Torsades de pointes medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

An understanding of the pathophysiology has led to development of treatment modalities like pacing, isoproterenol and drugs like magnesium and beta blockers.If the episode of does not terminate on its own and degenerates into ventricular fibrillation, cardioversion is required.

Medical Therapy

Acute Treatment

If the episode of does not terminate on its own and degenerates into ventricular fibrillation, cardioversion is required.

Contraindicated medications

Torsades de pointes is considered an absolute contraindication to the use of the following medications:

Procainamide

Lead II electrocardiogram showing Torsades being shocked by an Implantable cardioverter-defibrillator back to the patients baseline cardiac rhythm.

Once the patient is back in normal sinus rhythm, a vigorous search for and correction of conditions that predispose to torsades de pointes which include hypokalemia, hypomagnesemia, and bradycardia should be made. Magnesium sulfate (1-2 g IV over 30-60 seconds) reduces the influx of calcium thereby lowering the amplitude of early after depolarizations and should also be infused even if the magnesium is normal. ^[1]^[2] Administration of lidocaine is generally not effective, but mexiletene may be helpful in suppressing the recurrence of torsade de pointe.

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [3]

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) ^[3]

Class I
“1.Withdrawal of any offending drugs and correction of electrolyte abnormalities are recommended in patients presenting with torsades de pointes. (Level of Evidence: A) ”
“2. Acute and long-term pacing is recommended for patients presenting with torsades de pointes due to heart block and symptomatic bradycardia. (Level of Evidence: A)”

Class IIa
“1. Management with intravenous magnesium sulfate is reasonable for patients who present with LQTS and few episodes of torsades de pointes. Magnesium is not likely to be effective in patients with a normal QT interval. (Level of Evidence: B)”
“2. Acute and long-term pacing is reasonable for patients who present with recurrent pause-dependent torsades de pointes. (Level of Evidence: B)”
“3. Beta blockade combined with pacing is reasonable acute therapy for patients who present with torsades de pointes and sinus bradycardia. (Level of Evidence: C)”
“4. Isoproterenol is reasonable as temporary treatment in acute patients who present with recurrent pause-dependent torsades de pointes who do not have congenital LQTS. (Level of Evidence: B)”

Class IIb
“1. Potassium repletion to 4.5 to 5 mM/L may be considered for patients who present with torsades de pointes. (Level of Evidence: B)”
“2. Intravenous lidocaine or oral mexiletine may be considered in patients who present LQT3 and torsades de pointes. (Level of Evidence: C)”

References

↑ Hoshino K, Ogawa K, Hishitani T, Isobe T, Eto Y (2004). “Optimal administration dosage of magnesium sulfate for torsades de pointes in children with long QT syndrome”. J Am Coll Nutr. 23 (5): 497S–500S. PMID 15466950. Unknown parameter |month= ignored (help)
↑ Hoshino K, Ogawa K, Hishitani T, Isobe T, Etoh Y (2006). “Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome”. Pediatr Int. 48 (2): 112–7. doi:10.1111/j.1442-200X.2006.02177.x. PMID 16635167. Unknown parameter |month= ignored (help)
↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). “ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society”. Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.

[pmid15466950-1] Hoshino K, Ogawa K, Hishitani T, Isobe T, Eto Y (2004). “Optimal administration dosage of magnesium sulfate for torsades de pointes in children with long QT syndrome”. J Am Coll Nutr. 23 (5): 497S–500S. PMID 15466950. Unknown parameter |month= ignored (help)

[pmid16635167-2] Hoshino K, Ogawa K, Hishitani T, Isobe T, Etoh Y (2006). “Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome”. Pediatr Int. 48 (2): 112–7. doi:10.1111/j.1442-200X.2006.02177.x. PMID 16635167. Unknown parameter |month= ignored (help)

[pmid16935995-3] Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). “ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society”. Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.

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