Torsade de pointes: the long-short initiating sequence and other clinical features: observations in 32 patients

The clinical setting, precipitating factors, electrocardiographic features and response to treatment of 32 patients with torsade de pointes were reviewed. Thirty-one patients had underlying cardiac disease and 30 patients had a previous underlying cardiac arrhythmia. Antiarrhythmic medications, often in association with electrolyte abnormalities (such as hypokalemia and hypomagnesemia) were the most common precipitating factors. In 22 of 26 patients, the serum drug levels of the antiarrhythmic agents were found to be within the therapeutic range. However, before the administration of agents known to prolong the QT interval, 20 of the 32 patients had, either alone or in combination, baseline prolongation of the QT interval, hypokalemia or hypomagnesemia. All patients had QTc interval prolongation (mean 0.59 second) immediately before the development of torsade de pointes. Marked lability of T wave morphology was frequently noted. Cardiac pacing was the only consistently effective mode of therapy. A characteristic long-short ventricular cycle length as the initiating sequence was found in 41 of 44 episodes of torsade de pointes. Reported data support the high frequency of this electrocardiographic feature of torsade de pointes in which its onset could be analyzed. It is suggested that this electrocardiographic characteristic will aid in both establishing the diagnosis of torsade de pointes and distinguishing it from other polymorphic forms of ventricular tachycardia.

This article has been cited by other articles:

				J. Osorio, D. J. Dosdall, R. P. Robichaux Jr, P. B. Tabereaux, and R. E. Ideker In a Swine Model, Chest Compressions Cause Ventricular Capture and, By Means of a Long-Short Sequence, Ventricular Fibrillation Circ Arrhythm Electrophysiol, October 1, 2008; 1(4): 282 - 289. [Abstract] [Full Text] [PDF]

				M. O. Sweeney, L. L. Ruetz, P. Belk, T. J. Mullen, J. W. Johnson, and T. Sheldon Bradycardia Pacing-Induced Short-Long-Short Sequences at the Onset of Ventricular Tachyarrhythmias: A Possible Mechanism of Proarrhythmia? J. Am. Coll. Cardiol., August 14, 2007; 50(7): 614 - 622. [Abstract] [Full Text] [PDF]

				H. Nagele, S. Hashagen, M. Azizi, S. Behrens, and M.A. Castel Analysis of terminal arrhythmias stored in the memory of pacemakers from patients dying suddenly Europace, June 1, 2007; 9(6): 380 - 384. [Abstract] [Full Text] [PDF]

				K. M Dale, K. Lertsburapa, J. Kluger, and C M. White Moxifloxacin and Torsade de Pointes Ann. Pharmacother., February 1, 2007; 41(2): 336 - 340. [Abstract] [Full Text] [PDF]

				T. Noda, W. Shimizu, K. Satomi, K. Suyama, T. Kurita, N. Aihara, and S. Kamakura Classification and mechanism of Torsade de Pointes initiation in patients with congenital long QT syndrome Eur. Heart J., December 1, 2004; 25(23): 2149 - 2154. [Abstract] [Full Text] [PDF]

				D. M. Roden Drug-Induced Prolongation of the QT Interval N. Engl. J. Med., March 4, 2004; 350(10): 1013 - 1022. [Full Text] [PDF]

				C. Antzelevitch, L. Belardinelli, L. Wu, H. Fraser, A. C. Zygmunt, A. Burashnikov, J. M. Di Diego, J. M. Fish, J. M. Cordeiro, R. J. Goodrow Jr, et al. Electrophysiologic Properties and Antiarrhythmic Actions of a Novel Antianginal Agent Journal of Cardiovascular Pharmacology and Therapeutics, March 1, 2004; 9(1_suppl): S65 - S83. [Abstract] [PDF]

				E. Himmrich, O. Przibille, C. Zellerhoff, A. Liebrich, S. Rosocha, K. Andreas, D. Nebeling, B. Omogbehin, and J. Meyer Proarrhythmic Effect of Pacemaker Stimulation in Patients With Implanted Cardioverter-Defibrillators Circulation, July 15, 2003; 108(2): 192 - 197. [Abstract] [Full Text] [PDF]

