QT prolongation: Difference between revisions
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*Antiarrhythmics | *Antiarrhythmics | ||
**[[Amiodarone]], disopyramide, dofetilide, [[flecainide]], ibutilide, mexiletine, [[procainamide]], [[quinidine]], [[sotalol]] | **[[Amiodarone]], disopyramide, dofetilide, [[flecainide]], ibutilide, mexiletine, [[procainamide]], [[quinidine]], [[sotalol]] | ||
*Antibiotics | *[[Antibiotics ]] | ||
**Macrolide | **[[Macrolide]] | ||
***[[Azithromycin]], [[erythromycin]], [[clarithromycin]] | ***[[Azithromycin]], [[erythromycin]], [[clarithromycin]] | ||
**Fluoroquinolone | **[[Fluoroquinolone]] | ||
***[[Ciprofloxacin]], gatifloxacin (most common), [[gemifloxacin]], [[levofloxacin]], [[moxifloxacin]], [[ofloxacin]] | ***[[Ciprofloxacin]], gatifloxacin (most common), [[gemifloxacin]], [[levofloxacin]], [[moxifloxacin]], [[ofloxacin]] | ||
**Other | **Other | ||
***[[Pentamidine]], telithromycin, [[trimethoprim-sulfamethoxazole]] | ***[[Pentamidine]], telithromycin, [[trimethoprim-sulfamethoxazole]] | ||
*Antidepressants | *[[Antidepressants]] | ||
**[[Amitriptyline]], citalopram, [[doxepin]], fluoxetine, [[nortriptyline]], paroxetine, sertraline, [[venlafaxine]] | **[[Amitriptyline]], citalopram, [[doxepin]], fluoxetine, [[nortriptyline]], paroxetine, sertraline, [[venlafaxine]] | ||
*Antiemetics | *[[Antiemetics]] | ||
**Dolasetron, [[droperidol]], granisetron, [[ondansetron]] | **Dolasetron, [[droperidol]], granisetron, [[ondansetron]] | ||
*Antifungals | *Antifungals | ||
Revision as of 13:00, 30 March 2019
Background
- Prolonged ventricular repolarisation → increased risk of ventricular arrythmias
- Males >440-450 ms
- Females >500 ms
- Rule of thumb: Normal QT interveal is less than half of preceding RR interval
- QT interval is from the beginning of the Q wave to the end of the T wave
- Rate dependent and should become proportionately shorter with increasing heart rate
Clinical Features
- Most are asymptomatic
- History may include:
- Syncope
- Cardiac arrest
- Family history of long QT or sudden death
- Medication history may include QT prolonging medications
Differential Diagnosis
- Pause Dependent (Aquired)
- Drug induced
- Antidyrhythmics
- Phenothiazines
- TCAs
- Organophosphates
- Antihistamines
- Electrolyte Abnormalities (hypoKalemia, hypoMag, hypoCa)
- Hypokalemia triad
- Long QT, ST depressions, PVCs
- Hypokalemia triad
- Hypothermia
- Diet related (starvation, low protein)
- Severe Bradycardia/AV Block
- Hypothyroid
- Contrast injection
- CVA (intraparenchymal)
- Elevated intracranial pressure and Intracranial hemorrhage
- MI
- Drug induced
- Adrenergic Dependent
- Congenital
- Jarvel/Lange-Nielsen
- (+deafness; AR)
- Romano-Ward synd
- (nl hearing; AD)
- Sporatic
- Mitral valve prolapse
- Jarvel/Lange-Nielsen
- Acquired
- CVA (subarachnoid)
- Autonomic surg (catechol excess: neck dissection, carotid endarterect, truncal vagotomy)
- Congenital
Drug List
- Antiarrhythmics
- Amiodarone, disopyramide, dofetilide, flecainide, ibutilide, mexiletine, procainamide, quinidine, sotalol
- [[Antibiotics ]]
- Macrolide
- Fluoroquinolone
- Ciprofloxacin, gatifloxacin (most common), gemifloxacin, levofloxacin, moxifloxacin, ofloxacin
- Other
- Pentamidine, telithromycin, trimethoprim-sulfamethoxazole
- Antidepressants
- Amitriptyline, citalopram, doxepin, fluoxetine, nortriptyline, paroxetine, sertraline, venlafaxine
- Antiemetics
- Dolasetron, droperidol, granisetron, ondansetron
- Antifungals
- Antihypertensives
- Antineoplastics
- Lapatinib, nilotinib, sunitinib, tamoxifen
- Antimalarials
- Chloroquine, halofantrine
- Antipsychotics
- Chlorpromazine, clozapine, galantamine, haloperidol, lithium, paliperidone, pimozide, quetiapine, risperidone, thioridazine, ziprasidone
- Antivirals
- Amantadine, atazanavir, foscarnet
- Diuretics
- Indapamide
- Immune suppressants
- Opiates
- Phosphodiesterase inhibitors
- Sildenafil, vardenafil
- Skeletal muscle relaxants
- Tizanidine
- Urinary antispasmodics
- Solifenacin
Evaluation
Workup
- ECG
- CBC
- Chem 10
Diagnosis
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- ECG
- On visual inspection, QT takes up more than half the R-R distance
- Measure QT interval in lead II or V5-6
- QTc = QT /√R-R
Management
Pause Dependent (precipitated by bradycardia)
- Unstable/sustained torsades→ defibrilation (unsynchronized)
- Stable
- Treat underlying etiology
- Increase HR (isoproterenol or overdrive pacing)
- Magnesium sulfate IV
- Consider amiodarone
Adrenergic Dependent (precipited by tachycardia)
- Unstable/sustained torsades→ defibrilation (unsynchronized)
- Stable
- Slow HR (beta-blockers)
- May consider magnesium sulfate
Disposition
- Consider admission, especially for QT >500 or if symptomatic
- May require consultation for discontinuation of QT prolonging medications
- Avoid prescribing medications that may contribute to prolonged QT