Torsades de pointes differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Torsades de pointes should be differentiated from other conditions or disorders that may present in a similar way, such as other arrhythmias, drug toxicity, syncope and other cardiac conditions.

Differential Diagnosis

Ventricular Tachycardia (polymorphic, monomorphic)
Supraventricular tachycardia
Ventricular Fibrillation
Sudden Cardiac Death
Syncope
Renal Failure
Complication dialysis
Drug toxicity like antiarrhythmic, antihistaminics

The table below provides information on the differential diagnosis of torsades de pointes in terms of ECG appearance:


Disease Name	Causes	ECG Characteristics	ECG view
Ventricular tachycardia ^[1]^[2]^[3]^[4]^[5]	Ischemic heart disease Illicit drug use such as cocaine and methamphetamine Structural heart diseases Electrolyte disturbances Congestive heart failure Myocarditis Obstructive sleep apnea Pulmonary artery catheter Long QT syndrome	Ventricular tachycardia originates from a ventricular focus. Lasts more than 30 seconds. Broad QRS complexes: rate of >90 BPM.	^[6]
Ventricular fibrillation ^[7]^[8]^[9]^[10]	Acute coronary ischemia Cardiomyopathies Congenital heart disease Myocardial infarction Heart surgery Electrolyte abnormalities	Poorly identifiable QRS complexes and absent P waves The heart rate is >300 BPM Rhythm is irregular	^[11]
Ventricular flutter ^[12]^[13]^[14]	Electrolyte disturbances Medications such as: Disopyramide Quinidine	The ECG shows: A typical sinusoidal pattern Frequency of 300 bpm	^[15]
Asystole ^[16]^[17]	Hypovolemia Hypoxia Acidosis Hypothermia Hyperkalemia or Hypokalemia Hypoglycemia Cardiac Tamponade Tension pneumothorax Thrombosis Myocardial infarction Thrombosis Pulmonary embolism Cardiogenic shock Degeneration of the sinoatrial or atrioventricular nodes Ischemic stroke	There is no electrical activity in the asystole	^[18]
Pulseless electrical activity ^[19]^[20]	Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hypothermia Electrolyte disturbances Hypoglycemia Tablets or Toxins (Drug overdose) such as beta blockers, tricyclic antidepressants, or calcium channel blockers Tamponade Tension pneumothorax Thrombosis (Myocardial infarction) Thrombosis (Pulmonary embolism) Trauma (Hypovolemia from blood loss)	Several pattern are possible including: Normal sinus rhythm Sinus tachycardia, with discernible P waves and QRS complexes Bradycardia, with or without P waves	^[21]
Torsade de Pointes ^[22]^[23]^[24]	*Electrolyte disturbances Medications such as: Amiodarone Azithromycin Clozapine Famotidine Flecainide Foscarnet Levofloxacin Lithium Mirtazipine Quetiapine Risperidone Tacrolimus Tamoxifen Ziprasidone	Paroxysms of VT with irregular RR intervals. A ventricular rate between 200 and 250 beats per minute. Two or more cycles of QRS complexes with alternating polarity. Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion. Prolongation of the QT interval. Is often initiated by a PVC with a long coupling interval, R on T phenomenon. There are usually 5 to 20 complexes in each cycle.	^[25]