				S. M. Al-Khatib, N. M. A. LaPointe, J. M. Kramer, and R. M. Califf What Clinicians Should Know About the QT Interval JAMA, April 23, 2003; 289(16): 2120 - 2127. [Abstract] [Full Text] [PDF]

				B. Gorenek, G. Kudaiberdieva, O. Goktekin, Y. Cavusoglu, A. Birdane, A. Unalir, N. Ata, and B. Timuralp Long-short sequence may predict immediate recurrence of atrial fibrillation after external cardioversion Europace, January 1, 2003; 5(1): 11 - 16. [Abstract] [PDF]

				A. Halkin, A. Roth, I. Lurie, R. Fish, B. Belhassen, and S. Viskin Pause-dependent torsade de pointes following acute myocardial infarction: A variant of the acquired long QT syndrome J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1168 - 1174. [Abstract] [Full Text] [PDF]

				W. Haverkamp, L. Eckardt, G. Monnig, E. Schulze-Bahr, H. Wedekind, P. Kirchhof, F. Haverkamp, and G. Breithardt Clinical aspects of ventricular arrhythmias associated with QT prolongation Eur. Heart J. Suppl., September 1, 2001; 3(suppl_K): K81 - K88. [Abstract] [PDF]

				T.-M. Lu, C.-T. Tai, M.-H. Hsieh, C.-F. Tsai, Y.-K. Lin, W.-C. Yu, H.-M. Tsao, S.-H. Lee, Y.-A. Ding, M.-S. Chang, et al. Electrophysiologic characteristics in initiation of paroxysmal atrial fibrillation from a focal area J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1658 - 1664. [Abstract] [Full Text] [PDF]

				D. M. Roden Pharmacogenetics and drug-induced arrhythmias Cardiovasc Res, May 1, 2001; 50(2): 224 - 231. [Abstract] [Full Text] [PDF]

				S. C. Verduyn, J. M. v. Opstal, J. D. Leunissen, and M. A. Vos Assessment of the Pro-Arrhythmic Potential of Anti-Arrhythmic Drugs: An Experimental Approach Journal of Cardiovascular Pharmacology and Therapeutics, March 1, 2001; 6(1): 89 - 97. [PDF]

				M. A. Vos, B. Gorenek, S.C. Verduyn, F. F. van der Hulst, J. D. Leunissen, L. Dohmen, and H. J. Wellens Observations on the onset of Torsade de Pointes arrhythmias in the acquired long QT syndrome Cardiovasc Res, December 1, 2000; 48(3): 421 - 429. [Abstract] [Full Text] [PDF]

				D. M RODEN and M. E ANDERSON The pause that refreshes, or does it? Mechanisms in torsades de pointes Heart, September 1, 2000; 84(3): 235 - 237. [Full Text] [PDF]

				W Haverkamp, G Breithardt, A.J Camm, M.J Janse, M.R Rosen, C Antzelevitch, D Escande, M Franz, M Malik, A Moss, et al. The potential for QT prolongation and proarrhythmia by non-antiarrhythmic drugs: clinical and regulatory implications. Report on a Policy Conference of the European Society of Cardiology Eur. Heart J., August 1, 2000; 21(15): 1216 - 1231. [PDF]

				W. Haverkamp, G. Breithardt, A.J. Camm, M. J Janse, M. R Rosen, C. Antzelevitch, D. Escande, M. Franz, M. Malik, A. Moss, et al. The potential for QT prolongation and pro-arrhythmia by non-anti-arrhythmic drugs: Clinical and regulatory implications: Report on a Policy Conference of the European Society of Cardiology Cardiovasc Res, August 1, 2000; 47(2): 219 - 233. [Full Text] [PDF]

				P. G.A. Volders, M. A. Vos, B. Szabo, K. R. Sipido, S.H.M. de Groot, A. P.M. Gorgels, H. J.J. Wellens, and R. Lazzara Progress in the understanding of cardiac early afterdepolarizations and torsades de pointes: time to revise current concepts Cardiovasc Res, June 1, 2000; 46(3): 376 - 392. [Full Text] [PDF]

				H-F Tse, C-P Lau, and G M Ayers Incidence and modes of onset of early reinitiation of atrial fibrillation after successful internal cardioversion, and its prevention by intravenous sotalol Heart, September 1, 1999; 82(3): 319 - 324. [Abstract] [Full Text] [PDF]

