Skip to main content
SpringerLink
Log in

Toxicant-Induced Torsade de Pointes

  • Living reference work entry
  • First Online:
Critical Care Toxicology

  • 407 Accesses

Abstract

Torsade de pointes (TdP) is a rare but potentially life-threatening event in poisoned patients. The medical toxicologist must identify high risk patients and recognize preattack electrocardiographic (ECG) signs and be able to rapidly distinguish this arrhythmia from other ventricular arrhythmias as the treatment of TdP is unique. This chapter emphasizes the pathophysiology, risk factors, ECG signs, and clinical management of TdP in the poisoned patient as well as the clinical approach to QT-prolongation in poisoned patients.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Dessertenne F. La tachycardia ventriculaire a deux foyers opposes variables. Arch Mal Coeur. 1966;59:263–72.

    CAS  PubMed  Google Scholar 

  2. Mac William JA. Some applications of physiology to medicine. II. – Ventricular fibrillation and sudden death. Br Med J. 1923;2:215–9.

    Article  CAS  Google Scholar 

  3. Thomas SH, Behr ER. Pharmacological treatment of acquired QT prolongation and torsade de pointes. Br J Clin Pharmacol. 2015;online early. doi:10.1111/bcp.12726.

    Google Scholar 

  4. Weiss J, Garfinkel A, Karagueuzian H, et al. Early after depolarizations and cardiac arrhythmias. Heart Rhythm. 2010;7:1891–9.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf. 2012;3:241–53.

    Article  PubMed  PubMed Central  Google Scholar 

  6. CredibleMeds. QT drugs lists. Available at: http://www.crediblemeds.org. Accessed 31 May 2016.

  7. Schwartz PJ, Woosley RL. Predicting the unpredictable. Drug-induced QT prolongation and torsade de pointes. JACC. 2016;67:1639–50.

    Google Scholar 

  8. Mamiya K, Sadanaga T, Sekita A, Nabeyama Y, Yao H, Yukawa E. Lithium concentration correlates with QTc in patients with psychosis. J Electrocardiol. 2005;38:148–51.

    Article  PubMed  Google Scholar 

  9. Berling I, Isbister GK. Prolonged QT risk assessment in antipsychotic overdose using the QT nomogram. Ann Emerg Med. 2015;66:154–64.

    Article  PubMed  Google Scholar 

  10. Joy JP, Coulter CV, Duffull SB, Isbister GK. Prediction of torsade de pointes from the QT interval: analysis of a case series of amisulpride overdoses. Clin Pharmacol Ther. 2011;90:243–5.

    Article  CAS  PubMed  Google Scholar 

  11. Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004;350:1013–22.

    Article  CAS  PubMed  Google Scholar 

  12. Chan A, Isbister GK, Kirkpatrick CMJ, Dufful SB. Drug-induced QT prolongation and torsade de pointes: evaluation of a QT nomogram. Q J Med. 2007;100:609–15.

    Article  CAS  Google Scholar 

  13. Kay GN, Plumb VJ, Arciniegas JG, Henthorn RW, Waldo AL. Torsade de pointes: the long-short initiating sequence and other clinical features: observations in 32 patients. J Am Coll Cardiol. 1983;2:806–17.

    Article  CAS  PubMed  Google Scholar 

  14. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, et al. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2010;107:521–5.

    Google Scholar 

  15. Kao LW, Furbee RB. Drug-induced QT prolongation. Med Clin N Am. 2005;89:1125–44.

    Article  CAS  PubMed  Google Scholar 

  16. Roden DM, Iansmith DH. Effects of low potassium or magnesium concentrations on isolated cardiac tissue. Am J Med. 1987;82:18–23.

    Article  CAS  PubMed  Google Scholar 

  17. Lehtonen A, Fodstad H, Laitinen-Forsblom P, Toivonen L, Kontula K, Swan H. Further evidence of inherited long QT syndrome gene mutations in antiarrhythmic drug-associated torsade de pointes. Heart Rhythm. 2007;4:603–7.

    Article  PubMed  Google Scholar 

  18. Aström-Lilja C, Odeberg JM, Ekman E, Hägg S. Drug-induced torsade de pointes: a review of the Swedish pharmacovigilance database. Pharmacoepidemiol Drug Saf. 2008;17:587–92.

