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Pause-dependent torsade de pointes following acute myocardial infarction

A variant of the acquired long QT syndrome

^a Department of Cardiology, Tel Aviv-Sourasky Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

View larger version (39K): [in a new window]   Figure 1 Electrocardiogram (leads V1 through V6) of an 82-year-old woman who developed torsade de pointes three days after anterior myocardial infarction. The QT is normal on admission (QTc = 418 ms), increases by day 2 (QTc = 598 ms), reaches a maximal duration on day 3 (QTc = 645 ms) and normalizes by day 10 (QTc = 430 ms).

View larger version (28K): [in a new window]   Figure 2 QTc values (according to the longest QT of all 12 leads) in patients with torsade de pointes following myocardial infarction (black bars) and controls with uncomplicated myocardial infarction (white bars). Day 1: QTc during the hyperacute phase of the infarction. Day 2: QTc following resolution of ST changes. Days 3 to 10: QTc recorded during the day of torsade de pointes (patient group) or in the trace showing the longest QT during days 3 to 10 (controls). Discharge: The QTc at the time of hospital discharge (days 8 to 19). The QTc significantly increased in the controls by day 2 but notably more so in patients who eventually developed torsade de pointes: *p < 0.05; **p < 0.01. The QTc values derived from the mean QT of all the 12 leads gave similar differences among the groups (not shown).

View larger version (41K): [in a new window]   Figure 3 A 47-year-old man with infarct-related long QT syndrome. Day 1: Acute anterior infarction treated with streptokinase. Peak creatine kinase = 600 U/l (QTc = 450 ms). Day 2: Partial resolution of ST-elevation (QTc = 450 ms). Day 7: Inverted T-waves have developed (QTc = 469 ms). Catheterization showed subtotal occlusion of a small diagonal branch (treated conservatively). Day 9: Cardiac arrest with ventricular fibrillation (VF). Giant inverted T-waves are evident (QTc = 540 ms). Repeated cardiac catheterization showed no changes. Day 11: Recurrent pause-dependent torsade de pointes despite beta-blockers and magnesium. Note the "short-long-short" initiating sequence (S = short cycle; L = long cycle). Day 60: The QT interval two months after the infarct is normal (QTc = 400 ms).

View larger version (58K): [in a new window]   Figure 4 (Top) An 85-year-old man (Patient 2) with anterior infarction treated with tissue plasminogen activator. Day 1: Obvious ST elevation in the precordial leads (QTc = 440 ms). Day 2: Early appearance of giant inverted T-waves. (QT = 600 ms; QTc = 674 ms). Day 3: Brief burst of pause-dependent torsade de pointes. (Bottom) A 67-year-old man (Patient 3) with anterior infarction treated with primary angioplasty of the left anterior descending coronary artery. He had an uncomplicated course until day 6 but then had recurrent torsade de pointes deteriorating to ventricular fibrillation. Spontaneous termination of torsade de pointes is shown on the eighth day. Note the QT augmentation following the pause (arrowheads).