2. Indira 70/ F Retd. Matron GSH came with chief complains of Fever since 20-25 days Intermittent ,high grade asso. with chills n rigors Taking some oral medication from pvt. K/c/o SHT and DM since 15 yrs on Rx. 2 days later she had a cardiac arrest with the following ECG pattern

5. ECG findings :- Heart Rate – 50 bpm Regular Sinus rhythm Normal Axis P wave - normal PR interval - 0.12 sec QRS complex – normal width and shape QT interval – 0.56 sec QTc interval - 0.509 sec T wave – normal Impression :- Bradycardia with acquired prolonged QT syndrome Pt. was shifted to ICCU.

6. She developed cardiac arrest . Pulse – not felt BP - not recordable ECG showed Vent. Tachycardia 200 J Biphasic DC shock was given and was reverted to sinus rhythm

7. A Temporary Cardiac Pacemaker was inserted following Rt. Femoral Vein Catheterization and she was reverted to sinus rhythm over the next 2 days

8. QT interval : beginning of Q-wave upto the end of T-wave. QT interval : total duration of ventricular activity. Need for QTc Interval : The QT interval varies with RR interval. False high values may be noted in Bradycardias. LONG QT SYNDROME

9. Formula accepted for QTc is: BAZETT’s Formula : QTc = QT ∕√ (RR) A useful rule of thumb is that, with a normal heart rate ( 60 - 100 bpm), the QT interval SHOULD NOT exceed half the RR interval.

11. During Sleep

12. Hypocalcemia

13. Acute Myocarditis

14. Acute Myocadial Infarction

15. Hypothermia

16. HOCM

17. Cerebral Injury

19. DRUGS that may cause QT PROLONGATION AntiarrhythmicsClass 1: ajmaline*, cibenzoline*, dihydroquinidine*, disopyramide, encainide*, flecainide, mexiletine, pirmenol*, procainamide,propafenonequinidine*Class 3:almokalant*, amiodarone, azimilide*, bretylium, dofetilide*, dronedarone*, d-sotalol*, ersentilide*, ibutilide*, nifekalant*, sematilide*, sotalol, terikalant* Anti-anginals/vasodilatorsbepridil*, lidoflazine*, prenylamine*, ranolazine, terodiline*, vardenafil Anti-hypertensivesindapamide, isradipine, moexipril/hydrochlorthiazide, nicardipine Antihistaminesastemizole*, azelastine, diphenhydramine, ebastine*, hydroxyzine, terfenadine* Serotonin agonists and antagonistscisapride*, dolasetron, granisetron, ketanserin*, ondansetron AntimicrobialsMacrolide antibiotics: azithromycin, clarithromycin, erythromycin, roxithromycin*, spiramycin, telithromycin Quinolone antibiotics: ciprofloxacin, gatifloxacin*, gemifloxacin*, grepafloxacin*, levofloxacin, moxifloxacin, ofloxacin, sparfloxacin* Antifungals: cotrimoxazole, fluconazoleOthers: pentamidine, trimethoprimsulfaAntiviral: foscarnet (HIV)

20. DRUGS that may cause QT PROLONGATION Continued… AntimalarialsChloroquine, halofantrine*, lumefantrine, quinine Psychiatric drugsTricyclic antidepressants: amitriptyline, amoxapine*, clomipramine, desipramine*, doxepin, imipramine, nortriptyline, protriptyline*, trimipramine Phenothiazines: chlorpromazine, fluphenazine, prochlorperazine, thioridazine*, trifluoperazine Others: atomoxetine, citalopram, clozapine, droperidol*, fluoxetine, haloperidol, levomethadyl*, lithium, maprotiline, mesoridazine, methadone, paroxetine, pericycline, pimozide, quetiapine, risperidone, sertindole, sertraline, trazodone, venlafaxine, zimeldine*, ziprasidone Anticonvulsantfelbamate*, fosphenytoin Anti-migrainenaratriptan, sumatriptan, zolmitriptan Anti-cancerarsenic trioxide, geldanamycin*, sunitib, tacrolimus, tamoxifen Othersalfuzosin,chloral hydrate, clobutinol*, domperidone, galantamine, octreotide, organophosphates*, perflutren lipid microspheres, probucol, solifenacin, tizanidine, tolterodine, vasopressin Stimulant drugsSome cold remedies contain these drugs so it is important always to check the label.adrenaline (epinephrine), amphetamine, cocaine, dexmethylphenidate, dobutamine, dopamine, ephedrine, fenfluramine, isoprenaline (isoproterenol), levalbuterol, metaproterenol, methylphenidate, midodrine, norepinephrine (noradrenaline), phentermine, phenylephrine, phenylpropanolamine, pseudoephidrine, ritodrine, salbutamol (albuterol), salmeterol, sibutramine, terbutaline

21. Complications OF Long qt syndrome Torsades des pointes ( polymorphic ventricular tachycardia ) More commonly seen in women Manifestation of subclinical LQTS Potentiated by bradycardia and hypokalemia drug usually blocks Ikr channel triggered by early afterdepolarizations due to intracellular Ca+ accumulation from a prolonged actin potential plateau heterogenicity of myocardial repolarisation predisposes to polymorphic ventricular activity

22. Treatment Caution has to be exercised during administering multiple drug regimes. They may cause QT Prolongation and TDP. Correction of K+ and Mg++ levels Temporary Pacing Cautious Infusion of Isoprotenol Class 1B anti arrythmics(no QT prolongation seen)

23. THANK YOU