scholarly journals Managing QT prolongation in the Era of Coronavirus Disease 2019 (COVID-19)

2020 ◽  
Author(s):  
Sidhi Laksono Purwowiyoto ◽  
Dony Yugo Hermanto ◽  
Muhammad Iqbal
Keyword(s):  
Severe Acute Respiratory Syndrome ◽  
Drug Interactions ◽  
Clinical Outcomes ◽  
Qt Interval ◽  
Metabolic Disorders ◽  
Torsade De Pointes ◽  
Qt Prolongation ◽  
Multiorgan Dysfunction ◽  
Know How ◽  
Critical Patients

Indonesia has declared a COVID-19 outbreaks because of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in March 2020. COVID-19 has significantly increased morbidity and mortality worldwide. Some studies have shown good clinical outcomes with the use of combination of chloroquine or hydroxychloroquine and azithromycin. That drugs can prolong the QT interval and increase the risk of Torsade de Pointes (TdP). The risk is increasing in several conditions such as in critical patients, metabolic disorders, sepsis, multiorgan dysfunction and with drug-drug interactions. Cardiologists need to know how to manage this condition to reduce the risk of TdP.

scholarly journals Managing QT prolongation in the Era of Coronavirus Disease 2019 (COVID-19)

2020 ◽  
Author(s):  
Sidhi Laksono Purwowiyoto ◽  
Dony Yugo Hermanto ◽  
Muhammad Iqbal
Keyword(s):  
Severe Acute Respiratory Syndrome ◽  
Drug Interactions ◽  
Clinical Outcomes ◽  
Qt Interval ◽  
Metabolic Disorders ◽  
Torsade De Pointes ◽  
Qt Prolongation ◽  
Multiorgan Dysfunction ◽  
Know How ◽  
Critical Patients

Indonesia has declared a COVID-19 outbreaks because of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in March 2020. COVID-19 has significantly increased morbidity and mortality worldwide. Some studies have shown good clinical outcomes with the use of combination of chloroquine or hydroxychloroquine and azithromycin. That drugs can prolong the QT interval and increase the risk of Torsade de Pointes (TdP). The risk is increasing in several conditions such as in critical patients, metabolic disorders, sepsis, multiorgan dysfunction and with drug-drug interactions. Cardiologists need to know how to manage this condition to reduce the risk of TdP.

scholarly journals Prolonged QT Interval in a Patient With Coronavirus Disease-2019: Beyond Hydroxychloroquine and Azithromycin

2020 ◽  
Vol 8 ◽  
pp. 232470962094840
Author(s):  
B K Anupama ◽  
Soumya Adhikari ◽  
Debanik Chaudhuri
Keyword(s):  
Qt Interval ◽  
Ventricular Arrhythmias ◽  
Torsade De Pointes ◽  
Cardiac Pacing ◽  
Qt Prolongation ◽  
Medication Effects ◽  
Increased Risk ◽  
Repolarization Reserve ◽  
Prolonged Qt Interval ◽  
Prolonged Qt

Recent reports have suggested an increased risk of QT prolongation and subsequent life-threatening ventricular arrhythmias, particularly torsade de pointes, in patients with coronavirus disease-2019 (COVID-19) treated with hydroxychloroquine and azithromycin. In this article, we report the case of a 75-year-old female with a baseline prolonged QT interval in whom the COVID-19 illness resulted in further remarkable QT prolongation (>700 ms), precipitating recurrent self-terminating episodes of torsade de pointes that necessitated temporary cardiac pacing. Despite the correction of hypoxemia and the absence of reversible factors, such as adverse medication effects, electrolyte derangements, and usage of hydroxychloroquine/azithromycin, the QT interval remained persistently prolonged compared with the baseline with subsequent degeneration into ventricular tachycardia and death. Thus, we highlight that COVID-19 illness itself can potentially lead to further prolongation of QT interval and unmask fatal ventricular arrhythmias in patients who have a prolonged QT and low repolarization reserve at baseline.

