Electrocardiographic predictors of bradycardia-induced torsades de pointes in patients with acquired atrioventricular block

Abstract

Background: Predictors of torsades de pointes (TdP) in bradyarrhythmia-induced acquired long QT syndrome are not well defined.

Objective: The purpose of this study was to search for electrocardiographic (ECG) TdP predictors in patients with acquired atrioventricular block (AVB) and QT prolongation.

Methods: We analyzed 12-lead ECGs from 20 patients (15 females, age 65.9 ± 15.6 years) with TdP episodes from among 898 AVB patients (2.2%) in 3 tertiary hospitals. The ECG repolarization parameters in TdP patients were compared with those of 80 age- and sex-matched control AVB patients with no TdP episodes.

Results: TdP was initiated by premature ventricular complexes with a long-short sequence of activation. The average cycle length of the long sequence was 1289.9 ± 228.9 ms and was 2.3 ± 0.6 times longer than the cycle length of the short sequence. TdP patients had a significantly longer mean QT interval (716.4 ± 98.9 ms vs 523.2 ± 91.3 ms, P = .001), mean T peak to end interval (334.2 ± 59.1 ms vs 144.0 ± 73.7 ms, P = .001) and a higher T peak to end interval/QT ratio (0.49 ± 0.09 vs 0.27 ± 0.11, P = .001) compared with non-TdP controls. TdP patients showed a higher prevalence of notched T waves in which T2 was at least 3 mm taller than T1 (45.0% vs 1.3%, P = .001), triphasic T waves (30.0% vs 1.3%, P = .001), reversed asymmetry (20.0% vs 0%, P = .001), and T-wave alternans (35.0% vs 0%, P = .001). An algorithm combining these morphologic parameters was able to differentiate TdP patients from non-TdP patients with high sensitivity (85.0%) and specificity (97.5%).

Conclusion: An algorithm combining specific T-wave morphologies was useful for identifying patients with AVB who are at risk for developing TdP.

Keywords: Atrioventricular block; Bradycardia; Long QT syndrome; T waves; Torsades de pointes.