital, Milan, Italy (L.C., D.F., G.P.).,Department of Medicine & Surgery, University of Milano-Bicocca, Milan, Italy (L.C., D.F., G.P.)
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural & Metabolic Sciences, San Luca Hospital, Milan, Italy (L.C., D.F., G.P.).,Department of Medicine & Surgery, University of Milano-Bicocca, Milan, Italy (L.C., D.F., G.P.)
| | - Yi Li
- Wuhan Asia General Hospital, China (Y.L.)
| | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) (F.A., E.Z.).,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain (F.A., E.Z.)
| | - Eduardo Zatarain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) (F.A., E.Z.).,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain (F.A., E.Z.)
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, China (G.T.).,School of Life Sciences. The Hospital Authority of Hong Kong, Hong Kong, China (G.T.).,Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, China (G.T.)
| | - Keith Sai Kit Leung
- Aston Medical School, Aston University, Birmingham, United Kingdom (K.C.K.L.)
| | - Milton E Guevara-Valdivia
- UMAE Hospital de Especialidades Dr. Antonio Fraga Mouret CMN La Raza IMSS, CDMX, Mexico (M.E.G.-V., C.A.R.-S.)
| | - Carlos A Rivera-Santiago
- UMAE Hospital de Especialidades Dr. Antonio Fraga Mouret CMN La Raza IMSS, CDMX, Mexico (M.E.G.-V., C.A.R.-S.)
| | - Kyoko Soejima
- Kyorin University School of Medicine, Tokyo, Japan (K.S.)
| | - Paolo De Filippo
- Electrophysiology & Cardiac Pacing Unit, Cardiology Department, ASST Papa Giovanni XXIII, Bergamo, Italy (P.D.F., P.F., G.M.)
| | - Paola Ferrari
- Electrophysiology & Cardiac Pacing Unit, Cardiology Department, ASST Papa Giovanni XXIII, Bergamo, Italy (P.D.F., P.F., G.M.)
| | - Giovanni Malanchini
- Electrophysiology & Cardiac Pacing Unit, Cardiology Department, ASST Papa Giovanni XXIII, Bergamo, Italy (P.D.F., P.F., G.M.)
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, United Kingdom (P.K., S. Khawaja, G.W.M.)
| | - Saud Khawaja
- Imperial College Healthcare NHS Trust, London, United Kingdom (P.K., S. Khawaja, G.W.M.)
| | - Ghada W Mikhail
- Imperial College Healthcare NHS Trust, London, United Kingdom (P.K., S. Khawaja, G.W.M.)
| | - Mauricio Scanavacca
- Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil (M.S., A.H., B.R., L.S.)
| | - Ludhmila Abrahão Hajjar
- Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil (M.S., A.H., B.R., L.S.)
| | - Brenno Rizerio
- Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil (M.S., A.H., B.R., L.S.)
| | - Luciana Sacilotto
- Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil (M.S., A.H., B.R., L.S.)
| | - Reza Mollazadeh
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran (R.M., M.E., V.L.f.)
| | - Masoud Eslami
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran (R.M., M.E., V.L.f.)
| | - Vahideh Laleh Far
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran (R.M., M.E., V.L.f.)
| | | | - Giuseppe Boriani
- University of Modena & Reggio Emilia, Modena, Italy (V.M., G.B.)
| | - Federico Migliore
- Department of Cardiac, Thoracic, Vascular Sciences & Public Health, University of Padova, Italy (F.M., A.C., F.D.)
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, Vascular Sciences & Public Health, University of Padova, Italy (F.M., A.C., F.D.)
| | - Filippo Donato
- Department of Cardiac, Thoracic, Vascular Sciences & Public Health, University of Padova, Italy (F.M., A.C., F.D.)
| | - Paolo Compagnucci
- Cardiology & Arrhythmology Clinic, University Hospital "Ospedali Riuniti," Marche Polytechnic University, Ancona, Italy (P.C., M.C., A.D.R.)
| | - Michela Casella
- Cardiology & Arrhythmology Clinic, University Hospital "Ospedali Riuniti," Marche Polytechnic University, Ancona, Italy (P.C., M.C., A.D.R.)
| | - Antonio Dello Russo
- Cardiology & Arrhythmology Clinic, University Hospital "Ospedali Riuniti," Marche Polytechnic University, Ancona, Italy (P.C., M.C., A.D.R.)
| | - James Coromilas
- Division of Cardiovascular Disease & Hypertension, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.C., A. Aboyme)
| | - Andrew Aboyme
- Division of Cardiovascular Disease & Hypertension, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.C., A. Aboyme)
| | - Connor Galen O'Brien
- Department of Medicine, Division of Cardiology, University of California San Francisco School of Medicine (C.G.O.)
| | | | - Paul J Wang
- Division of Cardiology, Stanford University, CA (F.R., P.J.W.)
| | | | - Melissa Moey
- East Carolina University, Greenville, NC (A.N., M.M.)