P280 Concomitant use of ivabradine and cyp3a4 inhibitors in critical cardiac patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
Author(s):  
A Mohamed Ariff ◽  
H Abd Hadi ◽  
T W Nay ◽  
M I Thoulath ◽  
A T Jauhari Aktifanus ◽  
...  
Keyword(s):  
Critical Care ◽  
Drug Interactions ◽  
Cardiac Disease ◽  
Qt Interval ◽  
Qt Prolongation ◽  
Left Ventricular Ejection ◽  
Drug Event ◽  
Cyp3a4 Inhibitor ◽  
Life Threatening ◽  
Cyp3a4 Inhibitors

Abstract Background In recent years there have been warnings concerning drug-induced life-threatening arrhythmias. Drug interactions can increase the risk of QT interval prolongation via interaction of pharmacokinetic mechanism. Some drugs such as Ivabradine does not affect the repolarization or affect the QT interval themselves. However, it can increase the risk of QT prolongation when taken with drugs that block the metabolic breakdown which inhibit the CYP3A4 enzyme particularly. Predisposing factors of QT prolongation include female sex, age over 65 years, brady-arrhythmia, electrolyte disturbances (hypokalemia, hypomagnesaemia), cardiac disease (congestive heart failure, ventricular hypertrophy, myocardial infarction, atrial fibrillation), impaired hepatic/renal function and hypothyroidism.  Purpose To assess potential Ivabradine – CYP3A4 inhibitor interactions in a Cardiac Critical Care Unit (CCCU).  Method We prospectively observed patients admitted at CCCU received Ivabradine and CYP3A4 inhibitor (QTprolonging agent) concomitantlyfrom Feb 2018 to July 2018 at National Heart Institute, Malaysia. We use a clinical drug decision support system (CDDSS) to identify the potential drug-drug interactions (PDDI) and assessed the likelihood of drug - drug interactions (DDI) using Drug Interaction Probability Scale (DIPS).  Results Patients admitted at CCCU co-administered with Ivabradine and CYP3A4 inhibitors (amiodarone/azithromycin) were analyzed. The severity level for both potential Ivabradine – Azithromycin and Ivabradine – Amiodarone interactions were alerted by the CDDSS as Major. Total 10 (M = 70%) patients were screened. The mean age was ± 57 years old. They had no previous exposure to both or one of the medications before. All patients had underlying cardiac disease. The left ventricular ejection fractions (LVEF) ranged from 15% - 65%. Adverse drug event (ADE) occurred in 7 (70%) patients [Male = 5 (71%), Female = 2 (67%)]. 70% of patients had prolonged QT interval induced by Ivabradine – Amiodarone and Ivabradine – Azithromycin All patients had QTc interval < 500 ms before co-administration and had a change of ± 100 ms after coadministration. The onset of ADE ranged from day 2 to day 5 in all patients. One had life threatening arrhythmia; ventricular fibrillation and require defibrillator and another one patient had non-sustained ventricular tachycardia. The most common precipitating factor was underlying cardiac disease. All suspected precipitating drug was discontinued. DIPS revealed; 57% patients scored 9 points (highly probable DDI) and the rest scored between 5-7 points (probable DDI). Conclusion Ivabradine potentially associated to fatal arrhythmia when it is co-administered with CYP3A4 inhibitor. Hence, the physician should reconsider such combination within the correct clinical context to avoid cardiovascular deterioration especially in a critical care setting.

scholarly journals Risk of QT Prolongation through Drug-drug Interactions between Hydroxychloroquine and Concomitant Drugs Prescribed in Real-world Practice

2020 ◽  
Author(s):  
Byung Jin Choi ◽  
Yeryung Koo ◽  
Tae Young Kim ◽  
Wou Young Chung ◽  
Yun Jung Jung ◽  
...  
Keyword(s):  
Drug Interactions ◽  
Real World ◽  
Qt Interval ◽  
Qt Prolongation ◽  
Qtc Interval ◽  
Interval Prolongation ◽  
Qt Interval Prolongation ◽  
Life Threatening ◽  
Alternative Drugs

Abstract Background: Hydroxychloroquine has recently received attention as a treatment for COVID-19. However, hydroxychloroquine may prolong the QTc interval, thus increasing the risk of life-threatening arrhythmia. Many patients with COVID-19 have comorbidities, necessitating the use of several drugs simultaneously with hydroxychloroquine. However, the risk of QT prolongation due to drug-drug interactions (DDIs) between hydroxychloroquine and these co-medications has not been identified. Therefore, it is necessary to investigate the risk of QT interval prolongation due to DDIs between hydroxychloroquine and frequently used concurrent drugs.Methods and Results: Using 447,632 patients and 1,040,752 electrocardiograms, we investigated the risk of QT prolongation due to DDIs between hydroxychloroquine and 118 concurrent drugs frequently used in real-world practice. In the analysis, we observed that 11 drugs (trimebutine, tacrolimus, tramadol, rosuvastatin, ciclosporin, sulfasalazine, rofecoxib, diltiazem, piperacillin/tazobactam, and isoniazid) show DDIs with hydroxychloroquine in the direction of QT prolongation.Conclusions: We found 11 drugs that show significant (p <0.05) DDIs with hydroxychloroquine, thereby increasing the risk of QT prolongation in patients. It is necessary to consider prescribing alternative drugs that have less DDI when these drugs are concurrently administered with hydroxychloroquine. Further investigation is needed to assess more profoundly the risk of QT prolongation due to DDI with hydroxychloroquine of each drug that we found in this analysis.

