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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

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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T-wave alternans

C. Start intravenous magnesium

The ECG in Figure 1 shows T-wave alternans (TWA). The beat-to-beat opposite T-wave polarity was obvious in leads V3-V6, but only amplitude alternans was noted in leads III and aVF. The T wave, with a QTc of 670 milliseconds, extended to the next QRS complex, resulting in pseudo QRS widening of the next beat, mimicking premature ventricular contractions (PVCs) in a bigeminal pattern. The simultaneous narrow QRS in V2-V4, when compared with seeming J waves or QRS widening in other leads, confirmed that the apparent QRS widening was due to T-wave “contamination.” This finding preceded the development of TdP (Figure 2).

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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
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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.109.192704PubMedGoogle ScholarCrossref
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