Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study

doi:10.5847/wjem.j.1920-8642.2023.104

Abstract

Abstract:

BACKGROUND: Long QT syndrome (LQTS) is a heterogeneous syndrome that may be congenital or, more frequently, acquired. The real-world prevalence of acquired LQTS (aLQTS) in the emergency department (ED) remains to be determined. The aim of this study was to determine prevalence of aLQTS and its impact on symptoms on ED admissions.

METHODS: Electrocardiograms (ECG) of 5,056 consecutively patients admitted in the ED of a tertiary hospital between January 28^th and March 17^th of 2020 were reviewed. All patients with aLQTS were included. Clinical data with a focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without corrected QT (QTc) interval greater than 500 ms (value that is considered severely increased).

RESULTS: A total of 383 ECGs with prolonged QTc were recognized, corresponding to a prevalence of aLQTS at admission of 7.82%. Patients with aLQTS were more commonly men (53.3%) with an age of (73.49±14.79) years old and QTc interval of (505.3±32.4) ms. Only 20.4% of these patients with aLQTS were symptomatic. No ventricular arrhythmias were recorded. Patients with QT interval greater than 500 ms were more frequently female (59.5%; P<0.001) and were more frequently on QT prolonging drugs (77.3%; P=0.025). Main contributing factor was intake of antibiotics (odds ratio [OR] 4.680) followed by female gender (OR 2.473) and intake of antipsychotics (OR 1.925).

CONCLUSION: aLQTS is particularly prevalent in the ED. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made to avoid, detect and treat aLQTS as early as possible.

Key words: Long QT syndrome, Epidemiology, Drug interactions, Emergency department

Diogo de Almeida Fernandes, Guilherme de Freitas Camões, Diana Ferreira, Carolina Queijo, Carlos Fontes-Ribeiro, Lino Gonçalves, Rui Pina, Natália António. Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study[J]. World Journal of Emergency Medicine, 2023, 14(6): 454-461.

Figures/Tables 5

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Variables	Total
Sample, n (%)	383
Sex (male), n (%)	204 (53.3)
Age, years, mean±SD	73.49±14.79
QTc interval, ms, mean±SD	505.3±32.4
Symptomatic, n (%)	78 (20.4)
Palpitations	6 (7.7)
Presyncope	22 (29.2)
Syncope	39 (50.0)
Seizure	6 (7.7)
Cardiac arrest	5 (6.4)
Clinical risk factors, n (%)	344 (89.8)
Number of clinical risk factors	1.93 ± 1.27
Type of risk factor, n (%)
Autonomic nervous system	12 (3.1)
Endotracheal intubation	2 (0.5)
Migraine	1 (0.3)
Parkinson’s disease	9 (2.3)
Cardiovascular diseases	109 (28.5)
Aortic stenosis	7 (1.8)
Atrioventricular block	17 (4.4)
Bradycardia	7 (1.8)
Cardiomyopathy	23 (6.0)
Heart failure	35 (9.1)
Metabolic syndrome	4 (1.0)
Mitral stenosis	2 (0.5)
Myocardial infarction	16 (4.2)
Pauses	1 (0.3)
Stroke	21 (5.5)
Electrolyte disorders	40 (10.4)
Diarrhoea	2 (0.5)
Hypocalcaemia	9 (2.3)
Hypokalaemia	23 (6.0)
Hyponatremia	6 (1.6)
Haemodialysis	6 (1.6)
Endocrine disorders	40 (10.4)
Hyperparathyroidism	2 (0.5)
Hypothyroidism	14 (3.7)
Obesity	27 (7.0)
Environmental effects	48 (12.5)
Chronic obstructive pulmonary disease	23 (6.0)
Hypothermia	2 (0.5)
Hypoxia	21 (5.5)
Obstructive sleep apnea	6 (1.6)
General clinical factors	278 (72.6)
≥ 65 years old	234 (61.1)
Cirrhosis	8 (8.1)
Female sex	179 (46.7)
Inflammatory/auto-immune	47 (12.3)
HIV	3 (0.8)
Increased C-reactive protein	41 (10.7)
Rheumatoid arthritis	5 (1.3)
Miscellanea	12 (3.1)
Seizures/epilepsy	12 (3.1)

