Torsades de pointes electrocardiogram

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

Electrocardiography

EKG is the main diagnostic tool in patients with Torsade de pointes. EKG findings that can be seen are:

• Progressive change in polarity of QRS about the isoelectric line occurs
• Prolonged QT interval (QT ≥ 0.60 s or QTc ≥ 0.45 s)
• Pathological U
• Rotation of the heart's electrical axis by at least 180º
• Preceded by short long and short RR-intervals
• Triggered by an early premature ventricular contraction(R-on-T PVC)
• Paroxysms of 5-20 beats at a rate ≥ 200 bpm
• Patients may revert spontaneously to a nonpolymorphic ventricular tachycardia or ventricular fibrillation

Background

1. The peaks of the QRS complexes appear to twist around the isoelectric axis.
2. Polymorphic VT is distinguished from Torsades by the absence of QT prolongation in polymorphic VT.

EKG Findings

1. Paroxysms of VT with irregular RR intervals.
2. A ventricular rate between 200 and 250 beats per minute.
3. Two or more cycles of QRS complexes with alternating polarity.
4. Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion.
5. Prolongation of the QT interval.
6. Is often initiated by a PVC with a long coupling interval, R on T phenomenon.
7. There are usually 5 to 20 complexes in each cycle.

Examples

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

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  12 lead EKG at admission
• File:TdP.1.2.1.jpg
• File:TdP.1.2.2.jpg
• File:TdP.1.3.1.jpg
• File:TdP.1.3.2.jpg
• File:TdP.1.4.1.jpg
• File:TdP.1.4.2.jpg
• File:TdP.1.5.1.jpg
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Examples from different resources

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  Arrhythmias in a patient with short coupled torsade de pointes
• 
  Arrhythmias in a patient with short coupled torsades de pointes degenerating in ventricular fibrillation

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  Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles
• 
  Arrhythmias in a patient with short coupled torsade de pointes: frequent short coupled extrasystoles

• 
  A 12 lead ECG recording example of TdP

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