Barra Sérgio, Agarwal Sharad, Begley David, Providência Rui
Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK.
Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Postgrad Med J. 2014 Jun;90(1064):348-58. doi: 10.1136/postgradmedj-2013-132398. Epub 2014 Apr 2.
The mechanisms underlying drug induced QT prolongation and the immediate treatment of torsade de pointes have been extensively studied but the post-acute management of the Acquired Long QT Syndrome (ALQTS) remains to be addressed. We aimed to review the state of the art data regarding risk stratification, arrhythmic prevention and treatment of patients with ALQTS. A comprehensive review of the scientific data collectable from MEDLINE, EMBASE and COCHRANE (from inception to April 2013) was performed, and descriptive and qualitative information was extracted from the most relevant manuscripts. QT prolonging drugs are widely used in hospital clinical practice, and several studies have shown a high prevalence of QT interval prolongation in patients admitted to hospital and a high rate of prescription of QT interval prolonging drugs to patients presenting with QT interval prolongation. Therefore, the acute and post-acute management of ALQTS is of the utmost importance. Avoidance of offending triggers, electrocardiographic screening, pacing at a relatively fast lower rate limit and using pause prevention programming (preferably with concomitant β blocker treatment), implantable defibrillators in the highest risk patients, genetic testing and counselling in selected cases, and family screening are among the potentially applicable strategies. The latter is justifiable by the fact that some studies unveiled a surprisingly similar positive mutation rate in drug induced LQTS compared with congenital LQTS, supporting the hypothesis that the former can be regarded as a latent form of the latter. Drug challenge with D,L-sotalol in suspected LQTS and treatment with a carvedilol analogue, verapamil or an Ikr activating drug are still in need of further investigation. The post-acute management of patients with ALQTS has received scarce attention in the past, probably due to the fact that it is considered a reversible phenomenon in most cases. Considering the relatively high risk of arrhythmic recurrence in the highest risk ALQTS patients, effective preventive and treatment strategies are warranted, and further research is needed.
药物诱导的QT间期延长的机制以及尖端扭转型室速的即刻治疗已得到广泛研究，但获得性长QT综合征（ALQTS）的急性后期管理仍有待解决。我们旨在综述有关ALQTS患者风险分层、心律失常预防和治疗的最新数据。对从MEDLINE、EMBASE和COCHRANE（从创刊至2013年4月）收集到的科学数据进行了全面综述，并从最相关的手稿中提取了描述性和定性信息。QT间期延长药物在医院临床实践中广泛使用，多项研究表明，住院患者中QT间期延长的患病率很高，并且向QT间期延长的患者开具QT间期延长药物的比例也很高。因此，ALQTS的急性和急性后期管理至关重要。避免触发因素、心电图筛查、以相对较快的较低心率下限进行起搏并采用预防长间歇程控（最好联合β受体阻滞剂治疗）、对高危患者植入除颤器、对特定病例进行基因检测和咨询以及家族筛查都是可能适用的策略。后者是合理的，因为一些研究发现，药物诱导的LQTS与先天性LQTS的阳性突变率惊人地相似，这支持了前者可被视为后者的潜在形式这一假说。在疑似LQTS中使用D，L-索他洛尔进行药物激发试验以及使用卡维地洛类似物、维拉帕米或Ikr激活药物进行治疗仍需进一步研究。过去，ALQTS患者的急性后期管理很少受到关注，这可能是因为在大多数情况下它被认为是一种可逆现象。鉴于高危ALQTS患者心律失常复发的风险相对较高，需要有效的预防和治疗策略，并且还需要进一步研究。
