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| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} |
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| | ==[[Torsades de pointes overview|Overview]]== |
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| | ==[[Torsades de pointes historical perspective|Historical Perspective]]== |
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| ===Clinical Correlation === | | ==[[Torsades de pointes pathophysiology|Pathophysiology]]== |
| # Drugs: [[quinidine]], [[PCA]], [[norpace]], [[amiodarone]], [[phenothiazines]], [[Tricyclic antidepressants]], [[pentamidine]].
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| #* with [[quinidine]] majority of the cases occur within one week of initiation, and with therapeutic levels
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| # Electrolyte imbalances: [[Hypokalemia]], [[hypomagnesemia]], [[hypocalcemia]]
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| # [[CAD]]
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| # [[MVP]]
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| # Variant [[angina]]
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| # [[Myocarditis]]
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| # [[Subarachnoid hemorrhage]]
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| # Congenital QT prolongation
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| # Liquid protein diets
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| # [[Hypothyroidism]]
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| #* because of bradycardia and a prolonged QT syndrome
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| # Organophosphate poisoning <ref>Chou's Electrocardiography in Clinical Practice Third Edition, pp. 398-409.</ref> <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:194 ISBN 1591032016</ref>
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| ==Video: Torsade de pointes== | | ==[[Torsades de pointes causes|Causes]]== |
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| {{#ev:youtube|1ccTO6fNobU}}
| | ==[[Torsades de pointes differential diagnosis|Differentiating Torsades de pointes from other Diseases]]== |
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| {{#ev:youtube|JDumoHHZocA}}
| | ==[[Torsades de pointes risk factors|Risk Factors]]== |
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| | ==[[Torsades de pointes natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| '''Torsade de pointes is characterized by constantly changing rhythm amplitude. 'Torsade de pointes' in French means "Twisting of the Points". The changing rhythm amplitudes comes from the ventricular depolarizing waves constantly shifting its axis. It is usually caused by hypomagnesemia, hypokalemia, and malnourished alcoholics. Although Torsades de Pointes (TdP) is a rare ventricular arrhythmia, it can degenerate into ventricular fibrillation, leading to death without rapid medical intervention. TdP is associated with long QT syndrome, a condition whereby prolonged QT intervals are visible on the ECG.'''
| | ==Diagnosis== |
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| ==Other lab studies==
| | [[Torsades de pointes history and symptoms|History and Symptoms]] | [[Torsades de pointes physical examination|Physical Examination]] | [[Torsades de pointes laboratory findings|Laboratory Findings]] | [[Torsades de pointes electrocardiogram|Electrocardiogram]] | [[Torsades de pointes ekg examples|EKG Examples]] | [[Torsades de pointes echocardiography|Echocardiography]] | [[Torsades de pointes other diagnostic studies|Other Diagnostic Studies]] |
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| * Electrolytes levels to rule out [[hypokalemia]], [[hypomagnesemia]], and [[hypocalcemia]].
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| * [[Cardiac enzymes]]
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| * [[Echocardiography]] to rule out structural heart disease
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| ==Treatment== | | ==Treatment== |
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| ===Acute Treatment ===
| | [[Torsades de pointes medical therapy|Medical Therapy]] | [[Torsades de pointes primary prevention|Primary Prevention]] | [[Torsades de pointes secondary prevention|Secondary Prevention]] | [[Torsades de pointes cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Torsades de pointes future or investigational therapies|Future or Investigational Therapies]] |
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| If the episode of does not terminate on its own and degenerates into ventricular fibrillation, [[cardioversion]] is required.
