Prolonged QT: Pharmacotherapy

Advanced, Basic Sciences

Acquired Long QT syndrome: Due to heart disease, electrolyte abnormalities (hypokalemia, hypomagnesemia, hypocalcemia), or exposure to medications that are known to prolong QTc (quinidine, flecainide, sotalol, amiodarone, chloroquines, macrolide and quinoline antibiotics, haldol, citalopram, TCAs, methadone, ondansetron, donepazil, milrinone among others).

Acute management of prolonged QTc:

· Removal of inciting agents

· Avoid antiarrhythmics like amiodarone as this may increase the prolongation

In refractory cases, increasing the underlying heart rate with isoproteronol or transvenous pacing may be required.

Updated definition 2020:

Prolonged QT can be caused by a variety of reasons including medications and electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia). QT prolongation can also be inherited, the most common syndrome associated with long QT is Romano-Ward syndrome.

Common drugs that cause prolonged QT include:

  • Antiarrhythmics - flecainide, procainamide, sotalol, dofetilide, amiodarone
  • Psychiatric drugs - haloperidol, droperidol, amitriptyline, nortriptyline, lithium
  • Antihistamines - diphenhydramine, loratadine
  • Antiemetics - ondansetron
  • Antimicrobial and antimalarial - erythromycin, clarithromycin, ketoconazole, chloroquine
  • Other agents - methadone, organophosphates, papaverine, vasopressin, adenosine, tacrolimus, cocaine

***this is not a comprehensive list

Prolonged QT can lead to torsades de pointes, a fatal cardiac arrhythmia. Management of prolonged QT syndrome includes avoiding strenuous exercise, monitoring electrolytes, use of beta blockers to control heart rate and insertion of an implantable cardiac device.

Sources

    Roden DM. Drug-Induced Prolongation of the QT Interval. NEJM. 2004;350(25): 2618–2621

    Br J Clin Pharmacol;2016 Mar;81(3):420-7

    [PubMed: 26183037]

    Anesthesiology;2012 Aug;117(2):321-8

    [PubMed: 22692379]

    Anesthesiology. 2005 Dec;103(6):1315-6; author reply 1316-7

    [PubMed: 15618804]

    Heart;2003 Nov;89(11):1363-72

    [PubMed: 14594906]

47%

Answered correctly

2020

Year asked

55%

Answered correctly

2019

Year asked

Author
Susan Walters, MD and Colleen McKenna, MD