				P. C Viswanathan and Y. Rudy Pause induced early afterdepolarizations in the long QT syndrome: a simulation study Cardiovasc Res, May 1, 1999; 42(2): 530 - 542. [Abstract] [Full Text] [PDF]

				N. El-Sherif, E. B. Caref, M. Chinushi, and M. Restivo Mechanism of arrhythmogenicity of the short-long cardiac sequence that precedes ventricular tachyarrhythmias in the long QT syndrome J. Am. Coll. Cardiol., April 1, 1999; 33(5): 1415 - 1423. [Abstract] [Full Text] [PDF]

				M. K. Chung, R. A. Schweikert, B. L. Wilkoff, M. J. Niebauer, S. L. Pinski, R. G. Trohman, G. A. Kidwell, F. J. Jaeger, V. A. Morant, D. P. Miller, et al. Is hospital admission for initiation of antiarrhythmic therapy with sotalol for atrial arrhythmias required?: yield of in-hospital monitoring and prediction of risk for significant arrhythmia complications J. Am. Coll. Cardiol., July 1, 1998; 32(1): 169 - 176. [Abstract] [Full Text] [PDF]

				M. H. Lehmann, S. Hardy, D. Archibald, B. Quart, and D. J. MacNeil Sex Difference in Risk of Torsade de Pointes With d,l-Sotalol Circulation, November 15, 1996; 94(10): 2535 - 2541. [Abstract] [Full Text]

				N. El-Sherif, E. B. Caref, H. Yin, and M. Restivo The Electrophysiological Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: Tridimensional Mapping of Activation and Recovery Patterns Circ. Res., September 1, 1996; 79(3): 474 - 492. [Abstract] [Full Text]

				M. A. Vos, S. C. Verduyn, A. P.M. Gorgels, G. C. Lipcsei, and H. J.J. Wellens Reproducible Induction of Early Afterdepolarizations and Torsade de Pointes Arrhythmias by d-Sotalol and Pacing in Dogs With Chronic Atrioventricular Block Circulation, February 1, 1995; 91(3): 864 - 872. [Abstract] [Full Text]

				K. Olree and J. Stein-Gocken Torsade de Pointes and Elevated Magnesium and Calcium Requirements Associated With Intravenous Pentamidine Nutr Clin Pract, October 1, 1994; 9(5): 191 - 195. [Abstract] [PDF]

				D. M. Roden Risks and Benefits of Antiarrhythmic Therapy N. Engl. J. Med., September 22, 1994; 331(12): 785 - 791. [Full Text]

				R. R. Makkar, B. S. Fromm, R. T. Steinman, M. D. Meissner, and M. H. Lehmann Female Gender as a Risk Factor for Torsades de Pointes Associated With Cardiovascular Drugs JAMA, December 1, 1993; 270(21): 2590 - 2597. [Abstract] [PDF]

				L. A. Gould, R. Betzu, T. Vacek, R. T. Muller, V. Pradeep, and A. Scafa Magnesium Treatment Of Torsade de Pointes A Case Report Angiology, July 1, 1990; 41(7): 577 - 581. [Abstract] [PDF]

				E. J. Stanek, M. D. Schoen, and J. L. Bauman Issues in the Treatment of Ventricular Ectopy: Past, Present, and Future Controversy Journal of Pharmacy Practice, January 1, 1990; 3(5): 283 - 294. [PDF]

				T. A. Mattioni, T. A. Zheutlin, J. J. Sarmiento, M. Parker, M. Lesch, and R. F. Kehoe Amiodarone in Patients with Previous Drug-Mediated Torsade de Pointes: Long-Term Safety and Efficacy Ann Intern Med, October 1, 1989; 111(7): 574 - 580. [Abstract] [PDF]

				J. M. Herre Advances in the Management of Tachyarrhythmias J Intensive Care Med, March 1, 1987; 2(2): 65 - 75. [Abstract] [PDF]

				A. J. Moss Prolonged QT-Interval Syndromes JAMA, December 5, 1986; 256(21): 2985 - 2987. [Abstract] [PDF]