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur (C.S.K.)
| | - Wee Kooi Cheah
- Department of Medicine & Clinical Research Center, Taiping Hospital, Perak, Malaysia (W.K.C.)
| | - Angelo Auricchio
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A. Auricchio, G.C.)
| | - Giulio Conte
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A. Auricchio, G.C.)
| | - Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea (J.H., S.H.)
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea (J.H., S.H.)
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery & Neurosciences, University of Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.).,Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.)
| | - Federico Franchi
- Department of Medical Sciences, Surgery & Neurosciences, University of Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.).,Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.)
| | - Amato Santoro
- Department of Medical Sciences, Surgery & Neurosciences, University of Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.).,Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.)
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery & Neurosciences, University of Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.).,Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy (P.E.L., F.F., A. Santoro, P.L.C.)
| | - Jose A Joglar
- University of Texas Southwestern Medical Center, Dallas (J.A.G., A.G.R.)
| | - Anna G Rosenblatt
- University of Texas Southwestern Medical Center, Dallas (J.A.G., A.G.R.)
| | - Marco Zardini
- Division of Cardiology, University Hospital "Ospedale Maggiore," Parma, Italy (M.Z., S.B., R.B.)
| | - Serena Bricoli
- Division of Cardiology, University Hospital "Ospedale Maggiore," Parma, Italy (M.Z., S.B., R.B.)
| | - Rosario Bonura
- Division of Cardiology, University Hospital "Ospedale Maggiore," Parma, Italy (M.Z., S.B., R.B.)
| | - Julio Echarte-Morales
- Department of Cardiology, University Hospital of Leon, Spain (J.E.-M., T.B.-G., C.M.-C., F.F.-V.)
| | - Tomás Benito-González
- Department of Cardiology, University Hospital of Leon, Spain (J.E.-M., T.B.-G., C.M.-C., F.F.-V.)
| | - Carlos Minguito-Carazo
- Department of Cardiology, University Hospital of Leon, Spain (J.E.-M., T.B.-G., C.M.-C., F.F.-V.)
| | - Felipe Fernández-Vázquez
- Department of Cardiology, University Hospital of Leon, Spain (J.E.-M., T.B.-G., C.M.-C., F.F.-V.)
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.)
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Abstract
Background Amiodarone causes less drug-induced torsade de pointes (TdP) compared to other class III antiarrhythmics. Two theories proposed for this finding include that amiodarone has less repolarization heterogeneity, and/or decreases early after depolarization (EADs). Corrected QT (QTc) dispersion as measured on a surface electrocardiogram (ECG) represents spatial heterogeneity of ventricular repolarization. Objective The purpose of this study was to analyze the difference in QT dispersion between amiodarone and other class III antiarrhythmics and to determine the etiology of TdP. Methods This was a retrospective, observational study at Montefiore Medical Center between January 2005 and January 2015. Inclusion criteria were adults >18 years on amiodarone, dofetilide, or sotalol with prolonged QT interval on 12-lead ECG. ECGs were reviewed by three blinded observers. QTc was calculated using the Bazett and Framingham formulas. QTc dispersion was calculated by subtracting the shortest from the longest QTc. Analysis of variance (ANOVA) was applied for comparison between antiarrhythmic groups with Bonferroni correction for multiple comparisons. Results A total of 447 ECGs were reviewed and 77 ECGs met inclusion criteria. The average QT dispersion for amiodarone, dofetilide, and sotalol was 0.050, 0.037, and 0.034, respectively (p=0.006) and the average QTc dispersion by Bazett was 0.053, 0.038, and 0.037 (p=0.008) and by Framingham was 0.049, 0.036, and 0.035 (p=0.009), respectively. Conclusion Our results show that given the increase in QT dispersion seen with amiodarone, heterogeneous ventricular repolarization as measured by QTc dispersion likely does not account for the lower incidence of drug-induced TdP seen with amiodarone. The ability of amiodarone to decrease EADs via sodium-channel blockade is more likely the explanation for its lower incidence of drug-induced TdP.
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Affiliation(s)
- Ari Friedman
- Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, USA
| | - Jeremy Miles
- Cardiology, Montefiore Medical Center, Bronx, USA
| | - Jared Liebelt
- Cardiology, North Shore University Health Systems-Metro Chicago, Chicago, USA
| | | | | | - Rosy Thachil
- Cardiology, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, USA
| | - Michael Grushko
- Cardiology, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, USA
| | - Robert T Faillace
- Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, USA
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43
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Soghomonyan S, Stoicea N, Ackermann W, Bhandary SP. PONV management in patients with QTc prolongation on the EKG. Front Pharmacol 2021; 11:565704. [PMID: 33551794 PMCID: PMC7861054 DOI: 10.3389/fphar.2020.565704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/25/2020] [Indexed: 11/15/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.