scholarly journals The QT long syndrome: clinical and diagnostic aspect

2021 ◽  
Vol 69 (1) ◽  
Author(s):  
Constantin Martiniuc ◽  
◽  
Serghei Pisarenco ◽  
Iurie Simionica ◽  
◽  
...  
Keyword(s):  
Qt Interval ◽  
Torsade De Pointes ◽  
Qt Prolongation ◽  
Current Data ◽  
Polymorphic Ventricular Tachycardia ◽  
Interval Prolongation ◽  
Qt Interval Prolongation ◽  
Increased Risk ◽  
Wide Range ◽  
Life Threatening

QT interval prolongation is a predictor of the life-threatening cardiac arrhythmias — polymorphic ventricular tachycardia (torsade de pointes). Long QT syndrome may be congenital or acquired. It is known that a wide range of both antiarrhythmic and non-cardiac medications might lead to QT interval prolongation. List of drugs that cause QT prolongation is constantly growing and being updated. The review contains current data on the clinical significance of the control of QT interval duration within drug therapy. Clinical conditions associated with an increased risk of QT interval prolongation are described. Drugs that can induce QT prolongation are also discussed.

scholarly journals QT Interval Prolongation and Torsade De Pointes in Patients with COVID-19 treated with Hydroxychloroquine/Azithromycin

2020 ◽  
Author(s):  
Ehud Chorin ◽  
Lalit Wadhwani ◽  
Silvia Magnani ◽  
Matthew Dai ◽  
Eric Shulman ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Qt Interval ◽  
Potential Benefit ◽  
Drug Exposure ◽  
Torsade De Pointes ◽  
Careful Consideration ◽  
Qt Prolongation ◽  
Interval Prolongation ◽  
Qtc Prolongation ◽  
Qt Interval Prolongation

AbstractBackgroundThe emergence of the COVID-19 pandemic has resulted in over two million affected and over 150 thousand deaths to date. There is no known effective therapy for the disease. Initial reports suggesting the potential benefit of Hydroxychloroquine/Azithromycin (HY/AZ) have resulted in massive adoption of this combination worldwide. However, while the true efficacy of this regimen is unknown, initial reports have raised concerns regarding the potential risk of QT prolongation and induction of torsade de pointes (TdP).MethodsThis is a multicenter retrospective study of 251 patients with COVID-19 treated with HY/AZ. We reviewed ECG tracings from baseline and until 3 days after completion of therapy to determine the progression of QTc and incidence of arrhythmia and mortality.ResultsQTc prolonged in parallel with increasing drug exposure and incompletely shortened after its completion. Extreme new QTc prolongation to > 500 ms, a known marker of high risk for TdP had developed in 15.9% of patients. One patient developed TdP requiring emergent cardioversion. Seven patients required premature termination of therapy. The baseline QTc of patients exhibiting QTc prolongation of > 60 ms was normal.ConclusionThe combination of HY/AZ significantly prolongs the QTc in patients with COVID-19. This prolongation may be responsible for life threating arrhythmia in the form of TdP. This risk mandates careful consideration of HY/AZ therapy in lights of its unproven efficacy. Strict QTc monitoring should be performed if the regimen is given.

Torsade De Pointes Resulting from the Addition of Droperidol to an Existing Cytochrome P450 Drug Interaction

1998 ◽  
Vol 32 (7-8) ◽  
pp. 761-765 ◽  
Author(s):  
Elizabeth Landrum Michalets ◽  
Laura K Smith ◽  
Eric D Van Tassel
Keyword(s):  
Cytochrome P450 ◽  
Qt Interval ◽  
Tricyclic Antidepressants ◽  
Torsade De Pointes ◽  
Tendon Repair ◽  
Qt Prolongation ◽  
Drug Induced ◽  
Case Summary ◽  
P450 Inhibitors

