Individuals suffering from torsades de pointes suffer recurrent palpitation events, syncope and dizziness. In addition to this, patients also experience shortness of breath, difficulty in breathing, pain in chest and nausea accompanied by cold sweats. In many instances sudden death can occur due to cardiac arrest.

Research has also shown that period of stress, fear, anxiety or physical exertion can trigger episodes of torsades. Patients may also exhibit signs of rapid pulse rate, and transient periods of unconsciousness. Other physical symptoms would depend on the type of congenital disorder present. Individuals who experience sustained episodes of torsades may suffer from diaphoresis and pallor.

• Asymptomatic

  During the ensuing 6 months, the patient remained asymptomatic, and the QTc did not change. [ncbi.nlm.nih.gov]

  Significant findings: The patient was found to be in a polymorphic ventricular tachycardia; he was alert, awake and asymptomatic. [jetem.org]

• Antipsychotic Agent

  […] the hepatic metabolism of the antipsychotic agent. [jle.com]

  A randomized evaluation of the effects of six antipsychotic agents on QTc, in the absence and presence of metabolic inhibition. J Clin Psychopharmacology. 2004; 24 :62–69. [ PubMed ] 5. Stöllberger C, Huber JO, Finsterer J. [ncbi.nlm.nih.gov]

  Rampe D Murawsky M Grau J Lewis E The antipsychotic agent sertindole is a high affinity antagonist of human cardiac potassium channel HERG. J Pharmacol Exp Ther. 1998; 286: 788-793 15. [thelancet.com]

  Harrigan EP, Miceli JJ, Anziano R, Watsky E, Reeves KR, Cutler NR, et al.: A randomized evaluation of the effects of six antipsychotic agents on QTc, in the absence and presence of metabolic inhibition. J Clin Psychopharmacology 2004; 24: 62–9. [aerzteblatt.de]

  The antipsychotic agent sertindole is a high affinity antagonist of the human cardiac potassium channel HERG. J Pharmacol Exp Ther 1998 ; 286 : 788 –93. ↵ Committee of Safety of Medicines. Cardiac arrhythmias with pimozide (Orap). [doi.org]

• Malaise

  You will be able to get a quick price and instant permission to reuse the content in many different ways. torsade de pointes A 41 year old woman was admitted to the accident and emergency (A&E) department with a short history of lethargy and malaise followed [emj.bmj.com]

• Surgical Procedure

  We had a patient with bepridil-induced long QT interval who presented peroperative TdPVT concomitant with a transient bradycardia at the end of an uneventfull surgical procedure performed under combined general and epidural anesthesia. [journals.lww.com]

• Pneumonia

  Abstract Legionella infection most commonly manifests as pneumonia. Extrapulmonarylegionellosis is rare, but the clinical manifestations are often dramatic. [ncbi.nlm.nih.gov]

  The patient was admitted with diagnoses of community-acquired pneumonia and over-anticoagulation. He was given fresh frozen plasma and he was treated with intravenous erythromycin, 500 mg every 6 hours. [heartviews.org]

• Aspiration

  Medication included furosemide 200 mg daily and ciprofloxacin 250 mg twice daily, the latter having been prescribed following the aspiration of an infected renal cyst. [consultant360.com]

  Complications from these interventions can include aspiration pneumonia and broken ribs. Recurrent TdP rarely kills someone within the ICU, but it’s still harmful. A better approach to TdP My preferred approach to TdP is shown above. [emcrit.org]

  A chest X-ray displayed no aspiration pneumonia nor other cardiopulmonary anomalies. [jintensivecare.biomedcentral.com]

• Nausea

  Symptoms: Affected individuals suffer from rapid pulse rate, arrhythmias, shortness of breath, diaphoresis, nausea along with dizziness, pallor, chest pain and cold sweats. [symptoma.com]

  Abstract A 75-year-old woman presenting with pre-syncope, shortness of breath and nausea was admitted to the emergency department following treatment with clarithromycin. [ncbi.nlm.nih.gov]

  Symptoms of torsades de pointes include: heart palpitations dizziness nausea cold sweats chest pain shortness of breath rapid pulse low blood pressure In more serious cases, torsades de pointes can cause lack of consciousness, known as syncope, or even [medicalnewstoday.com]

• Diarrhea

  Common causes for Torsades de Pointes include electrolyte imbalances, which may be a result of diarrhea, vomiting, dialysis and dehydration. Alcoholics are also more prone to this dysrhythmia. [alivecor.com.hk]