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Affiliation(s)
- S Soghomonyan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - W Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - S P Bhandary
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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44
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Kumar S, Gayle JA, Mogalapalli A, Hussain ST, Castiglioni A. Escitalopram Induced Torsade de Pointes and Cardiac Arrest in a Patient With Surgically Treated Mitral Valve Prolapse. Cureus 2020; 12:e11960. [PMID: 33425536 PMCID: PMC7788002 DOI: 10.7759/cureus.11960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A 54-year-old female, with a history of prosthetic mitral valve replacement due to mitral valve prolapse one year prior, was admitted after suffering a cardiopulmonary arrest. Her initial rhythm demonstrated Torsade de Pointes with the initial electrocardiogram (ECG) showing a prolonged QT interval. Laboratory test results were normal including potassium and magnesium serum levels, and imaging did not show significant abnormalities. A review of patients' medicines showed that the patient started taking escitalopram one month prior to the presentation for major depressive disorder. Selective serotonin reuptake inhibitors (SSRI) are widely prescribed and continue to be a mainstay of treatment for multiple psychiatric conditions. It is important to keep the potential cardiovascular side effects of SSRIs in mind when prescribing. Consideration of underlying cardiac conditions is vital to decrease the likelihood of poor outcomes.
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Affiliation(s)
- Sundeep Kumar
- Cardiovascular Disease, Saint Louis University Hospital, St. Louis, USA.,Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Jovan A Gayle
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Akhil Mogalapalli
- Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Sayed T Hussain
- Cardiology, University of Central Florida College of Medicine, Orlando, USA
| | - Analia Castiglioni
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
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45
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Yonai R, Kawabata M, Maeda S, Kawashima T, Tsuda Y, Nakasone T, Nakane H, Hirao K. Torsade de pointes induced by intravenous amiodarone therapy accompanied by marked augmentation of the transmural dispersion of repolarization in a patient with tachycardia-induced-cardiomyopathy. Ann Noninvasive Electrocardiol 2020; 26:e12810. [PMID: 33070441 PMCID: PMC8164138 DOI: 10.1111/anec.12810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/26/2020] [Indexed: 11/30/2022] Open
Abstract
We report a 77-year-old human on renal dialysis for end-stage renal disease with heart failure and atrial fibrillation (AF) complicated by a high ventricular frequency. The underlying disease was thought as tachycardia-induced-cardiomyopathy. Intravenous infusion of amiodarone was initiated, and direct current cardioversion succeeded in converting AF to sinus rhythm. Then, excessive increases in the QT and Tpeak-Tend (Tp-e) intervals were seen and hypokalemia induced by hemodialysis led to the development of numerous episodes of torsades de pointes (TdP). Magnesium repletion was effective in preventing TdP, while Tp-e intervals returned to the previous values 2 days after the discontinuation of amiodarone.
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Affiliation(s)
- Ryo Yonai
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Mihoko Kawabata
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Shingo Maeda
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Tomoyuki Kawashima
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Yasuhide Tsuda
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Takashi Nakasone
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Hiroki Nakane
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | - Kenzo Hirao
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
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46
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Saleh M, Gabriels J, Chang D, Fishbein J, Qiu M, Mountantonakis SE, Epstein LM. Safely Administering Potential QTc Prolonging Therapy Across a Large Health Care System in the COVID-19 Era. Circ Arrhythm Electrophysiol 2020; 13:e008937. [PMID: 33003964 PMCID: PMC7668332 DOI: 10.1161/circep.120.008937] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Supplemental Digital Content is available in the text. Background: The severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2) has resulted in a global pandemic. Hydroxychloroquine±azithromycin have been widely used to treat coronavirus disease 2019 (COVID-19) despite a paucity of evidence regarding efficacy. The incidence of torsade de pointes remains unknown. Widespread use of these medications forced overwhelmed health care systems to search for ways to effectively monitor these patients while simultaneously trying to minimize health care provider exposure and use of personal protective equipment. Methods: Patients with COVID-19 positive who received hydroxychloroquine±azithromycin across 13 hospitals between March 1 and April 15 were included in this study. A comprehensive search of the electronic medical records was performed using a proprietary python script to identify any mention of QT prolongation, ventricular tachy-arrhythmias and cardiac arrest. Results: The primary outcome of torsade de pointes was observed in 1 (0.015%) out of 6476 hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin. Sixty-seven (1.03%) had hydroxychloroquine±azithromycin held or discontinued due to an average QT prolongation of 60.5±40.5 ms from a baseline QTc of 473.7±35.9 ms to a peak QTc of 532.6±31.6 ms. Of these patients, hydroxychloroquine±azithromycin were discontinued in 58 patients (86.6%), while one or more doses of therapy were held in the remaining nine (13.4%). A simplified approach to monitoring for QT prolongation and arrythmia was implemented on April 5. There were no deaths related to the medications with the simplified monitoring approach and health care provider exposure was reduced. Conclusions: The risk of torsade de pointes is low in hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin therapy.