QT prolonging drugs	Total	Type of drug	n (%)
Patients on QT prolonging drugs, n (%)	273 (71.3)	Clomipramine	2 (0.5)
Number of QT prolonging drugs	1.56 ± 1.42	Duloxetine	1 (0.3)
Type of drug	n ()	Escitalopram	17 (4.4)
Antiarrhythmics	27 (7.0)	Fluoxetine	7 (1.8)
Amiodarone	18 (4.7)	Maprotiline	1 (0.3)
Ivabradine	6 (1.6)	Mirtazapine	16 (4.2)
Propafenone	2 (0.5)	Paroxetine	9 (2.3)
Sotalol	1 (0.3)	Sertraline	23 (6.0)
Antibiotics	17 (4.4)	Trazodone	19 (5.0)
Azithromycin	3 (0.8)	Venlafaxine	3 (0.8)
Ciprofloxacin	5 (1.3)	Diuretics	166 (43.3)
Clarithromyin	1 (0.3)	Chlorthalidone	1 (0.3)
Hydroxychloroquine	4 (1.0)	Hydrochlorothiazide	26 (6.8)
Levofloxacin	4 (1.0)	Indapamide	21 (5.5)
Antihistamine	5 (1.3)	Furosemide	131 (34.2)
Hydroxyzine	5 (1.3)	Metolazone	1 (0.3)
Antiemetic	9 (2.3)	Antimigraine	0
Domperidone	4 (1.0)	Bronchodilators	0
Metoclopramide	4 (1.0)	Hormones	0
Ondansetrom	1 (0.3)	PPIs	120 (31.3)
Antifungal0		Esomeprazole	17 (4.4)
Immunomodulators	1 (0.3)	Lansoprazole	9 (2.3)
Mesalazine	1 (0.3)	Omeprazole	21 (5.5)
Opioid	10 (2.6)	Pantoprazole	73 (19.3)
Buprenorphine	1 (0.3)	Other	37 (9.7)
Methadone	2 (0.5)	Alfusozin	3 (0.8)
Tramadol	7 (1.8)	Amantadine	1 (0.3)
Antipsychotics	68 (17.8)	Carbamazepina	1 (0.3)
Amisulpride	1 (0.3)	Donepezilo	4 (1.0)
Aripiprazole	1 (0.3)	Galantamine	2 (0.5)
Ciamenazine	1 (0.3)	Isradipine	1 (0.3)
Haloperidol	6 (1.6)	Lercanidipine	1 (0.3)
Levomepromazine	1 (0.3)	Levetiracetam	6 (1.6)
Lithium	1 (0.3)	Loperamide	1 (0.3)
Melperone	3 (0.8)	Memantine	8 (2.1)
Olanzapine	6 (1.6)	Mirabegron	2 (0.5)
Quetiapine	34 (8.9)	Phenytoin	1 (0.3)
Risperidone	17 (4.4)	Pregabaline	2 (0.5)
Tiapride	7 (1.8)	Propofol	1 (0.3)
Antidepressants	85 (22.2)	Ranolazine	2 (0.5)
Amitriptyline	4 (1.0)	Tizanidine	1 (0.3)
Citalopram	1 (0.3)

Variables	QTc interval ≤500 ms (n=220)	QTc interval >500 ms (n=163)	P-value
Sex (male), n (%)	138 (62.7)	66 (40.5)	<0.001^§
Age, years, mean±SD	72.61 ± 14.40	74.67 ± 15.28	0.547^†
Symptomatic, n (%)	51 (23.2)	27 (16.6)	0.112^§
Palpitations	5 (9.8)	1 (3.7)
Presyncope	14 (27.5)	8 (29.6)
Syncope	25 (49.0)	14 (51.9)
Seizure	4 (7.8)	2 (7.4)
Cardiac arrest	3 (5.9)	2 (7.4)
Patients on QT prolonging drugs, n (%)	147 (66.8)	126 (77.3)	0.025^§
Number of QT prolonging drugs, mean±SD	1.35 ± 1.30	1.85 ± 1.51	0.001^†
Type of drug, n (%)
Antiarrhythmic	13 (5.9)	14 (8.6)	0.311^§
Antibiotics	4 (1.8)	13 (8.0)	0.004^§
Antihistamine	3 (1.4)	2 (1.2)	1.000^#
Antiemetic	7 (3.2)	2 (1.2)	0.312^#
Immunomodulators	0	1 (0.6)	0.426^#
Opioid	4 (1.8)	6 (3.7)	0.335^#
Antipsychotics	30 (13.6)	38 (23.3)	0.014^§
Antidepressants	40 (18.2)	45 (27.6)	0.028^§
Diuretics	86 (39.1)	80 (49.1)	0.051^§
PPIs	69 (31.4)	51 (31.3)	0.987^§
Other	17 (7.7)	20 (12.3)	0.137^§
Clinical risk factors, n (%)	197 (89.5)	147 (90.2)	0.838^§
Number of clinical risk factors, mean±SD	1.83 ± 1.25	2.08 ± 1.28	0.055^†
Type of risk factor, n (%)
Autonomic nervous system	9 (4.1)	3 (1.8)	0.211^§
Cardiovascular diseases	60 (27.3)	49 (30.1)	0.568^§
Electrolyte disorders	20 (9.1)	20 (12.3)	0.315^§
Endocrine disorders	28 (12.7)	12 (7.4)	0.090^§
Environmental effects	26 (11.8)	22 (13.5)	0.624^§
General clinical factors	158 (71.8)	120 (73.6)	0.696^§
Inflammatory/auto-immune	22 (10.0)	25 (15.3)	0.115^§
Miscellanea	6 (2.7)	6 (3.7)	0.596^§

Factors	OR	95% CI	P-value
Female	2.473	1.633-3.747	<0.001
Patients on QT prolonging drugs	1.691	1.066-2.683	0.026
Number of QT prolonging drugs	1.289	1.113-1.494	0.001
Antibiotics	4.680	1.497-14.631	0.008
Antipsychotics	1.925	1.134-3.269	0.015
Antidepressants	1.716	1.057-2.787	0.029
Diuretics	1.502	0.997-2.262	0.052
Number of clinical risk factors	1.171	0.997-1.376	0.055
Endocrine disorders	0.545	0.268-1.107	0.093

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