Torsade de pointes: Difference between revisions

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	Torsade de pointes;
DiseasesDB	29252
eMedicine	med/2286 emerg/596
MeSH	D016171

VisualWikitext

Revision as of 16:04, 21 April 2009

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Torsade de pointes or torsades is a French term that literally means "twisting of the points" is a ventricular tachycardia associated with a long QT time on the resting ECG.

Torsade de pointes is typically initiated by a short-long-short interval. A ventricle extrasystole (first beat: short) is followed by a compensatory pause. The following beat (second beat: long) has a longer QT interval. If the next beat follows shortly thereafter, ther is a good chance that this third beat falls within the QT interval, resulting in the R on T phenomenon and subsequent Torsade de pointes. During Torsade de pointes the ventricles depolarize in a circular fashion resulting in QRS complexes with a continuously turning heart axis around the baseline (hence the name Torsade de Pointes). Read the chapter on the Long QT Syndrome for an list of causes.

Also, a more rare form of short coupled Torsade de pointes has been observed.^[1]

History

It was first described by Dessertenne in 1966^[2] and refers to a specific variety of ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram (ECG).

Terminology

The French term is largely due to the fact that the phenomenon was originally described in a French medical journal by Dessertenne in 1966, when he observed this rhythm disorder in an 80-year-old female patient with complete intermittent atrioventricular block.

There has been much debate in the Circulation journal among French and American scientist whether one should write Torsades de Pointes or Torsade de Pointes.

As for now Torsade is prefered (unless one sees rotations around more than one axis in one episode), but both forms are used in similar frequency.^[3]

Presentation

Characteristic tracing showing the "twisting" (blue line) of Torsade de pointes

Torsades is a rapid, polymorphic ventricular tachycardia with a characteristic twist of the QRS complex around the isoelectric baseline. It is also associated with a fall in arterial blood pressure, which gives rise to the syncopal symptoms experienced by patients.

Although torsade de pointes is a rare ventricular arrhythmia, it can degenerate into ventricular fibrillation, which will lead to sudden death in the absence of medical intervention. Torsade de pointes is associated with Long QT syndrome, a condition whereby prolonged QT intervals are visible on the ECG.

Causes

Long QT syndrome can either be inherited as congenital mutations of ion channels carrying the cardiac impulse/action potential or acquired as a result of drugs that block these cardiac ion currents.

Common causes for torsades de pointes include hypomagnesemia and hypokalemia. It is commonly seen in malnourished individuals and chronic alcoholics. Drug interactions such as erythromycin or Avelox, taken concomitantly with inhibitors like nitroimidazole, Diarrhea, dietary supplements, and various medications like methadone, Lithium, tricyclic antidepressants or phenothiazines may also contribute.

Factors that are associated with an increased tendency toward torsades de pointes include:

The List of Drugs that Causing Torsades de pointes

Drugs that are generally accepted to have a risk of causing torsades de pointes

The List of Drugs that Possible Causing Torsades de pointes

Drugs that in some reports have been associated with torsades de pointes and/or QT prolongation but at this time lack substantial evidence for causing torsades de pointes.

The List of Drugs that Causing Torsades de pointes in Certain Conditions

Drugs that, in some reports, have been weakly associated with torsades de pointes and/or QT prolongation but that are unlikely to be a risk for torsades de pointes when used in usual recommended dosages and in patients without other risk factors (e.g., concomitant QT prolonging drugs, bradycardia, electrolyte disturbances, congenital long QT syndrome, concomitant drugs that inhibit metabolism)

Treatment

Treatment is directed at withdrawal of the offending agent, infusion of magnesium sulfate ^[4]^[5], antiarrhythmic drugs e.g lidocaine or isoproterenol can be used but amiodarone use is contraindicated because it can potentially cause torsades de pointes, and electrical therapy can be used as needed.

Because of the polymorphic nature of torsade de pointes, synchronized cardioversion may not be possible, and the patient may require an unsynchronized shock (or defibrillation).

Infusion of magnesium sulfate is the drug of choice in stable patient. Temporary overdrive pacing is indicated in patients who are refractory to intravenous magnesium administration.

