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      Sleep-Associated Torsades de Pointes: A Case Report

      case-report
      Author(s): , MD, , MD
      Publication date (Electronic):
      Journal: Clinical Practice and Cases in Emergency Medicine
      Publisher: Depatment of Emergency Medicine

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          Abstract

          Torsades de Pointes (TdP) is a polymorphic ventricular tachycardia that occurs in the presence of an acquired or congenital long QT syndrome (LQTS). We present the case of a 57 year-old man with end-stage renal disease on methadone maintenance in which there occurred multiple episodes of TdP during sleep. The patient was found to have a QTc interval of 548 milliseconds, and the dysrhythmia was successfully treated with isoproterenol infusion and methadone substitution. It is surmised that the patient had a multifactorial, acquired LQTS that during somnolence, reached a critical threshold of QT prolongation to lead to the development of TdP.

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          Most cited references17

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          Sudden and cardiac death rates in hemodialysis patients.

          W Bleyer, David Russell, Scott Satko (1999)
          Sudden and cardiac death (including death from congestive heart failure, myocardial infarction, and sudden death) are common occurrences in hemodialysis patients. The intermittent nature of hemodialysis may lead to an uneven distribution of sudden and cardiac death throughout the week. The purpose of this study was to assess the septadian rhythm of sudden and cardiac death in hemodialysis patients. Data from the United States Renal Data System (USRDS) were obtained to examine the day of death for United States hemodialysis and peritoneal dialysis patients from 1977 through 1997. The days of death were also determined for patients in the Case Mix Adequacy Study of the USRDS. There was an even distribution of sudden and cardiac deaths for patients on peritoneal dialysis, and hemodialysis patients dying of noncardiac deaths also had an even distribution. For all hemodialysis patients, Monday and Tuesday were the most common days of sudden and cardiac death. For patients in the Case Mix Adequacy Study designated as Monday, Wednesday, and Friday dialysis patients, 20.8% of sudden deaths occurred on Monday compared with the 14.3% expected (P = 0.002). Similarly, 20.2% of cardiac deaths occurred on Monday compared with the 14.3% expected (P = 0.0005). Similar trends were found on Tuesday for Tuesday, Thursday, and Saturday dialysis patients. The intermittent nature of hemodialysis may contribute to an increased sudden and cardiac death rate on Monday and Tuesday for patients enrolled in the USRDS.
          Article 0 comments Cited 63 times – based on 0 reviews     Review now
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            QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel.

            Steven T. Taylor, Matthew Campbell, Catherine M. Kotz … (2011)
            In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.
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              REM-related bradyarrhythmia syndrome.

              Jon-Erik Holty, Christian Guilleminault (2011)
              Cardiac arrhythmias during sleep are relatively common and include a diverse etiology, from benign sinus bradycardia to potentially fatal ventricular arrhythmias. Predisposing factors include obstructive sleep apnea and cardiac disease. Rapid eye movement (REM)-related bradyarrhythmia syndrome (including sinus arrest and complete atrioventricular block with ventricular asystole) in the absence of an underlying cardiac or physiologic sleep disorder was first described in the early 1980s. Although uncertain, the underlying pathophysiology likely reflects abnormal autonomic neural-cardiac inputs during REM sleep. The autonomic nervous system (ANS) is a known key modulator of heart rate fluctuations and rhythm during sleep and nocturnal heart rate reflects a balance between the sympathetic-parasympathetic systems. Whether the primary trigger for REM-related bradyarrhythmias reflects abnormal centrally mediated control of the ANS during REM sleep or anomalous baroreflex parasympathetic influences is unknown. This review focuses on the salient features of the REM-related bradyarrhythmia syndrome and explores potential mechanisms with a particular assessment of the relationship between the ANS and nocturnal heart rate fluctuations.
              Article 0 comments Cited 11 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Pract Cases Emerg Med
                Journal ID (iso-abbrev): Clin Pract Cases Emerg Med
                Title: Clinical Practice and Cases in Emergency Medicine
                Publisher: Depatment of Emergency Medicine
                ISSN (Electronic): 2474-252X
                Publication date Collection: March 2017
                Publication date (Electronic): 23 January 2017
                Volume: 1
                Issue: 1
                Pages: 9-12
                Affiliations
                SUNY Downstate University Hospital of Brooklyn, Kings County Hospital Center, Department of Emergency Medicine, Brooklyn, New York
                Author notes
                Address for Correspondence: Guy Carmelli, MD, SUNY Downstate University Hospital of Brooklyn, 450 Clarkson Avenue, Box 1228, Brooklyn, NY 11203-2098. Email: Guy.carmelli@ 123456downstate.edu .
                Article
                Publisher ID: cpcem-01-09
                DOI: 10.5811/cpcem.2016.10.31352
                PMC ID: 5965430
                PubMed ID: 29849392
                SO-VID: 2569ecf2-3c6d-455f-8151-b4dd564f381f
                Copyright © Copyright: © 2017 Carmelli et al.
                License:

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

                History
                Date received : 20 June 2016
                Date accepted : 10 October 2016
                Categories
                Subject: Case Report

                Data availability:

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