Co-Prescription of QT-Interval Prolonging Drugs: An Analysis in a Large Cohort of Geriatric Patients

Schächtele, Simone; Tümena, Thomas; Gaßmann, K-G; Fromm, Martin F.; Maas, Renke

doi:10.1371/journal.pone.0155649

Cited by 47 publications

(58 citation statements)

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“…With respect to determinants of prolonged QTc, several factors have been reported in literature [22,23], including advancing age, female gender and drug therapies. Although QT interval is usually longer in adult women than in men until the sixth decade [5,24], only few studies have investigated QT length in older patients [23]. In our sample of elderly patients, we observed an association between male sex and prolonged QTc (OR 2.09, 95% CI 1.34-3.26).…”

Section: Discussionmentioning

confidence: 99%

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope

Bo¹,

Ceccofiglio

Mussi

et al. 2019

European Journal of Internal Medicine

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Background: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. Methods: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12-lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. Results: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with oneyear mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. Conclusions: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF. 1. Introduction Long QT syndrome is an electro-physiologic disorder in which the ventricular repolarization is lengthened, with an increased susceptibility to ventricular tachy-arrhythmias, potentially leading to syncope, cardiac arrest and sudden cardiac death [1]. Acquired prolonged QT interval is the most common form of long QT syndrome, and usually results from the complex interplay between several factors

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Section: Discussionmentioning

confidence: 99%

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope

Bo¹,

Ceccofiglio

Mussi

et al. 2019

European Journal of Internal Medicine

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“…In a cohort study of 130 434 geriatric patients (mean age = 81 y) receiving discharge prescriptions in Germany, nearly 60% received one or more QTc-prolonging drugs, and more than 20% were prescribed two or more. 6 Of those who received two or more QTc-prolonging drugs, more than 50% received prescriptions for two drugs on the "Known" list at www.crediblemeds.org. The investigators did not report whether any patients developed TdP.…”

Section: Prevalence Of Qtc Prolongation and Tdpmentioning

confidence: 99%

“…Electrocardiographic (ECG) monitoring is conducted in seriously ill hospitalized patients and others with a cardiovascular predisposition to diagnose arrhythmias, acute coronary syndromes, and silent myocardial ischemia, and to identify drug‐induced QT prolongation . Nearly 60% of older adults receive one or more QT interval‐prolonging drugs, and more than 20% receive two or more . Residents of nursing facilities (NFs) who are 65 years and older receive multiple medications and have chronic comorbidities, increasing their risk of adverse drug events including QT prolongation .…”

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confidence: 99%

“…5 Nearly 60% of older adults receive one or more QT interval-prolonging drugs, and more than 20% receive two or more. 6 Residents of nursing facilities (NFs) who are 65 years and older receive multiple medications and have chronic comorbidities, increasing their risk of adverse drug events including QT prolongation. 5,7-9 ECG monitoring is not performed routinely in this population.…”

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confidence: 99%

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Navigating the Minefield of QTc Interval‐Prolonging Therapy in Nursing Facility Residents

Zarowitz

Tisdale

2019

J American Geriatrics Society

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BACKGROUND The exponential increase in the number of medications associated with clinically important prolongation of the heart rate‐corrected QT interval (QTc) places older adults at increased risk of arrhythmias including life‐threatening torsade de pointes (TdP) and sudden death. Risk factors, other than age older than 65 years and female sex, include multiple concurrent drugs that prolong QTc and a variety of underlying predisposing conditions. Although electronic medical records and pharmacy dispensing systems can alert clinicians to the risk of QTc‐prolonging therapy, more than 95% of safety alerts are overridden, and many systems have deactivated QTc drug interaction alerts. The clinical consequences, magnitude of the effect, mitigation strategies, and recommended monitoring are not well defined for nursing facility (NF) residents. DESIGN Narrative review. SETTING NFs in the United States. PARTICIPANTS NF residents. RESULTS Medications known to prolong QTc include selected anti‐infectives, antidepressants, urinary anticholinergics, antipsychotics, and cholinesterase inhibitors (eg, donepezil), used commonly in NFs. Drug‐drug interactions are a risk when adding a medication that exaggerates the effect or inhibits the metabolism of a QTc‐prolonging medication. The vast majority of patients in whom TdP is induced by noncardiac drugs have risk factors that are easily identifiable. CONCLUSIONS Recommendations are provided to improve standardization and use of drug interaction alerts, evaluate the risk of QTc‐prolonging drugs in older adults receiving generally lower doses, validate a QTc risk score addressing complex multimorbidity, garner evidence to guide clinical decision making, avail NFs of access to electrocardiograms and interpretive recommendations, and develop standards of practice for hosting risk discussions with residents and their families. J Am Geriatr Soc, 1–8, 2019.

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“…In the setting of sepsis, a multifactorial genesis is involved, inducing QT prolongation and triggering arrhythmia [19]. Pharmacokinetic interactions can lead to overtreatment, and poly-medication is associated with increased risk [78]. Cytochrome-P450 inhibitors competing for the same enzyme system can increase this risk [79].…”

Section: Drug-induced Qt Prolongationmentioning

confidence: 99%

Cardiac arrest among patients with infections: causes, clinical practice and research implications

Leoni

Rello

2017

Clinical Microbiology and Infection

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The incidence of sepsis is increasing, and the condition is now the leading cause of death in general intensive care units. Our review failed to identify studies of the causes of cardiac arrest among infected patients, even though non-cardiac causes represent 15% of out-of-hospital cardiac arrests and though one-third of events have positive blood cultures. Sudden cardiac arrest is the result of local damage to the heart and of the impact of systemic and pulmonary conditions on cardiac performance, and its danger is underestimated. Necropsy findings in sudden death often identify myocarditis as an unexpected cause. The role of hypoxaemia, severe pulmonary thromboembolism with subsequent pulseless cardiac activity, alterations of electrolytes and hydrogen concentrations, distort fluid distribution with reduced pre-load, direct myocyte damage and adverse cardiac effects related to antibiotic use need to be defined. Many cardiac arrests might be preventable. Because cardiopulmonary resuscitation is challenging and usually unsuccessful in patients with sepsis, research is needed to help predict which patients are at risk. Only half of pneumonia patients with cardiac arrest in the ward receive prior ECG monitoring. Telemedicine and non-invasive monitoring in the ward, avoidance of antibiotics associated with prolonged QT syndrome, and adequate haemodynamic resuscitation might be important in preventing in-hospital arrests among patients with infections.

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Co-Prescription of QT-Interval Prolonging Drugs: An Analysis in a Large Cohort of Geriatric Patients

Cited by 47 publications

References 44 publications

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope

Navigating the Minefield of QTc Interval‐Prolonging Therapy in Nursing Facility Residents

Cardiac arrest among patients with infections: causes, clinical practice and research implications

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