  Taking a drug (sertraline) that can prolong the QT interval and her probable hypokalemia and hypomagnesemia from digoxin, furosemide, and diarrhea further increased her risk. [nursingcenter.com]

  She suffered from repeated diarrhea and vomiting, and experienced syncope. She was admitted to our hospital and was diagnosed with acute colitis and syncope. On admission, her heart rate was 54 beats/min with regular rhythm. [ncbi.nlm.nih.gov]

  Diarrhea is also a potential confounder because diarrhea may lead to electrolyte abnormalities, which may cause TdP/QTP. Antibiotics, such as penicillin combinations and fluoroquinolones, cause diarrhea in many patients. [medsci.org]

• Vomiting

  Common causes for Torsades de Pointes include electrolyte imbalances, which may be a result of diarrhea, vomiting, dialysis and dehydration. Alcoholics are also more prone to this dysrhythmia. [alivecor.com.hk]

  Forty-eight hours prior to presentation, the patient had intractable nausea and vomiting and was unable to take anything orally. [ncbi.nlm.nih.gov]

  Gastrointestin al and abdominal pains Dyspepsia Flatulence Last Update: 2012-04-11 Usage Frequency: 1 Romanian Aritmie ventriculară, Alungirea intervalului QT, torsada vârfurilor * English Vomiting Gastrointestinal and abdominal pains Dyspepsia Flatulence [mymemory.translated.net]

• Tachycardia

  Why is this an important form of ventricular tachycardia to differentiate from the more classic monomorphic ventricular tachycardia? View this short 9 minute video on QT intervals and Torsades de Pointes. [aliem.com]

  However, as the ECG is being performed, she slumps over and you see torsades de pointes: My approach Treat the ventricular tachycardia Torsades de pointes is a ventricular tachycardia. In the unstable patient, cardiovert. [first10em.com]

  This is a relatively rare variety of ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram (ECG). [alivecor.com.hk]

  […] torsades de pointes [ tor-sahd´ duh pwahnt ] an atypical rapid ventricular tachycardia with periodic waxing and waning of amplitude of the QRS complexes on the electrocardiogram. [medical-dictionary.thefreedictionary.com]

  Torsades de pointes is a type of ventricular tachycardia which may eventually resolve on its own; but can recur increasing the risk for other conditions. [symptoma.com]

• Heart Disease

  Isoproterenol is contraindicated in patients with hypertension or ischemic heart disease, whereas institution of cardiac pacing requires skilled personnel and fluoroscopy. [ncbi.nlm.nih.gov]

  A 60 year old man with Ischaemic Heart Disease. Polymorphous ventricular tachycardia (Torsade de pointes). [ecglibrary.com]

  Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias [acc.org]

  METHODS AND RESULTS We observed 14 patients aged 34.6 +/- 10 years (mean +/- SD) with no structural heart disease who presented with syncope related to a typical ECG aspect of torsade de pointes. [doi.org]

• Fracture

  It can also be seen with clavicular fractures, especially in neonates secondary to birth trauma. [emedicine.medscape.com]

  Initiation of a protocolized magnesium infusion immediately following the first episode of TdP may prevent recurrence and thereby avoid complications (e.g. cardiac arrest, rib fractures). [emcrit.org]

  Trauma, including minor trauma (sprains/strains), fractures, dislocations, and subluxations, often result in spasms of cervical musculature. [medscape.com]

• Suggestibility

  These findings suggest that BiVP may be helpful in patients with LQTS and refractory TdP. ©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc. [ncbi.nlm.nih.gov]

  This suggests that institutions may have to determine the risk score that is most appropriate for their clinical environment. [onlinejacc.org]

• Withdrawn

  In the case of the new atypical antipsychotic agents, it is possible to rank the risks of different drugs, with sertindole (now withdrawn from sale) having the highest risk, and ziprasidone somewhat lower, followed by risperidone and finally by quetiapine [jle.com]

  Any offending agent should be withdrawn. Predisposing conditions such as hypokalemia, hypomagnesemia, and bradycardia should be identified and corrected. [emedicine.medscape.com]

  Since the first edition of this book was published in 2005, numerous drugs have been withdrawn from the market in the United States as a result of morbidity and/or mortality associated with drug-induced diseases. [books.google.it]

