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Cardiology

A Woman With Recurrent Torsade de Pointes

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Cardiology

Published Online: January 18, 2023

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Cody McCoy, MD¹;

John M. Miller, MD¹;

Tanyanan Tanawuttiwat, MD, MPH¹

Author Affiliations

¹Division of Cardiovascular Medicine, Indiana University, Indianapolis

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A woman in her mid-40s presented to the emergency department after a fall with head trauma. A head computed tomography showed a 0.9-cm left subdural hematoma with a mild left to right midline shift. Her ethanol level was 202 mg/dL (to convert to millimoles per liter, multiply by 0.2171); magnesium, 1.7 mg/dL (to convert to millimoles per liter, multiply by 0.4114); potassium, 4.4 mEq/L (to convert to millimoles per liter, multiply by 1); and ionized calcium, 4.6 mg/dL (to convert to millimoles per liter, multiply by 0.25). The patient developed cardiac arrest due to ventricular arrhythmias in the emergency department and was successfully resuscitated. Echocardiography demonstrated a left ventricular ejection fraction of 50% and no regional wall motion abnormalities. She subsequently underwent embolization of the middle meningeal artery. After embolization, however, a worsening rightward midline shift was discovered. As a result, on the 11th day of her hospitalization, she had a burr hole evacuation. During day 15 of admission, the patient had 3 episodes of torsade de pointes (TdP) while receiving 50 mg of metoprolol succinate daily, and her 12-lead electrocardiogram (ECG) is shown in Figure 1.

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A woman in her mid-40s presented to the emergency department after a fall with head trauma. A head computed tomography showed a 0.9-cm left subdural hematoma with a mild left to right midline shift. Her ethanol level was 202 mg/dL (to convert to millimoles per liter, multiply by 0.2171); magnesium, 1.7 mg/dL (to convert to millimoles per liter, multiply by 0.4114); potassium, 4.4 mEq/L (to convert to millimoles per liter, multiply by 1); and ionized calcium, 4.6 mg/dL (to convert to millimoles per liter, multiply by 0.25). The patient developed cardiac arrest due to ventricular arrhythmias in the emergency department and was successfully resuscitated. Echocardiography demonstrated a left ventricular ejection fraction of 50% and no regional wall motion abnormalities. She subsequently underwent embolization of the middle meningeal artery. After embolization, however, a worsening rightward midline shift was discovered. As a result, on the 11th day of her hospitalization, she had a burr hole evacuation. During day 15 of admission, the patient had 3 episodes of torsade de pointes (TdP) while receiving 50 mg of metoprolol succinate daily, and her 12-lead electrocardiogram (ECG) is shown in Figure 1.

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Article Information

Corresponding Author: Tanyanan Tanawuttiwat, MD, MPH, Division of Cardiovascular Medicine, Indiana University, 1800 N Capitol Ave, Room 300B, Indianapolis, IN 46202 (ttanawu@iu.edu).

Published Online: January 18, 2023. doi:10.1001/jamacardio.2022.5094

Conflict of Interest Disclosures: Dr Miller reports fellowship support and lecture fees from Medtronic, Boston Scientific, Biosense-Webster, Abbott Electrophysiology, and Biotronik, Inc.

Additional Contributions: The authors are grateful to Peng-Seng Chen, MD, for his invaluable suggestions. We also thank the patient for granting permission to publish this information.

References

Shimizu W , Antzelevitch C . Cellular and ionic basis for T-wave alternans under long-QT conditions. Circulation. 1999;99(11):1499-1507. doi:10.1161/01.CIR.99.11.1499 PubMed Google Scholar Crossref

Bao M , Zhang J , Huang C , Jiang H , Liu J , Zhao D . Abnormal intracellular calcium handling underlying T-wave alternans and its hysteresis. Cardiology. 2007;108(3):147-156. doi:10.1159/000096566 PubMed Google Scholar Crossref

Nieminen T , Verrier RL . Usefulness of T-wave alternans in sudden death risk stratification and guiding medical therapy. Ann Noninvasive Electrocardiol. 2010;15(3):276-288. doi:10.1111/j.1542-474X.2010.00376.x PubMed Google Scholar Crossref

Drew BJ , Ackerman MJ , Funk M , et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the American College of Cardiology Foundation. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation. 2010;121(8):1047-1060. doi:10.1161/CIRCULATIONAHA.109.192704 PubMed Google Scholar Crossref

Al-Khatib SM , Stevenson WG , Ackerman MJ , et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.