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Affiliation(s)
- Moussa Saleh
- Department of Cardiology (M.S., J.G., D.C., S.E.M., L.M.E.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - James Gabriels
- Department of Cardiology (M.S., J.G., D.C., S.E.M., L.M.E.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - David Chang
- Department of Cardiology (M.S., J.G., D.C., S.E.M., L.M.E.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - Joanna Fishbein
- Biostatistics Unit (J.F.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - Michael Qiu
- Institute of Health Innovations and Outcomes Research & Center for Research Informatics & Innovation (M.Q.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - Stavros E Mountantonakis
- Department of Cardiology (M.S., J.G., D.C., S.E.M., L.M.E.), The Feinstein Institutes for Medical Research, Northwell Health, NY
| | - Laurence M Epstein
- Department of Cardiology (M.S., J.G., D.C., S.E.M., L.M.E.), The Feinstein Institutes for Medical Research, Northwell Health, NY
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47
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Mizuno M, Masumori C, Sakurai K, Nakano M, Aso K. Anti-Ro/SSA antibody-related atrioventricular block-induced torsade de pointes. Pediatr Int 2020; 62:1101-1103. [PMID: 32744378 DOI: 10.1111/ped.14232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Masanori Mizuno
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Chikako Masumori
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kenzo Sakurai
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Marie Nakano
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kentaro Aso
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
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48
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Anupama BK, Adhikari S, Chaudhuri D. Prolonged QT Interval in a Patient With Coronavirus Disease-2019: Beyond Hydroxychloroquine and Azithromycin. J Investig Med High Impact Case Rep 2020; 8:2324709620948407. [PMID: 32762368 PMCID: PMC7418230 DOI: 10.1177/2324709620948407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Recent reports have suggested an increased risk of QT prolongation and subsequent life-threatening ventricular arrhythmias, particularly torsade de pointes, in patients with coronavirus disease-2019 (COVID-19) treated with hydroxychloroquine and azithromycin. In this article, we report the case of a 75-year-old female with a baseline prolonged QT interval in whom the COVID-19 illness resulted in further remarkable QT prolongation (>700 ms), precipitating recurrent self-terminating episodes of torsade de pointes that necessitated temporary cardiac pacing. Despite the correction of hypoxemia and the absence of reversible factors, such as adverse medication effects, electrolyte derangements, and usage of hydroxychloroquine/azithromycin, the QT interval remained persistently prolonged compared with the baseline with subsequent degeneration into ventricular tachycardia and death. Thus, we highlight that COVID-19 illness itself can potentially lead to further prolongation of QT interval and unmask fatal ventricular arrhythmias in patients who have a prolonged QT and low repolarization reserve at baseline.
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Affiliation(s)
- B K Anupama
- SUNY Upstate Medical University, Syracuse, NY, USA
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49
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Affiliation(s)
- Adi Lador
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
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50
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Abstract
Brugada syndrome, also called Pokkuri Death Syndrome, is an autosomal dominant electrophysiological phenomenon that increases the risk of spontaneous ventricular tachyarrhythmia and sudden cardiac death. Due to sodium channel mutations in the cardiac membrane, most commonly SCN5A and SCN10A, the heart can be triggered into a fatal arrhythmia. Brugada syndrome can be triggered by fever, and medications including antiarrhythmics, psychotropics, and recreational drugs like cocaine and marijuana. We report a case that demonstrates the diagnosis of Brugada syndrome in an otherwise very healthy 22-year-old African-American male. He presented after a syncopal event and developed spontaneous ventricular tachycardia and torsades de pointes. Electrocardiogram (EKG) findings documented a type I Brugada pattern and, once stabilized, the patient underwent an internal cardioverter defibrillator (ICD) placement.
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Affiliation(s)
| | - Adam Rosenblum
- Internal Medicine, Campbell University School of Osteopathic Medicine, Fayetteville, USA
| | - Alex Byrd
- Internal Medicine, Cape Fear Valley Health System, Fayetteville, USA
| | | | - Manoj Bhandari
- Cardiology, Cape Fear Valley Health System, Fayetteville, USA
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