  In fact, drug-induced QT prolongation is the most common cause of drugs being withdrawn from the U.S. market or from development in the last 20 years. [forums.studentdoctor.net]

  Candidate drugs that are determined not to cause cardiac ion channel blockage are more likely to pass successfully through clinical phases II and III trials (and preclinical work) and not be withdrawn even later from the marketplace due to cardiotoxic [arxiv.org]

• Anxiety Disorder

  Opipramol for the treatment of generalized anxiety disorder: a placebo-controlled trial including an alprazolam-treated group. J Clin Psychopharmacol. 2001; 21 :59–65. [ PubMed ] e44. [ncbi.nlm.nih.gov]

  Norman TR, Olver JS: Duloxetine in the treatment of generalized anxiety disorder. Neuropsychiatr Dis Treat 2008; 4: 1169–80. MEDLINE e48. [aerzteblatt.de]

• Renal Insufficiency

  If this treatment is unsuccessful, a 2nd bolus is given in 5 to 10 minutes, and a magnesium infusion of 3 to 20 mg/minute may be started in patients without renal insufficiency. [msdmanuals.com]

  If this treatment is unsuccessful, a 2nd bolus is given in 5 to 10 min, and a magnesium infusion of 3 to 20 mg/min may be started in patients without renal insufficiency. [merckmanuals.com]

• Kidney Failure

  Some people with stomach ulcers, asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers. [patient.info]

• Seizure

  The episode during which the boy had “seizures” was triggered by the alarm clock in the early morning. Figure 1: Torsade de pointes in a long QT syndrome type 2 patient. [thecardiologyadvisor.com]

  These were corrected by intravenous electrolyte replacement, and the seizures then ceased. [consultant360.com]

  ECG monitoring is required for patients presenting with seizures. We would also suggest that a 12 lead ECG is mandatory where seizures are of new onset or are associated with any atypical features. [emj.bmj.com]

  The hallmark phenotypic features are syncope, seizure or sudden death, however most of the mutation carriers are asymptomatic and their risk for arrhythmias such as Torsade de pointes (TdP) are low. [ncbi.nlm.nih.gov]

• Irritability

  In V-tach, there's either an irritated area of the ventricles, or some sort of abnormal circuit that's going around in circles firing away, making the heart beat really fast. However, V-tach is still an organized rhythm. [khanacademy.org]

  Worms can sometimes become directly visible on the irritated anus. Who is at most risk of trichuriasis? Children are particularly vulnerable to trichuriasis. Infection in children can cause growth retardation and impair normal development. [dermnetnz.org]

  With a condition called benign paroxysmal torticollis, there may be recurrent episodes, or “attacks,” of head tilting; often these attacks are accompanied by other symptoms, such as vomiting, irritability and/or drowsiness. [childrenshospital.org]

Making an appropriate diagnosis of torsades de pointes is necessary to separate the condition from other variants of ventricular tachycardia. Failure to promptly diagnose the condition can lead to continuation of rhythm disturbances. Diagnosis of torsades de pointes includes the following tests:

• Electrocardiography (ECG): This is one of the most important and preliminary diagnostic procedure that should be carried out. The patient should be continuously monitored through ECG, when torsades has occurred as a secondary response to drug therapy or other chronic diseases [9].
• Laboratory studies: These include measuring calcium, potassium and magnesium levels. In addition, cardiac enzymes are also analyzed to determine myocardial ischemia as the underlying etiology.
• Imaging studies: Chest radiographs along with echocardiography are indicated in order to evaluate presence of structural abnormalities of heart.

• Hypermagnesemia

  Because of the danger of hypermagnesemia (depression of neuromuscular function), the patient requires close monitoring. [emedicine.medscape.com]

  […] minutes), but in the unstable patient it is reasonable to give it as a slow IV push Start an infusion at 1-4 grams/hr Monitor magnesium levels: if >2.5 mmol/L cut infusion in half; if >3mmol/L stop the infusion Monitor clinically: The major side effect of hypermagnesemia [first10em.com]

  ECG showing the QRS complexes “twisting” around the isoelectric line Management Increasing HR decreases QT interval Magnesium sulfate - decreases calcium influx 1-2gm IV over 1-2 min, repeat in 5-15min; then 1-2gm/hr (3-10mg/min) drip Danger of hypermagnesemia [wikem.org]

