Skip to main content
SpringerLink
Log in

Torsades de pointes: Prevention and therapy

  • Forum on Torsades de Pointes Part Three
  • Published:
Cardiovascular Drugs and Therapy Aims and scope Submit manuscript

Summary

Torsades de pointes (TdP) is a life-threatening ventricular tachycardia that occurs in the setting of a prolonged QT interval and is most frequently related to administration of antiarrhythmic drugs. Patients with organic heart disease, with low serum electrolyte levels, with a previous episode of TdP and with bradycardia or baseline QT prolongation may be at increased risk of developing TdP. After initiation of a QT prolonging therapy, the dosage should be modified if the QT interval reaches 560–600 ms. Cessation of medication and immediate hospitalization are indicated in the presence of lightheadedness, syncope, or increased frequency and complexity of ventricular premature beats. The conventional therapy of TdP with isoproterenol or cardiac pacing, although usually effective, has certain disadvantages. Isoproterenol is contraindicated in patients with hypertension or ischemic heart disease, whereas institution of cardiac pacing requires skilled personnel and fluoroscopy.

Recently, infusion of magnesium sulfate has been shown to abolish TdP both in the clinical and experimental setting. Compared with conventional therapy, magnesium sulfate has the advantage of safety and simplicity of its administration. In doubtful cases, if does not aggravate a ventricular tachycardia that is not TdP, as may occur with isoproterenol. This advantage and the prompt effectiveness of the drug in four clinical series, including 31 patients, support the use of magnesium sulfate as the first line of therapy for TdP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Dessertenne F. La tachycardie ventriculaire a deux foyers opposes variables.Arch Mal Coeur 1966;59:263–272.

    PubMed  CAS  Google Scholar 

  2. Selzer A, Wray HW. Quinidine syncope: Paroxysmal ventricular fibrillation occuring during treatment of chronic atrial arrhythmias.Circulation 1964;30:17–23.

    PubMed  CAS  Google Scholar 

  3. Slama R, Coumel PH, Motte G, et al. Tachycardies ventriculaires et torsades de pointes: Frontieres morphologiques entre les dysrythmies ventriculaires.Arch Mal Coeur 1973;66:1401–1411.

    PubMed  CAS  Google Scholar 

  4. Krikler DM, Curry PVL. Torsade de pointes, an atypical ventricular tachycardia.Br Heart J 1976;38:117–120.

    Article  PubMed  CAS  Google Scholar 

  5. Reynolds EW, Vander Ark CR. Quinidine syncope and the delayed repolarization syndromes.Mod Concepts Cardiovase Dis 1976;45:117–122.

    CAS  Google Scholar 

  6. Smith WM, Gallagher JJ. “Les torsades de pointes:” An unusual ventricular arrhythmia.Ann Intern Med 1980;93: 578–584.

    PubMed  CAS  Google Scholar 

  7. Keren A, Tzivoni D, Gavish A, et al. Etiology, warning signs and therapy of torsades de pointes: A study of 10 patients.Circulation 1981;64:1167–174.

    PubMed  CAS  Google Scholar 

  8. Kay GN, Plumb VJ, Arciniegas JG, et al. Torsade de pointes: The long-short initiating sequence and other clinical features. Observation in 32 patients.J Am Coll Cardiol 1983;2:806–817.

    PubMed  CAS  Google Scholar 

  9. Bauman JL, Bauernfeind RA, Hoff JV, et al. Torsade de pointes due to quinidine: Observations in 31 patients.Am Heart J 1984;107:425–430.

    Article  PubMed  CAS  Google Scholar 

  10. Bayes de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death: Mechanisms of production of fatal arrhythmia on the basis of data from 157 cases.Am Heart J 1989;117:151–159.

    Article  Google Scholar 

  11. Roden DM, Woosley RL, Primm RK. Incidence and clinical features of the quinidine-associated long QT syndrome: Implications for patients care.Am Heart J 1986;111:1086–1093.

    Article  Google Scholar 

  12. Strasberg B, Sclarovsky S, Erdberg A, et al. Procainamide-induced polymorphous ventricular tachycardia.Am J Cardiol 1981;47:1309–1314.

    Article  PubMed  CAS  Google Scholar 

  13. Sclarovsky S, Strasberg B, Lewin RF, Agmon J. Polymorphous ventricular tachycardia: Clinical features and treatment.Am J Cardiol 1979;44:339–344.

