Prevention of Torsade de Pointes in Hospital Settings: A Scientific Statement From the American Heart Association and the American College of Cardiology Foundation

Circulation (Impact Factor: 14.43). 02/2010; 121(8):1047-60. DOI: 10.1161/CIRCULATIONAHA.109.192704
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Available from: Michael John Ackerman, Feb 14, 2014
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    • "With this novel continuous QTc measurement tool now available, further study should explore whether it is appropriate to monitor intensive care patients with continuous monitoring of the QTc interval, in particular when the severity of illness is high. Recent statement from the American Heart Association recommends hospitalized that patients should have continuous QTc monitoring when they receive QTcprolonging drugs, when electrolyte disturbances (potassium or magnesium) are present, when bradycardia is present, or when the reason for admission was drug overdose [7]. A previous study showed that 69% of the intensive care patients had 1 or more American Heart Association indications for continuous QTc monitoring [6] [19]. "
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    ABSTRACT: Purpose: Critically ill patients are at risk for prolongation of the interval between the Q wave and the T wave in the electrocardiogram (corrected QT [QTc]). Corrected QT prolongation is probably a dynamic process. It is unknown how many patients have a QTc prolongation during their intensive care stay and how variable QTc prolongation is. Materials and methods: In a prospective cohort study, continuous 5-minute QTc measurements of 50 consecutive patients were collected. A prolonged QTc interval was more than 500 milliseconds for at least 15 minutes. The QT variance and variability index was used to evaluate QTc variation. Results: Fifty-two percent of included patients had a prolonged QTc interval. In a single patient, 0.2% to 91.3% of the QTc intervals over time were prolonged. The use of erythromycin and amiodarone was associated with the mean QTc (P = .02 and P = .006, respectively). The Acute Physiology and Chronic Health Evaluation IV and Sequential Organ Failure Assessment scores were significantly higher in patients with a prolonged QTc interval (30.8 vs 8.6 and 7 vs 5.5, respectively). Eighty-four percent of all patients received at least 1 QTc-prolonging drug. The QT variance and QTc variance were significantly higher in patients with a prolonged QTc (P = .019 and P = .001, respectively). Conclusion: Continuous QTc monitoring showed a prolonged QTc interval in 52% of intensive care patients. Severity of illness and QT and QTc variances are higher in these patients.
    Full-text · Article · May 2014 · Journal of Critical Care
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    • "Patients who did not receive any kind of 5-HT3 receptor antagonist intraoperatively were enrolled in the control group. Patients with ischemic heart disease, previous myocardial infarction, congestive heart failure, congenital long QT syndrome, preoperative QTc prolongation > 500 ms, or significant arrhythmias including atrial fibrillation, bundle branch block, or atrioventricular block were excluded, because these are known risk factors for QTc prolongation and torsade de pointes [13]. Patients with an anesthetic duration < 2 h were also excluded. "
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    ABSTRACT: Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P < 0.001). The changes in the QTc intervals were not different between the two groups (P = 0.41). However, six patients in the palonosetron group showed a QTc interval > 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.
    Full-text · Article · Nov 2013 · Korean journal of anesthesiology
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    • "In addition, a long list of warnings of TdP risk from regulatory agencies has begun to accrue, resulting in a reduction of therapeutic alternatives in the prescribers’ toolkit. From the clinical standpoint, TdP frequently terminates spontaneously, causing syncope, but can sometimes degenerate into ventricular fibrillation with cardiac arrest and sudden cardiac death (SCD) if not resuscitated [4]. The point at which the physician observes an evolving arrhythmic event (such as TdP) therefore influences how the event will be described and reported. "
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    ABSTRACT: BACKGROUND: Drug-induced torsades de pointes (TdP) and related clinical entities represent a current regulatory and clinical burden. OBJECTIVE: As part of the FP7 ARITMO (Arrhythmogenic Potential of Drugs) project, we explored the publicly available US FDA Adverse Event Reporting System (FAERS) database to detect signals of torsadogenicity for antipsychotics (APs). METHODS: Four groups of events in decreasing order of drug-attributable risk were identified: (1) TdP, (2) QT-interval abnormalities, (3) ventricular fibrillation/tachycardia, and (4) sudden cardiac death. The reporting odds ratio (ROR) with 95 % confidence interval (CI) was calculated through a cumulative analysis from group 1 to 4. For groups 1+2, ROR was adjusted for age, gender, and concomitant drugs (e.g., antiarrhythmics) and stratified for AZCERT drugs, lists I and II ( , as of June 2011). A potential signal of torsadogenicity was defined if a drug met all the following criteria: (a) four or more cases in group 1+2; (b) significant ROR in group 1+2 that persists through the cumulative approach; (c) significant adjusted ROR for group 1+2 in the stratum without AZCERT drugs; (d) not included in AZCERT lists (as of June 2011). RESULTS: Over the 7-year period, 37 APs were reported in 4,794 cases of arrhythmia: 140 (group 1), 883 (group 2), 1,651 (group 3), and 2,120 (group 4). Based on our criteria, the following potential signals of torsadogenicity were found: amisulpride (25 cases; adjusted ROR in the stratum without AZCERT drugs = 43.94, 95 % CI 22.82-84.60), cyamemazine (11; 15.48, 6.87-34.91), and olanzapine (189; 7.74, 6.45-9.30). CONCLUSIONS: This pharmacovigilance analysis on the FAERS found 3 potential signals of torsadogenicity for drugs previously unknown for this risk.
    Full-text · Article · Apr 2013 · Drug Safety
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