• Magnesium Increased

  Isoproterenol has been shown to help prevent Torsades de Pointes in patients with prolonged QT that is refractory to magnesium. It is a non-selective beta agonist, which increases the heart rate and shortens the QT interval. [ncbi.nlm.nih.gov]

• Prolonged QT Interval

  If the prolonged QT interval is acquired in nature, the prognosis is excellent, with correction of precipitating factor. In many cases prolonged QT interval may be a congenital affair. [symptoma.com]

  Methadone is known to prolong QT interval and sometimes cause torsade de pointes (TdP) and ventricular fibrillation (VF). Treatment of TdP by antiarrhythmic drugs that prolong QT interval may worsen TdP. [ncbi.nlm.nih.gov]

  In patients with acquired prolonged QT intervals, such as Broka et al.'s, this resulting bradycardia directly causes further prolongation of the QT interval, which could induce torsade de pointes. [journals.lww.com]

  Torsades de Pointes is associated with long QT syndrome, a condition whereby prolonged QT intervals are visible on the ECG. [alivecor.com.hk]

  Any prolonged QT interval during the initial doses may lead to reduction or termination of the medication. Very few patients had to stop taking Dofetilide because of QT prolongation. [onlinejacc.org]

• Torsades De Pointes

  Drug-induced torsades de pointes is known to majorly strike the female population. Cause: Torsades de pointes can either be acquired or congenital in nature. [symptoma.com]

  Cite this article as: Justin Morgenstern, "Torsades de Pointes: Approach to resuscitation", First10EM blog, January 9, 2017. Available at: https://first10em.com/torsades-de-pointes/. [first10em.com]

  This is Torsades de pointes Torsades de Pointes = Polymorphic VT with long QT Torsades occurs when a PVC occurs during the T Wave (R on T) THIS explains WHY ‘overdrive pacing’ works – see Treatment below The QT conundrum: The QT is heart rate-dependent [blog.ercast.org]

• T Wave Alternans

  Cellular and ionic basis for T-wave alternans under long-QT conditions Circulation 1999 ; 99 : 1499 -1507. [30], Goetsch B, Antz M, et al. [academic.oup.com]

  U wave was observed in 86 episodes (56.9%), among that in 69 episodes, the U/T wave ratio was > 1. Macro T wave alternans was observed in 4 patients. [ncbi.nlm.nih.gov]

  Occasionally persons with LQTS display T-wave alternans, meaning that the amplitude or direction of the T-wave alternates from one beat to the next. T-wave alternans is an indicator of very high risk of torsade de pointes. [ecgwaves.com]

• Short term and long term management is indicated in treatment of torsades de pointes. The short term management is similar for both the congenital and acquired forms of the condition; with an exception that β-1 adrenergic stimulation is given only in acquired form and should not be used for treatment of congenital form.
• Direct current (DC) cardioversion is kept as the last option and employed in cases when other treatment modes do not show the desired effect. Amongst the available drugs, magnesium is the treatment of choice and is extremely helpful in terminating the episodes of arrhythmia. It is administered at the rate of 1 – 2 g intravenously in 30 – 60 seconds initially [10]. The dosage is repeated every 5 – 15 minutes. Other drugs that can also be given include lidocaine, mexiletine and isoproterenol.

The condition resolves almost spontaneously; however can recur until the underlying etiology is completely treated. In untreated cases, or if there is a delay in initiation of treatment, there are chances of patients falling prey to sudden death. If the prolonged QT interval is acquired in nature, the prognosis is excellent, with correction of precipitating factor [8].

In many cases prolonged QT interval may be a congenital affair. Individuals with Jervell and Lange-Nielson syndrome and Romano Ward syndrome are likely to exhibit prolonged QT interval. These syndromes are associated with sudden death either due to primary onset of ventricular fibrillation or induced ventricular fibrillation due to torsades.

Electrolyte imbalances can predispose an individual to develop torsades de pointes. Certain drugs such as tricyclic antidepressants, cisapride, high-dose methadone, lithium carbonate, ziprasidone and chemotherapeutic agents can also increase the likelihood of prolonging QT interval [2] [3].

The exact incidence of torsades de pointes is unknown. It has been estimated that, women are 3 to 4 times more likely to have prolonged QT intervals. In addition, women also are at an increased risk of secondary development of torsades de pointes in response to drugs [4].

Torsades de pointes increases the risk of sudden death and it has been reported that about 300,000 sudden deaths occur in US every year. Of these, 5% of the cases occur due to torsades. Individuals in the age group of 35 to 50 years are more prone to suffer from prolonged QT interval [5].