    Article  Google Scholar 

  14. Olshansky B, Martins J, Hunt S. N-acetyl procainamide causing torsades de pointes.Am J Cardiol 1982;50:1439–1441.

    Article  PubMed  CAS  Google Scholar 

  15. Tzivoni D, Keren A, Stern S, Gottlieb S. Atypical ventricular tachycardia induced by disopyramide.Arch Intern Med 1981;141:946–947.

    Article  PubMed  CAS  Google Scholar 

  16. Nicholson WJ, Martin CE, Gracey JG, Knoch HR. Disopyramide-induced ventricular fibrillation.Am J Cardiol 1979;43:1053–1055.

    Article  PubMed  CAS  Google Scholar 

  17. Veglia L, Scandiffio T, Guerrichio G. Torsioni di punta e amiodarone.G Ital Cardiol 1978;8:1025–1029.

    PubMed  CAS  Google Scholar 

  18. McComb JM, Logan KR, Khan MM, et al. Amiodarone-induced ventricular fibrillation.Eur J Cardiol 1980;11: 381–385.

    PubMed  CAS  Google Scholar 

  19. Keren A, Tzivoni D, Gottlieb S, et al. Atypical ventricular tachycardia (torsade de pointes) induced by amiodarone: Arrhythmia previously induced by quinidine and disopyramide.Chest 1982;81:384–386.

    Article  PubMed  CAS  Google Scholar 

  20. Neuvonen PJ, Elonen E, Vuorenmaa T, Laaks OM. Prolonged QT interval and severe tachyarrhythmias, common features of sotalol intoxication.Eur J Clin Pharmacol 1981;20:85–89.

    Article  PubMed  CAS  Google Scholar 

  21. McKibbin JK, Pocock WA, Barlow JB, et al. Sotalol, hypokalaemia, syncope, and torsade de pointes.Br Heart J 1984;51:157–162.

    Article  PubMed  CAS  Google Scholar 

  22. Samet JM, Surawicz B. Cardiac function in patients treated with phenothiazines: Comparison with quinidine.J Clin Pharmacol 1974;14:588–596.

    PubMed  CAS  Google Scholar 

  23. Ludomirsky A, Klein HO, Sarelli P, et al. QT prolongation and polymorphous (“torsade de pointes”) ventricular arrhythmias associated with organophosphorus insecticide poisining.Am J Cardiol 1982;49:1654–1658.

    Article  PubMed  CAS  Google Scholar 

  24. Denes P, Gabster A, Huang SK. Clinical, electrocardiographic and follow-up observations in patients having ventricular fibrillation during Holter monitoring. Role of quinidine therapy.Am J Cardiol 1981;48:9–16.

    Article  PubMed  CAS  Google Scholar 

  25. Curry P, Fitchett D, Stubbs W, Krikler D. Ventricular arrhythmias and hypokalemia.Lancet 1976;2:231–233.

    Article  PubMed  CAS  Google Scholar 

  26. Loeb HS, Pietras RJ, Gunner RM, Tobin JR. Paroxysmal ventricular fibrillation in two patients with hypomagnesemia: Treatment by transvenous pacing.Circulation 1968; 37:210–215.

    Google Scholar 

  27. Nguyen PT, Scheinman MM, Seger J. Polymorphopus ventricular tachycardia: Clinical characterization, therapy, and the QT interval.Circulation 1986;74:340–349.

    PubMed  CAS  Google Scholar 

  28. Mattioni TA, Zheutlin TA, Sarmiento JJ, et al. The longterm safety and efficacy of amiodarone in patients with prior drug-mediated torsade de pointes.Ann Intern Med 1989;111:574–580.

    PubMed  CAS  Google Scholar 

  29. Surawicz B, Knoebel SB. Long QT. Good, bad or indifferent? JAm Coll Cardiol 1984;4:398–413.

    PubMed  CAS  Google Scholar 

  30. Zipes DP. Proarrhythmic effects of antiarrhythmic drugs.Am J Cardiol 1987;59:26E-31E.

    Article  PubMed  CAS  Google Scholar 

  31. Stratmann HG, Kennedy HL. Torsades de pointes associated with drugs and toxins: Recognition and management.Am Heart J 1987;113:1470–1481.

    Article  PubMed  CAS  Google Scholar 

  32. Jackman WM, Friday KJ, Anderson JL, et al. The long QT syndromes: A critical review, new clinical observations and a unifying hypothesis.Prog Cardiovasc Dis 1988;31: 115–172.

