eMedicine Specialties > Cardiology > Arrhythmias

Torsade de Pointes: Follow-up

Author: Jatin Dave, MD, MPH, Instructor, Department of Medicine, Department of Internal Medicine, Division of Aging, Harvard Medical School; Staff Physician, Brigham and Women's Hospital
Coauthor(s): Revat Lakhia, MD, Visiting Staff, Department of Internal Medicine, Brigham and Women's Hospital; Graduate Student in Public Health, Department of Health Science, West Chester University of Pennsylvania
Contributor Information and Disclosures

Updated: Jul 30, 2009

Follow-up

Further Inpatient Care

Patients should be admitted to the intensive care or telemetry unit for continuous cardiac monitoring.

Further Outpatient Care

  • Close follow-up is needed to optimize treatment, especially if patients are at high risk, eg, recurrent syncopal episodes, failure of medical therapy, or history of cardiac arrest.
  • Patients should be asked about dizziness, syncopal episodes, and palpitations.
  • Patients with ICDs should be monitored regularly to check the proper functioning of the device.
  • Patients with acquired long QT syndrome should be educated regarding the potential offending agents. They should also be educated regarding the importance of avoiding commonly used drugs that can cause QT prolongation.

Inpatient & Outpatient Medications

  • Beta-blockers - Propranolol used most commonly
  • Mexiletine

Transfer

Consider transfer to a facility at which the condition can be managed by an electrophysiologist, or at least a cardiologist, especially in patients with cardiac arrest.

Deterrence/Prevention

  • Avoid offending drugs that prolong the QT interval either directly or by inhibiting the metabolism of a torsadogenic drug.
  • Prevent predisposing conditions such as hypokalemia, hypomagnesemia, and hypocalcemia, especially in patients shown to have long QT interval.
  • Screen families of patients with torsade for whom the cause for prolonged QT is suggested to be congenital.
  • Educate patients and their families about the condition and predisposing factors.
  • The role of routine electrocardiography to look for QT prolongation is unclear.
  • If QT prolongation is found, it should be worked up and managed aggressively.

Complications

  • Monomorphic ventricular tachycardia
  • Ventricular fibrillation
  • Sudden cardiac death

Prognosis

  • In congenital long QT syndrome, the mortality rate for untreated patients is 50% in 10 years, which can be reduced to 3-4% with therapeutic intervention.
  • In acquired long QT syndrome, the prognosis is excellent once the inciting factor has been identified and reliably withheld.

Patient Education

  • Instruct patients to use medications only with the approval of a physician.
  • Instruct patients to avoid competitive sports (in cases of congenital long QT syndrome).
  • Close follow-up is needed because of a risk of sudden cardiac death.
  • Offer emotional support; suggest attending a cardiac support group.
  • Patients should be taught how to monitor their pulse and recognize adverse drug effects.
  • Families should undergo training for basic life support.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize heralding syncope
  • Failure to screen family in cases of congenital long QT syndrome
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author John Michael Gaziano, MD, MPH to the development and writing of this article.



More on Torsade de Pointes

Overview: Torsade de Pointes
Differential Diagnoses & Workup: Torsade de Pointes
Treatment & Medication: Torsade de Pointes
Follow-up: Torsade de Pointes
Multimedia: Torsade de Pointes
References
Further Reading
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References

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  2. Antzelevitch C, Sicouri S. Clinical relevance of cardiac arrhythmias generated by afterdepolarizations. Role of M cells in the generation of U waves, triggered activity and torsade de pointes. J Am Coll Cardiol. Jan 1994;23(1):259-77. [Medline].

  3. Nikolic G, Bishop RL, Singh JB. Sudden death recorded during Holter monitoring. Circulation. Jul 1982;66(1):218-25. [Medline].

  4. Lehmann MH, Timothy KW, Frankovich D, et al. Age-gender influence on the rate-corrected QT interval and the QT-heart rate relation in families with genotypically characterized long QT syndrome. J Am Coll Cardiol. Jan 1997;29(1):93-9. [Medline].

  5. Nguyen PT, Scheinman MM, Seger J. Polymorphous ventricular tachycardia: clinical characterization, therapy, and the QT interval. Circulation. Aug 1986;74(2):340-9. [Medline].

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  16. Locati EH, Maison-Blanche P, Dejode P, et al. Spontaneous sequences of onset of torsade de pointes in patients with acquired prolonged repolarization: quantitative analysis of Holter recordings. J Am Coll Cardiol. Jun 1995;25(7):1564-75. [Medline].

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Further Reading

Related guidelines

ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices).

(1) ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1999 guidelines for the Management of Acute Myocardial Infarction). (2) 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young.

ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation).

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Keywords

torsade de pointes, quinidine syncope, polymorphic ventricular tachycardia, VT, prolonged QT interval, arrhythmia, TdP, torsade de pointes ventricular tachycardia, TdPVT, ventricular fibrillation, early after depolarization, EAD, afterdepolarization, arrhythmia, torsades de pointes, torsades, torsade, sudden cardiac death, SCD, sudden death, ventricular fibrillation, tachyarrhythmia

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Contributor Information and Disclosures

Author

Jatin Dave, MD, MPH, Instructor, Department of Medicine, Department of Internal Medicine, Division of Aging, Harvard Medical School; Staff Physician, Brigham and Women's Hospital
Jatin Dave, MD, MPH is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, American Medical Association, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Revat Lakhia, MD, Visiting Staff, Department of Internal Medicine, Brigham and Women's Hospital; Graduate Student in Public Health, Department of Health Science, West Chester University of Pennsylvania
Revat Lakhia, MD is a member of the following medical societies: Medical Council of India
Disclosure: Nothing to disclose.

Medical Editor

Justin D Pearlman, MD, PhD, ME, MA, Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center
Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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