The major and basic phenomenon behind the onset of lengthened QT interval in individuals is the current flow which is ionic in nature and that takes place during the repolarization phase. The morphology of QRS complex is different with each heart beat; however, the electrocardiogram appears like twisted ribbons, which is characteristic of torsades de pointes [6].

The appearance of twisted ribbons in electrocardiogram can be attributed to lengthened QT intervals which is the resultant reaction of delayed depolarization phase. This is considered to be the most vulnerable period, wherein majority of the myocardial tissue is ready to accept signals [7].

Individuals are advised to avoid those drugs that can lengthen the QT interval. Individuals with family history of torsades de pointes are at an increased risk of contracting the condition and therefore such families should be regularly screened. Certain predisposing factors such as hypomagnesemia, hypocalcemia and hypokalemia should be prevented.

Torsades de pointes is a type of ventricular tachycardia which may eventually resolve on its own; but can recur increasing the risk for other conditions. The ventricular heart rate in torsades de pointes is recorded to be 150 to 250 beats per minute. The condition is distinctly different from other forms of ventricular tachycardia due to its morphological characteristics, underlying etiology and types of therapy [1].

• Definition: Torsades de pointes is a form of ventricular tachycardia characterized by onset of prolonged QT intervals. Women are at a higher risk of contracting the condition than males. Drug-induced torsades de pointes is known to majorly strike the female population.
• Cause: Torsades de pointes can either be acquired or congenital in nature. Various factors such as drugs, underlying disease conditions and liver or renal failure can also lead to development of the characteristic prolonged QT interval.
• Symptoms: Affected individuals suffer from rapid pulse rate, arrhythmias, shortness of breath, diaphoresis, nausea along with dizziness, pallor, chest pain and cold sweats. In addition, other signs and symptoms of the underlying disease condition or congenital abnormality would also accompany.
• Diagnosis: Electrocardiography that shows prolonged QT interval is the characteristic finding in patients suffering from torsades de pointes. In addition, laboratory studies that are also conducted include evaluation of hypokalemia, hypocalcemia and hypomagnesemia. Imaging studies such as chest radiographs along with echocardiography is also indicated to determine presence of structural heart disease if any. Cardiac enzymes are also determined to evaluate myocardial ischemia.
• Treatment: Short term treatment of torsades de pointes is almost on similar lines for both congenital and acquired forms, except for β-1 adrenergic stimulation. Pharmacologic therapy includes intravenous administration of magnesium at rate of 1 – 2 g in 30 – 60 seconds. This remains the treatment of choice in majority of cases. Cardioversion is employed only when other methods do not work.

1. Pacha O, Kadikoy H, Amro M, Haque W, Abdellatif A. Torsades de pointes and prolonged QT syndrome in Takotsubo cardiomyopathy. J Cardiovasc Med (Hagerstown). Jan 13 2010
2. Alipour A, Cruz R, Lott RS. Torsade de pointes after ziprasidone overdose with coingestants. J ClinPsychopharmacol. Feb 2010;30(1):76-7.
3. Straus SM, Bleumink GS, Dieleman JP, et al. Antipsychotics and the risk of sudden cardiac death. Arch Intern Med 2004; 164:1293.
4. Makkar RR, Fromm BS, Steinman RT, et al. Female gender as a risk factor for torsades de pointes associated with cardiovascular drugs. JAMA 1993; 270:2590.
5. Lehmann MH, Timothy KW, Frankovich D, Fromm BS, Keating M, Locati EH, 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 CollCardiol. Jan 1997;29(1):93-9
6. El-Sherif N, Turitto G. Torsade de pointes. CurrOpinCardiol 2003; 18:6.
7. Li H, Fuentes-Garcia J, Towbin JA.Current concepts in long QT syndrome.PediatrCardiol 2000; 21:542.
8. Camm AJ, Janse MJ, Roden DM, et al. Congenital and acquired long QT syndrome. Eur Heart J 2000; 21:1232.
9. Moskovitz JB, Hayes BD, Martinez JP, Mattu A, Brady WJ. Electrocardiographic implications of the prolonged QT interval. Am J Emerg Med. May 2013;31(5):866-71
10. Tzivoni D, Banai S, Schuger C, et al. Treatment of torsade de pointes with magnesium sulfate. Circulation 1988; 77:392.a