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| [[Image:Torsades_converted_by_AICD_ECG_strip_Lead_II.JPG|thumb|center|800px|Lead II [[electrocardiogram]] showing [[Torsades]] being shocked by an [[Implantable cardioverter-defibrillator]] back to the patients baseline [[cardiac rhythm]].]] | |
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| Once the patient is back in normal sinus rhythm, a vigorous search for and correction of conditions that predispose to torsades de pointes which include [[hypokalemia]], [[hypomagnesemia]], and [[bradycardia]] should be made. [[Magnesium sulfate]] (1-2 g IV over 30-60 seconds) reduces the influx of calcium thereby lowering the amplitude of early after depolarizations and should also be infused even if the magnesium is normal. <ref name="pmid15466950">{{cite journal |author=Hoshino K, Ogawa K, Hishitani T, Isobe T, Eto Y |title=Optimal administration dosage of magnesium sulfate for torsades de pointes in children with long QT syndrome |journal=J Am Coll Nutr |volume=23 |issue=5 |pages=497S–500S |year=2004 |month=October |pmid=15466950 |doi= |url=http://www.jacn.org/cgi/pmidlookup?view=long&pmid=15466950}}</ref><ref name="pmid16635167">{{cite journal |author=Hoshino K, Ogawa K, Hishitani T, Isobe T, Etoh Y |title=Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome |journal=Pediatr Int |volume=48 |issue=2 |pages=112–7 |year=2006 |month=April |pmid=16635167 |doi=10.1111/j.1442-200X.2006.02177.x |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1328-8067&date=2006&volume=48&issue=2&spage=112}}</ref>
| | ==Case Studies== |
| Administration of [[lidocaine]] is generally not effective, but mexiletene may be helpful in suppressing the recurrence of torsade de pointes.
| | [[Torsades de pointes case study one|Case #1]] |
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| ==Additional Information== | | ==Related Chapters== |
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| *[[Torsade de Pointes and Polymorphic VT]] | | *[[Torsade de Pointes and Polymorphic VT]] |
| | | *[[Long QT syndrome]] |
| ==Examples==
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| '''EKG's shown below are courtesy of [[C. Michael Gibson]] MS MD, and copylefted'''
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| <gallery perRow="3">
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| image:TdP.1.1.jpg|12 lead EKG at admission
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| image:TdP.1.2.1.jpg
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| image:TdP.1.2.2.jpg
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| image:TdP.1.3.1.jpg
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| image:TdP.1.3.2.jpg
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| image:TdP.1.4.1.jpg
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| image:TdP.1.4.2.jpg
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| image:TdP.1.5.1.jpg
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| image:TdP.1.5.2.jpg
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| image:TdP.1.6.1.jpg
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| image:TdP.1.6.2.jpg
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| image:TdP.1.7.jpg
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| </gallery>
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| '''Examples from different resources'''
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| <div align="left">
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| <gallery heights="175" widths="175">
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| image:shortcoupled_tdp1.jpg|Arrhythmias in a patient with short coupled torsade de pointes<ref name="Leenhardt"> Leenhardt A, Glaser E, Burguera M, Nuernberg M, Maison-Blanche P, and Coumel P. Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994 Jan; 89(1) 206-15. PMID 8281648 </ref>
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| image:shortcoupled_tdp2.jpg|Arrhythmias in a patient with short coupled torsades de pointes degenerating in [[ventricular fibrillation]]<ref name="Leenhardt"> Leenhardt A, Glaser E, Burguera M, Nuernberg M, Maison-Blanche P, and Coumel P. Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994 Jan; 89(1) 206-15. PMID 8281648 </ref>
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| image:shortcoupled_tdp3.jpg|Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles<ref name="Leenhardt"> Leenhardt A, Glaser E, Burguera M, Nuernberg M, Maison-Blanche P, and Coumel P. Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994 Jan; 89(1) 206-15. PMID 8281648 </ref>
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| image:shortcoupled_tdp4.jpg|Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles <ref name="Leenhardt"> Leenhardt A, Glaser E, Burguera M, Nuernberg M, Maison-Blanche P, and Coumel P. Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994 Jan; 89(1) 206-15. PMID 8281648 </ref>
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| image:12leadTorsade.jpg|A 12 lead ECG recording example of TdP<ref>Khan IA. Twelve-lead electrocardiogram of torsade de pointes Tex Heart Inst J. 2001; 28 (1): 69. PMID 11330748 </ref>
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| </gallery>
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| </div>
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| [[Image:Tosadesdepointes.jpg|center|thumb|300px|Characteristic tracing showing the "twisting" (blue line) of Torsade de pointes]]
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| ==References==
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| {{Reflist|2}}
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| [[de:Torsade de pointes]]
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| [[pl:Torsade de pointes]] | | [[pl:Torsade de pointes]] |
| [[tr:Torsade de pointes]] | | [[tr:Torsade de pointes]] |
