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ECG OF THE WEEK
-Dr. Devendra Patil
Prof. Dr. S.Magheshkumar’s Unit
Indira 70/ F Retd. Matron GSH came with chief complains of Fever since 20-25 days Intermittent ,high grade
asso. with chills n rigors
Taking some oral medication from pvt.
K/c/o SHT and DM since 15 yrs on Rx.
2 days later she had a cardiac arrest with the following ECG pattern
ECG findings :-
Heart Rate – 50 bpmRegular Sinus rhythmNormal Axis P wave - normalPR interval - 0.12 secQRS complex – normal width and shape
QT interval – 0.56 secQTc interval - 0.509 secT wave – normal
Impression :- Bradycardia with acquired prolonged QT syndrome
Pt. was shifted to ICCU.
She developed cardiac arrest .Pulse – not feltBP - not recordableECG showed Vent. Tachycardia
200 J Biphasic DC shock was given and was reverted to sinus rhythm
A Temporary Cardiac Pacemaker was inserted following Rt. Femoral Vein Catheterization and she was reverted to sinus rhythm over the next 2 days
QT interval : beginning of Q-wave upto the end of T-wave.
QT interval : total duration of ventricular activity.
Need for QTc Interval :The QT interval varies with
RR interval. False high values may be noted in Bradycardias.
LONG QT SYNDROME
Formula accepted for QTc is:
BAZETT’s Formula : QTc = QT ∕√ (RR)
A useful rule of thumb is that, with a normal heart rate ( 60 - 100 bpm), the QT interval SHOULD NOT exceed half the RR interval.
LONG QT SYNDROME
ACQUIREDCONGENITAL
Due to Genetic defects in K+ channels involved during repolarization.Severe form Includes: 1. Jervell Lange Syndrome (deafness, syncopal attacks , sudden death )
2. Romano Ward Syndrome (similar to Jervell Lange syndrome but without deafness )
•DRUGS •During Sleep•Hypocalcemia•Acute Myocarditis•Acute Myocadial Infarction• Hypothermia•HOCM•Cerebral Injury•Advanced AV Blocks
Congenital LONG QT SYNDROME
LQT1 GeneMost common typeQT interval fails to shorten post exerciseT wave is broad and occupies majority QT intervalMost common triggers: exercise, emotional stress.80% have first presentation < 20 yrsJervell Lange syndrome and Romano Ward syndrome are severe forms.
LQT2 Gene T wave tends to be bifid and notchedAdditional Triger factors are sleep, auditory stimulationRespond to B-Blockers
LQT3 GenePoorest prognosis amongst allT wave is asymmetrical or Late biphasicTrigger factor : Bradycardia ( sleep )B-Blockers ContraindicatedExercise is not Restricted
AntiarrhythmicsClass 1: ajmaline*, cibenzoline*, dihydroquinidine*, disopyramide, encainide*, flecainide, mexiletine, pirmenol*, procainamide, propafenone quinidine*Class 3: almokalant*, amiodarone, azimilide*, bretylium, dofetilide*, dronedarone*, d-sotalol*, ersentilide*, ibutilide*, nifekalant*, sematilide*, sotalol, terikalant*
Anti-anginals/vasodilatorsbepridil*, lidoflazine*, prenylamine*, ranolazine, terodiline*, vardenafil
Anti-hypertensivesindapamide, isradipine, moexipril/hydrochlorthiazide, nicardipine
Antihistaminesastemizole*, azelastine, diphenhydramine, ebastine*, hydroxyzine, terfenadine*
Serotonin agonists and antagonistscisapride*, dolasetron, granisetron, ketanserin*, ondansetron
AntimicrobialsMacrolide antibiotics: azithromycin, clarithromycin, erythromycin, roxithromycin*, spiramycin, telithromycin
Quinolone antibiotics: ciprofloxacin, gatifloxacin*, gemifloxacin*, grepafloxacin*, levofloxacin, moxifloxacin, ofloxacin, sparfloxacin*
Antifungals: cotrimoxazole, fluconazole Others: pentamidine, trimethoprim sulfa Antiviral: foscarnet (HIV)
DRUGS that may cause QT PROLONGATION
Antimalarials Chloroquine, halofantrine*, lumefantrine, quinine
Psychiatric drugsTricyclic antidepressants: amitriptyline, amoxapine*, clomipramine, desipramine*, doxepin, imipramine, nortriptyline, protriptyline*, trimipramine
Phenothiazines: chlorpromazine, fluphenazine, prochlorperazine, thioridazine*, trifluoperazine
Others: atomoxetine, citalopram, clozapine, droperidol*, fluoxetine, haloperidol, levomethadyl*, lithium, maprotiline, mesoridazine, methadone, paroxetine, pericycline, pimozide, quetiapine, risperidone, sertindole, sertraline, trazodone, venlafaxine, zimeldine*, ziprasidone
Anticonvulsantfelbamate*, fosphenytoin
Anti-migrainenaratriptan, sumatriptan, zolmitriptan
Anti-cancerarsenic trioxide, geldanamycin*, sunitib, tacrolimus, tamoxifen
Othersalfuzosin, chloral hydrate, clobutinol*, domperidone, galantamine, octreotide, organophosphates*, perflutren lipid microspheres, probucol, solifenacin, tizanidine, tolterodine, vasopressin
Stimulant drugsSome cold remedies contain these drugs so it is important always to check the label.adrenaline (epinephrine), amphetamine, cocaine, dexmethylphenidate, dobutamine, dopamine, ephedrine, fenfluramine, isoprenaline (isoproterenol), levalbuterol, metaproterenol, methylphenidate, midodrine, norepinephrine (noradrenaline), phentermine, phenylephrine, phenylpropanolamine, pseudoephidrine, ritodrine, salbutamol (albuterol), salmeterol, sibutramine, terbutaline
DRUGS that may cause QT PROLONGATION Continued…
COMPLICATIONS OF LONG QT SYNDROME Torsades des pointes ( polymorphic
ventricular tachycardia )More commonly seen in women
Manifestation of subclinical LQTS
Potentiated by bradycardia and hypokalemia
drug usually blocks Ikr channel
triggered by early afterdepolarizations due to intracellular Ca+ accumulation from a prolonged actin potential plateau
heterogenicity of myocardial repolarisation predisposes to polymorphic ventricular activity
TREATMENT Caution has to be exercised during
administering multiple drug regimes. They may cause QT Prolongation and TDP.
Correction of K+ and Mg++ levels Temporary Pacing Cautious Infusion of Isoprotenol Class 1B anti arrythmics (no QT
prolongation seen)
THANK YOU