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MACROSCOPIC T-WAVE ALTERNANS: AN UNUSUAL COMPANION OF QT PROLONGATION
1265 JACC April 5, 2016 Volume 67, Issue 13
FIT Clinical Decision Making MACROSCOPIC T-WAVE ALTERNANS: AN UNUSUAL COMPANION OF QT PROLONGATION Poster Contributions Poster Area, South Hall A1 Monday, April 04, 2016, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision Making: Arrhythmias and Clinical Electrophysiology Abstract Category: Arrhythmias and Clinical EP Presentation Number: 1264-320 Authors: Mohammad Khalid Mojadidi, Ninel Hovnanians, Michael Kaufmann, James Hill, University of Florida, Gainesville, FL, USA
Background: Macroscopic T-wave alternans (MTWA) is beat to beat variability in the vector or amplitude of T-waves on surface ECG. Often linked with acquired long-QT syndrome, MTWA is a sign of electrical instability and impending reentrant arrhythmias. This is a case of medication related QT-prolongation with MTWA. Case: A 55-year-old female with COPD, clostridium difficile colitis, alcohol and tobacco abuse was admitted for hyponatremia and necrotizing pneumonia.
Decision Making: Admission antibiotics were ceftriaxone, vancomycin, and metronidazole for colitis. Echo showed a 20% EF with wall motion suggestive of stress cardiomyopathy. ECG showed sinus tachycardia with QS in the precordial leads (Figure 1). Six days later, she developed new QT-prolongation and MTWA (Figure 2) with negative troponins. Medications were aspirin, metoprolol, lisinopril, cefepime, atorvastatin, pantoprazole, metronidazole, vancomycin and heparin. Potassium was 2.9 mEq/L and magnesium was 1.6 mEq/L. Electrolytes were repleted; metronidazole and pantoprazole were stopped. The QTc improved, MTWA disappeared, but diffuse T-wave inversions remained (Figure 3). No arrhythmias occurred and the EF improved to 45% on repeat echo. She was discharged without an ICD. Conclusions: MTWA with QT-prolongation is a sign of electrical instability and impending ventricular arrhythmia. QT-prolonging drugs can cause this rare ECG finding. Treatment is: stop offending drugs, replete electrolytes and provide close monitoring and supportive care.
FIT Clinical Decision Making MACROSCOPIC T-WAVE ALTERNANS: AN UNUSUAL COMPANION OF QT PROLONGATION Poster Contributions Poster Area, South Hall A1 Monday, April 04, 2016, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision Making: Arrhythmias and Clinical Electrophysiology Abstract Category: Arrhythmias and Clinical EP Presentation Number: 1264-320 Authors: Mohammad Khalid Mojadidi, Ninel Hovnanians, Michael Kaufmann, James Hill, University of Florida, Gainesville, FL, USA
Background: Macroscopic T-wave alternans (MTWA) is beat to beat variability in the vector or amplitude of T-waves on surface ECG. Often linked with acquired long-QT syndrome, MTWA is a sign of electrical instability and impending reentrant arrhythmias. This is a case of medication related QT-prolongation with MTWA. Case: A 55-year-old female with COPD, clostridium difficile colitis, alcohol and tobacco abuse was admitted for hyponatremia and necrotizing pneumonia.
Decision Making: Admission antibiotics were ceftriaxone, vancomycin, and metronidazole for colitis. Echo showed a 20% EF with wall motion suggestive of stress cardiomyopathy. ECG showed sinus tachycardia with QS in the precordial leads (Figure 1). Six days later, she developed new QT-prolongation and MTWA (Figure 2) with negative troponins. Medications were aspirin, metoprolol, lisinopril, cefepime, atorvastatin, pantoprazole, metronidazole, vancomycin and heparin. Potassium was 2.9 mEq/L and magnesium was 1.6 mEq/L. Electrolytes were repleted; metronidazole and pantoprazole were stopped. The QTc improved, MTWA disappeared, but diffuse T-wave inversions remained (Figure 3). No arrhythmias occurred and the EF improved to 45% on repeat echo. She was discharged without an ICD. Conclusions: MTWA with QT-prolongation is a sign of electrical instability and impending ventricular arrhythmia. QT-prolonging drugs can cause this rare ECG finding. Treatment is: stop offending drugs, replete electrolytes and provide close monitoring and supportive care.