    Article  PubMed  CAS  Google Scholar 

  33. Lewis BH, Antman EM, Graboys TB. Detailed analysis of 24 hour ambulatory electrocardiographic recordings during ventricular fibrillation or torsade de pointes.J Am Coll Cardiol 1983;2:426–436.

    PubMed  CAS  Google Scholar 

  34. Tzivoni D, Keren A, Cohen AM, Stern S. Magnesium therapy for torsade de pointes.Am J Cardiol 1984;53:528–530.

    Article  PubMed  CAS  Google Scholar 

  35. Keren A, Tzivoni D, Gohlman JM, et al. Ventricular pacing in atypical ventricular tachycardia.J Electrocardiol 1981; 14:201–206.

    Article  PubMed  CAS  Google Scholar 

  36. Motte G, Laine JF, Sebag C, Davy JM. Torsade de pointes favorisées par l’atropine.Nouv Presse Med 1982;11:3571–3580.

    PubMed  CAS  Google Scholar 

  37. Tzivoni D, Keren A, Stern S. Torsades de pointes versus polymorphous ventricular tachycardia.Am J Cardiol 1983;52:639–640.

    Article  PubMed  CAS  Google Scholar 

  38. Milne JR, Ward DE, Spureil, Camm AJ. The long QT syndrome: Effects of drugs and left stellate ganglion block.Am Heart J 1982;104:194–203.

    Article  PubMed  CAS  Google Scholar 

  39. Tzivoni D, Banai S, Schuger C, et al. Treatment of torsade de pointes with magnesium sulfate.Circulation 1988;77: 392–397.

    PubMed  CAS  Google Scholar 

  40. Chadda K, Ballas M, Bodenheimer MM. Efficacy of magnesium in patients with hypomagnesemia and cardiac arrhythmia (abstr).Circulation 1984;70(Suppl II):444.

    Google Scholar 

  41. Iseri LT, Chung P, Tobis J. Magnesium therapy for intractable ventricular tachyarrhythmias in normomagnesemic patients.West J Med 1983;138:823–828.

    PubMed  CAS  Google Scholar 

  42. Perticone F, Adinolfi L, Bonaduce D. Efficacy of magnesium sulfate in the treatment of torsade de pointes.Am Heart J 1986;112:847–849.

    Article  PubMed  CAS  Google Scholar 

  43. Etienne Y, Blanc JJ, Songy B. Antiarrhythmic effect of intravenous magnesium sulphate in torsade de pointes: Results in six cases.Arch Mal Coeur Vaiss 1986;79:362–367.

    PubMed  CAS  Google Scholar 

  44. Bailie DS, Inoue H, Kaseda S, et al. Magnesium suppression of early afterdepolarization and ventricular tachyarrhythmias induced by cesium in dogs.Circulation 1988;77: 1395–1402.

    PubMed  CAS  Google Scholar 

  45. Davidenko JM, Cohen L, Goodrow R, Antzelevitch C. Quinidine-induced action potential prolongation, early afterdepolarizations, and triggered activity in canine Purkinje fibers. Effects of stimulation rate, potassium, and magnesium.Circulation 1989;79:674–686.

    PubMed  CAS  Google Scholar 

  46. Toivonen LK, Leinonen H. Limited effect of magnesium sulfate on torsade de pointes ventricular tachycardia.Int J Cardiol 1986;12:260–262.

    Article  PubMed  CAS  Google Scholar 

  47. DiCarlo LA, Morady F, de Buitleir M, et al. Effect of magnesium sulfate on cardiac conduction and refractoriness in humans.J Am Coll Cardiol 1986;7:1356–1362.

    Article  PubMed  Google Scholar 

  48. Rogiers P, Vermeier W, Kesteloot H, Stroobandt R. Effect of the infusion of magnesium sulfate during atrial pacing on ECG intervals, serum electrolytes, and blood pressure.Am Heart J 1989;117:1278–1283.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The Heiden Department of Cardiology, Bikur Cholim Hospital, 5-7 Strauss St., P.O. Box 492, Jerusalem, Israel

    Andre Keren & Dan Tzivoni

  2. Hebrew University Hadassah Medical School, Jerusalem, Israel

    Andre Keren & Dan Tzivoni

Authors
  1. Andre Keren
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dan Tzivoni
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Keren, A., Tzivoni, D. Torsades de pointes: Prevention and therapy. Cardiovasc Drug Ther 5, 509–513 (1991). https://doi.org/10.1007/BF03029778

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03029778

Key Words

Search

Navigation