OBJECTIVE: To report a case of QT prolongation associated with concomitant cyclobenzaprine and fluoxetine administration followed by torsade de pointes potentiated by droperidol. CASE SUMMARY: A 59-year-old white woman who had been receiving long-term fluoxetine and cyclobenzaprine therapy was admitted for Achilles tendon repair. Baseline QTc was prolonged at 497 msec. Prior to surgery, the patient received droperidol, an agent known to prolong the QT interval. During surgery the patient developed torsade de pointes, which progressed into ventricular fibrillation. On postoperative day 1, after cyclobenzaprine discontinuation, the QTc decreased toward normal (440 msec). DISCUSSION: Cyclobenzaprine shares anticholinergic effects, tachycardia, and dysrhythmic potential with the tricyclic antidepressants (TCAs). Fluoxetine is a known inhibitor of the CYP2D6 isoenzyme (along with CYP3A4 and CYP2C) and has been shown to increase TCA serum concentrations. The combination of cyclobenzaprine and fluoxetine resulted in significant QT prolongation in our patient that progressed to torsade de pointes after preoperative droperidol administration. Resolution of QT abnormalities after cyclobenzaprine discontinuation provided further evidence of a drug-induced etiology. Other possible medical and drug-related causes of torsade de pointes are reviewed and ruled out. CONCLUSIONS: Clinicians should be aware of the dysrhythmic potential of cyclobenzaprine and fluoxetine, monitor for other cytochrome P450 inhibitors, and avoid concomitant drugs known to prolong the QT interval.

scholarly journals The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

2020 ◽  
Vol 17 (6) ◽  
pp. 365-383
Author(s):  
Milo Gatti ◽  
Emanuel Raschi ◽  
Elisabetta Poluzzi ◽  
Cristian Martignani ◽  
Stefania Salvagni ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Drug Interactions ◽  
Anticancer Agents ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Torsade De Pointes ◽  
Bleeding Risk ◽  
Qt Prolongation ◽  
Thrombotic Risk ◽  
Mortality And Morbidity

Abstract Purpose of Review Cardiotoxicity by anticancer agents has emerged as a multifaceted issue and is expected to affect both mortality and morbidity. This review summarizes clinical challenges in the management of oncological patients requiring anticoagulants for atrial fibrillation (AF) also considering the current outbreak of the COVID-19 (coronavirus disease 2019) pandemic, since this infection can add challenges to the management of both conditions. Specifically, the aims are manyfold: (1) describe the evolving use of direct oral anticoagulants (DOACs) in AF patients with cancer; (2) critically appraise the risk of clinically important drug-drug interactions (DDIs) between DOACs and oral targeted anticancer agents; (3) address expected DDIs between DOACs and candidate anti-COVID drugs, with implications on management of the underlying thrombotic risk; and (4) characterize the proarrhythmic liability in cardio-oncology in the setting of COVID-19, focusing on QT prolongation. Recent Findings AF in cardio-oncology poses diagnostic and management challenges, also due to the number of anticancer drugs recently associated with AF onset/worsening. Oral targeted drugs can potentially interact with DOACs, with increased bleeding risk mainly due to pharmacokinetic DDIs. Moreover, the vast majority of oral anticancer agents cause QT prolongation with direct and indirect mechanisms, potentially resulting in the occurrence of torsade de pointes, especially in susceptible patients with COVID-19 receiving additional drugs with QT liability. Summary Oncologists and cardiologists must be aware of the increased bleeding risk and arrhythmic susceptibility of patients with AF and cancer due to DDIs. High-risk individuals with COVID-19 should be prioritized to target preventive strategies, including optimal antithrombotic management, medication review, and stringent monitoring.

scholarly journals Polymorphic Ventricular Tachycardia Associated with High-Dose Methadone Use

2020 ◽  
Vol 2020 ◽  
pp. 1-5 ◽  
Author(s):  
Weng-Chio Tam ◽  
U-Po Lam ◽  
Toi-Meng Mok ◽  
Tou Chang ◽  
Wa Ho ◽  
...  
Keyword(s):  
Qt Interval ◽  
Normal Limit ◽  
Torsade De Pointes ◽  
Qt Prolongation ◽  
Polymorphic Ventricular Tachycardia ◽  
High Dose ◽  
Cardiac Side Effects ◽  
Aged Woman ◽  
Middle Aged Woman ◽  
Artery Disease

Methadone is a well-tolerated drug that has been used for pain control and the treatment of opioid addiction. However, some fatal cardiac side effects have been reported previously, including ventricular arrhythmia, stress cardiomyopathy, and coronary artery disease. We reported a middle-aged woman receiving high-dose methadone whom was presented with QT prolongation and torsade de pointes. We replaced the methadone with benzodiazepine and gave lidocaine use simultaneously. Thus, QT interval was shortened within the normal limit. Methadone-induced torsade de pointes is a rare but serious event, and QT interval should be monitored periodically to prevent this fatal adverse event, especially some patients with high-dose methadone use.

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