Torsades de Pointes

Drug-induced torsades de pointes (TDP) is the epitome of a therapeutic intervention gone awry despite the best intentions - Sami Viskin

Torsades de Pointes
Torsades de Pointes

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Torsades de Pointes: Approach to resuscitation

A 46 year old female is referred into the emergency department after multiple syncopal episodes. Her family physician did blood work and found her to be hypokalemic. She is on venlafaxine for depression and amitriptyline for sciatica. She is currently on a course of moxifloxacin for her sinusitis and this morning took a dose of fluconazole for the resultant candidiasis. On arrival, she is alert and looks well. However, as the ECG is being performed, she slumps over and you see torsades de pointes:

Torsades de pointes is a ventricular tachycardia. In the unstable patient, cardiovert. In the pulseless, defibrillate. (The polymorphic nature of the rhythm may interfere with the defibrillator’s…

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  Torsades de Pointes: Approach to resuscitation

Almost all of the antiarrhythmics that we normally use to treat ventricular tachycardia, such as amiodarone and procainamide, will prolong the QT further, and therefore can make your patient worse. Do not give amiodarone or procainamide. The medical treatment for stable torsades de pointes is magnesium.


Torsades de pointes is very bad. It easily degenerates into Ventricular Fibrillation (VF) and that’s sudden cardiac death. How many cases of torsades have you seen in your career? Are your ready for it when you see it?

Life in The Fastlane

Polymorphic ventricular tachycardia (PVT) is a form of ventricular tachycardia in which there are multiple ventricular foci with the resultant QRS complexes varying in amplitude, axis and duration. The commonest cause of PVT is myocardial ischaemia. Torsades de pointes (TdP) is a specific form of polymorphic ventricular tachycardia occurring in the context of QT prolongation; it has a characteristic morphology in which the QRS complexes “twist” around the isoelectric line. For TdP to be diagnosed, the patient has to have evidence of both PVT and QT prolongation.


Torsades de pointes is usually not sustained and terminates spontaneously but frequently recurs unless the underlying cause is corrected. Torsades de pointes may degenerate into sustained ventricular tachycardia or ventricular fibrillation. Torsades is a life-threatening arrhythmia and may present as sudden cardiac death in patients with structurally normal hearts.


Torsades de Pointes is a type of polymorphic ventricular tachycardia characterized by a gradual change in amplitude and twisting of the QRS complexes around an isoelectric line on the electrocardiogram. Torsades de Pointes is associated with QTc prolongation, which is the heart rate adjusted lengthening of the QT interval. A QTc is considered long when it is greater than 450 ms in males and 460 ms in females. A QTc greater than 500 ms has been associated with a two-fold to three-fold increase in risk for Torsades de Pointes. The rhythm may terminate spontaneously or may degenerate into ventricular fibrillation.

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