If the patient is unstable, immediate defibrillation is indicated.

Additional Information

Torsade de Pointes and Polymorphic VT

External Links

Torsade de Pointes related drug list

Examples: EKG's shown below are courtesy of C. Michael Gibson MS MD, and copylefted

12 lead EKG at admission
File:TdP.1.2.1.jpg
File:TdP.1.2.2.jpg

File:TdP.1.5.1.jpg

Examples from different resources

Arrhythmias in a patient with short coupled torsade de pointes^[6]
Arrhythmias in a patient with short coupled torsades de pointes degenerating in ventricular fibrillation^[7]

Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles^[8]
Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles ^[9]

A 12 lead ECG recording example of TdP^[10]

References

↑ 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
↑ Dessertenne F (1966). "[Ventricular tachycardia with 2 variable opposing foci]". Archives des maladies du coeur et des vaisseaux (in French). 59 (2): 263–72. PMID 4956181.
↑ Moise NS. As Americans, we should get this right. Circulation 1999 Sep 28; 100(13) 1462. PMID 10500317
↑ Hoshino K, Ogawa K, Hishitani T, Isobe T, Eto Y (2004). "Optimal administration dosage of magnesium sulfate for torsades de pointes in children with long QT syndrome". J Am Coll Nutr. 23 (5): 497S–500S. PMID 15466950. Unknown parameter |month= ignored (help)
↑ Hoshino K, Ogawa K, Hishitani T, Isobe T, Etoh Y (2006). "Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome". Pediatr Int. 48 (2): 112–7. doi:10.1111/j.1442-200X.2006.02177.x. PMID 16635167. Unknown parameter |month= ignored (help)
↑ 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
↑ 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
↑ 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
↑ 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
↑ Khan IA. Twelve-lead electrocardiogram of torsade de pointes Tex Heart Inst J. 2001; 28 (1): 69. PMID 11330748

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Template:WikiDoc Sources

[1] 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

[2] Dessertenne F (1966). "[Ventricular tachycardia with 2 variable opposing foci]". Archives des maladies du coeur et des vaisseaux (in French). 59 (2): 263–72. PMID 4956181.

[3] Moise NS. As Americans, we should get this right. Circulation 1999 Sep 28; 100(13) 1462. PMID 10500317

[pmid15466950-4] Hoshino K, Ogawa K, Hishitani T, Isobe T, Eto Y (2004). "Optimal administration dosage of magnesium sulfate for torsades de pointes in children with long QT syndrome". J Am Coll Nutr. 23 (5): 497S–500S. PMID 15466950. Unknown parameter |month= ignored (help)

[pmid16635167-5] Hoshino K, Ogawa K, Hishitani T, Isobe T, Etoh Y (2006). "Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome". Pediatr Int. 48 (2): 112–7. doi:10.1111/j.1442-200X.2006.02177.x. PMID 16635167. Unknown parameter |month= ignored (help)

[6] 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

[7] 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

[8] 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

[9] 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

[10] Khan IA. Twelve-lead electrocardiogram of torsade de pointes Tex Heart Inst J. 2001; 28 (1): 69. PMID 11330748

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@@ Line 172: / Line 172: @@
 ==Treatment==
-Treatment is directed at '''withdrawal of the offending agent''', '''infusion of [[magnesium sulfate]]''', [[antiarrhythmic drug]]s''' e.g [[lidocaine]] or [[isoproterenol]] can be used but amiodarone use is contraindicated because it can potentially cause torsades de pointes, and '''electrical therapy''' can be used as needed.
+Treatment is directed at '''withdrawal of the offending agent''', '''infusion of [[magnesium sulfate]]''' <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>, [[antiarrhythmic drug]]s''' e.g [[lidocaine]] or [[isoproterenol]] can be used but amiodarone use is contraindicated because it can potentially cause torsades de pointes, and '''electrical therapy''' can be used as needed.
 Because of the polymorphic nature of [[torsade de pointes]], synchronized [[cardioversion]] may not be possible, and the patient may require an unsynchronized shock (or [[defibrillation]]).

v t e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes


Torsade de pointes
DiseasesDB	29252
eMedicine	med/2286 emerg/596
MeSH	D016171