High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality

Pickham, David; Helfenbein, Eric; Shinn, Julie A.; Chan, Garrett K.; Funk, Marjorie; Weinacker, Ann; Liu, Jiani; Drew, Barbara J.

doi:10.1097/ccm.0b013e318232db4a

Cited by 138 publications

(129 citation statements)

References 2 publications

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“…Investigations have reported prevalence of QTc prolongation >500 milliseconds in monitored patients ranging from 2.6% to 24%. [73][74][75] A major risk factor for acquired LQTS and TdP in hospitalized patients is the initiation, increased dose, or overdose of QTprolonging drugs. Drugs from a wide range of classes have been implicated (Table 4).…”

Section: Overview Of Qtc Monitoringmentioning

confidence: 99%

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Sandau¹,

Funk²,

Auerbach³

et al. 2017

Circulation

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186

214

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Background and Purpose: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. Methods: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. Results: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. Conclusions: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.

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Section: Overview Of Qtc Monitoringmentioning

confidence: 99%

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Sandau¹,

Funk²,

Auerbach³

et al. 2017

Circulation

Self Cite

186

214

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“…More women than men developed QT prolongation and significant predictors were female sex, administration of QT-prolonging drugs, cerebrovascular incident, hypertension, thyroid disease, diabetes, renal disease, hepatic disease, electrolyte and creatinine abnormalities. Patients with QT prolongation were 'overrepresented in hospital deaths' which was 'attributable to greater illness severity and existing comorbidities' [Pickham et al 2012]. An independent study has recently considered factors influencing mortality in patients in an ICU setting receiving antibiotic therapy for severe bacterial infection [Suefke et al 2012].…”

Section: Discussionmentioning

confidence: 99%

“…This raises a question as to whether or not illness severity may be a factor in the development of erythromycin-linked acquired long QT syndrome? The recent 'QT in Practice' (QTIP) study examined the incidence of QTc interval prolongation in the critical care setting and found episodes of QTc prolongation to >500 ms of 15 minutes or more in 252 of 1039 patients studied (24%) [Pickham et al 2012]. More women than men developed QT prolongation and significant predictors were female sex, administration of QT-prolonging drugs, cerebrovascular incident, hypertension, thyroid disease, diabetes, renal disease, hepatic disease, electrolyte and creatinine abnormalities.…”

Section: Discussionmentioning

confidence: 99%

Erythromycin, QTc interval prolongation, andtorsade de pointes: Case reports, major risk factors and illness severity

Hancox¹,

Hasnain

Vieweg

et al. 2014

Therapeutic Advances in Infection

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Abstract:Objectives: Erythromycin is a macrolide antibiotic that is widely used for various infections of the upper respiratory tract, skin, and soft tissue. Similar to other macrolides (clarithromycin, azithromycin), erythromycin has been linked to QTc interval prolongation and torsade de pointes (TdP) arrhythmia. We sought to identify factors that link to erythromycin-induced/ associated QTc interval prolongation and TdP. Methods and Results: In a critical evaluation of case reports, we found 29 cases: 22 women and 7 men (age range 1895 years). With both oral and intravenous erythromycin administration, there was no significant relationship between dose and QTc interval duration in these cases. Notably, all patients had severe illness. Other risk factors included female sex, older age, presence of heart disease, concomitant administration of either other QTc prolonging drugs or agents that were substrates for or inhibitors of CYP3A4. Most patients had at least two risk factors. Conclusions: On the basis of case report evaluation, we believe that major risk factors for erythromycin-associated TdP are female sex, heart disease and old age, particularly against a background of severe illness. Coadministration of erythromycin with other drugs that inhibit or are metabolized by CYP3A4 or with QTc prolonging drugs should be avoided in this setting.

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“…Also, several studies have shown a high prevalence of QT interval prolongation (>500 ms) in patients admitted to hospital (24% of patients admitted to one of six critical care units over a 2 month period in a study by Pickham et al ,4 and 22.3% of those admitted to the internal medicine ward in a different study5) and a surprisingly high rate (up to 50%) of prescription of QT interval prolonging drugs to patients presenting with QT interval prolongation 5 6. However, the exact incidences of LQTS and TdP remain largely unknown and are likely to be under reported by virtue of a failure to establish a clinical diagnosis of acquired or congenital LQTS based on baseline ECG measurements.…”

Section: Epidemiology Of Acquired Qt Prolongationmentioning

confidence: 99%

Post-acute management of the acquired long QT syndrome

Barra

Agarwal

Begley

et al. 2014

Postgraduate Medical Journal

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The mechanisms underlying drug induced QT prolongation and the immediate treatment of torsade de pointes have been extensively studied but the post-acute management of the Acquired Long QT Syndrome (ALQTS) remains to be addressed. We aimed to review the state of the art data regarding risk stratification, arrhythmic prevention and treatment of patients with ALQTS. A comprehensive review of the scientific data collectable from MEDLINE, EMBASE and COCHRANE (from inception to April 2013) was performed, and descriptive and qualitative information was extracted from the most relevant manuscripts. QT prolonging drugs are widely used in hospital clinical practice, and several studies have shown a high prevalence of QT interval prolongation in patients admitted to hospital and a high rate of prescription of QT interval prolonging drugs to patients presenting with QT interval prolongation. Therefore, the acute and post-acute management of ALQTS is of the utmost importance. Avoidance of offending triggers, electrocardiographic screening, pacing at a relatively fast lower rate limit and using pause prevention programming (preferably with concomitant β blocker treatment), implantable defibrillators in the highest risk patients, genetic testing and counselling in selected cases, and family screening are among the potentially applicable strategies. The latter is justifiable by the fact that some studies unveiled a surprisingly similar positive mutation rate in drug induced LQTS compared with congenital LQTS, supporting the hypothesis that the former can be regarded as a latent form of the latter. Drug challenge with D,L-sotalol in suspected LQTS and treatment with a carvedilol analogue, verapamil or an Ikr activating drug are still in need of further investigation. The post-acute management of patients with ALQTS has received scarce attention in the past, probably due to the fact that it is considered a reversible phenomenon in most cases. Considering the relatively high risk of arrhythmic recurrence in the highest risk ALQTS patients, effective preventive and treatment strategies are warranted, and further research is needed.

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High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality

Cited by 138 publications

References 2 publications

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Erythromycin, QTc interval prolongation, andtorsade de pointes: Case reports, major risk factors and illness severity

Post-acute management of the acquired long QT syndrome

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