    Article  PubMed  Google Scholar 

  19. Isbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment of the QT interval in clinical practice. Br J Clin Pharmacol. 2012;76:48–57.

    Article  PubMed Central  Google Scholar 

  20. Berling I, Isbister GK, Calver L, Clunas S. Digital Holter measurement of QT prolongation in ziprasidone overdose. Clin Toxicol (Phila). 2011;49:694–6.

    Article  CAS  Google Scholar 

  21. Isbister GK. How do we assess whether the QT interval is abnormal: myths, formulae and fixed opinion. Clin Toxicol. 2015;53:189–91.

    Article  Google Scholar 

  22. Othong R, Devlin JJ, Kazzi ZN. Medical toxicologists’ practice patterns regarding drug-induced QT prolongation in overdose patients: a survey in the United States of America, Europe, and Asia Pacific region. Clin Toxicol. 2015;53:204–9.

    Article  CAS  Google Scholar 

  23. Fossa AA, Wisialowski T, Magnano A, Wolfgang E, Winslow R, Gorczyca W, et al. Dynamic beat-to-beat modeling of the QT-RR interval relationship: analysis of QT prolongation during alterations of autonomic state versus human ether a-go-go-related gene inhibition. J Pharmacol Exp Ther. 2005;312:1–11.

    Article  CAS  PubMed  Google Scholar 

  24. Höjer J. Prophylactic management of QTc-prolongation in drug-poisoning – new guidelines from the Swedish poison centre. Abstract. Clin Toxicol. 2013;51:288.

    Article  Google Scholar 

  25. Höjer J. QTc-prolongation in acute drug-poisoning. Guidelines for management from the Swedish Poisons Information Centre. Lakartidningen. 2013;110:953–5.

    PubMed  Google Scholar 

  26. Fontaine G, Frank R, Grosgogeat Y. Torsades de pointes: definition and management. Mod Concepts Cardiovasc Dis. 1982;51:103–9.

    CAS  PubMed  Google Scholar 

  27. Kolte D, Vijayaraghavan K, Khera S, et al. Role of magnesium in cardiovascular diseases. Cardiol Rev. 2014;22:182–92.

    Article  PubMed  Google Scholar 

  28. Arstall MA, Hii JTY, Lehman RG, Horowitz JD. Sotalol-induced torsade de pointes: management with magnesium infusion. Postgrad Med J. 1992;68:289–90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Charlton NP, Lawrence DT, Brady WJ, Kirk MA, Holstege CP. Termination of drug-induced torsade de pointes with overdrive pacing. Am J Emerg Med. 2010;28:95–102.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Karolinska Institute, Swedish Poisons Information Centre, Stockholm, Sweden

    Jonas Höjer

  2. School of Medicine, Vanderbilt University, Nashville, TN, USA

    Donna Seger

Authors
  1. Jonas Höjer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Donna Seger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Jonas Höjer or Donna Seger .

Editor information

Editors and Affiliations

  1. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Jeffrey Brent

  2. Office of New Drugs Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA

    Keith Burkhart

  3. Clinical Toxicology, St Thomas' Hospital, London, United Kingdom

    Paul Dargan

  4. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Benjamin Hatten

  5. Med & Toxicological Intensive Care Unit, Lariboisière Hospital Paris-Diderot University, Paris, France

    Bruno Megarbane

  6. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Robert Palmer

Grading System for Levels of Evidence Supporting Recommendations in Critical Care Toxicology, 2nd Edition

  1. I

    Evidence obtained from at least one properly randomized controlled trial.

  2. II-1

    Evidence obtained from well-designed controlled trials without randomization.

  3. II-2

    Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

  4. II-3

    Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

  5. III

    Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees.

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this entry

Cite this entry

Höjer, J., Seger, D. (2016). Toxicant-Induced Torsade de Pointes. In: Brent, J., Burkhart, K., Dargan, P., Hatten, B., Megarbane, B., Palmer, R. (eds) Critical Care Toxicology. Springer, Cham. https://doi.org/10.1007/978-3-319-20790-2_121-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-20790-2_121-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Cham

  • Online ISBN: 978-3-319-20790-2

  • eBook Packages: Springer Reference Biomedicine and Life SciencesReference Module Biomedical and Life Sciences

Publish with us

Policies and ethics

Search

Navigation