References

↑ Ajijola, Olujimi A.; Tung, Roderick; Shivkumar, Kalyanam (2014). "Ventricular tachycardia in ischemic heart disease substrates". Indian Heart Journal. 66: S24–S34. doi:10.1016/j.ihj.2013.12.039. ISSN 0019-4832.
↑ Meja Lopez, Eliany; Malhotra, Rohit (2019). "Ventricular Tachycardia in Structural Heart Disease". Journal of Innovations in Cardiac Rhythm Management. 10 (8): 3762–3773. doi:10.19102/icrm.2019.100801. ISSN 2156-3977.
↑ Coughtrie, Abigail L; Behr, Elijah R; Layton, Deborah; Marshall, Vanessa; Camm, A John; Shakir, Saad A W (2017). "Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort". BMJ Open. 7 (10): e016627. doi:10.1136/bmjopen-2017-016627. ISSN 2044-6055.
↑ El-Sherif, Nabil (2001). "Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics". Journal of Cardiovascular Electrophysiology. 12 (8): 973–976. doi:10.1046/j.1540-8167.2001.00973.x. ISSN 1045-3873.
↑ de Riva, Marta; Watanabe, Masaya; Zeppenfeld, Katja (2015). "Twelve-Lead ECG of Ventricular Tachycardia in Structural Heart Disease". Circulation: Arrhythmia and Electrophysiology. 8 (4): 951–962. doi:10.1161/CIRCEP.115.002847. ISSN 1941-3149.
↑ ECG found in of https://en.ecgpedia.org/index.php?title=Main_Page
↑ Koplan BA, Stevenson WG (March 2009). "Ventricular tachycardia and sudden cardiac death". Mayo Clin. Proc. 84 (3): 289–97. doi:10.1016/S0025-6196(11)61149-X. PMC 2664600. PMID 19252119.
↑ Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S (May 2017). "Ventricular arrhythmias and sudden death in tetralogy of Fallot". Arch Cardiovasc Dis. 110 (5): 354–362. doi:10.1016/j.acvd.2016.12.006. PMID 28222965.
↑ Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ (August 1992). "Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms". Circulation. 86 (2): 467–74. doi:10.1161/01.cir.86.2.467. PMID 1638716.
↑ Bektas, Firat; Soyuncu, Secgin (2012). "Hypokalemia-induced Ventricular Fibrillation". The Journal of Emergency Medicine. 42 (2): 184–185. doi:10.1016/j.jemermed.2010.05.079. ISSN 0736-4679.
↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
↑ Thies, Karl-Christian; Boos, Karin; Müller-Deile, Kai; Ohrdorf, Wolfgang; Beushausen, Thomas; Townsend, Peter (2000). "Ventricular flutter in a neonate—severe electrolyte imbalance caused by urinary tract infection in the presence of urinary tract malformation". The Journal of Emergency Medicine. 18 (1): 47–50. doi:10.1016/S0736-4679(99)00161-4. ISSN 0736-4679.
↑ Koster, Rudolph W.; Wellens, Hein J.J. (1976). "Quinidine-induced ventricular flutter and fibrillation without digitalis therapy". The American Journal of Cardiology. 38 (4): 519–523. doi:10.1016/0002-9149(76)90471-9. ISSN 0002-9149.
↑ Dhurandhar RW, Nademanee K, Goldman AM (1978). "Ventricular tachycardia-flutter associated with disopyramide therapy: a report of three cases". Heart Lung. 7 (5): 783–7. PMID 250503.
↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
↑ ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
↑ ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
↑ "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.
↑ Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007
↑ ECG found in wikimedia Commons
↑ Li M, Ramos LG (July 2017). "Drug-Induced QT Prolongation And Torsades de Pointes". P T. 42 (7): 473–477. PMC 5481298. PMID 28674475.
↑ Sharain, Korosh; May, Adam M.; Gersh, Bernard J. (2015). "Chronic Alcoholism and the Danger of Profound Hypomagnesemia". The American Journal of Medicine. 128 (12): e17–e18. doi:10.1016/j.amjmed.2015.06.051. ISSN 0002-9343.
↑ Khan IA (2001). "Twelve-lead electrocardiogram of torsades de pointes". Tex Heart Inst J. 28 (1): 69. PMC 101137. PMID 11330748.
↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

[AjijolaTung2014-1] Ajijola, Olujimi A.; Tung, Roderick; Shivkumar, Kalyanam (2014). "Ventricular tachycardia in ischemic heart disease substrates". Indian Heart Journal. 66: S24–S34. doi:10.1016/j.ihj.2013.12.039. ISSN 0019-4832.

[Meja_LopezMalhotra2019-2] Meja Lopez, Eliany; Malhotra, Rohit (2019). "Ventricular Tachycardia in Structural Heart Disease". Journal of Innovations in Cardiac Rhythm Management. 10 (8): 3762–3773. doi:10.19102/icrm.2019.100801. ISSN 2156-3977.

[CoughtrieBehr2017-3] Coughtrie, Abigail L; Behr, Elijah R; Layton, Deborah; Marshall, Vanessa; Camm, A John; Shakir, Saad A W (2017). "Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort". BMJ Open. 7 (10): e016627. doi:10.1136/bmjopen-2017-016627. ISSN 2044-6055.

[El-Sherif2001-4] El-Sherif, Nabil (2001). "Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics". Journal of Cardiovascular Electrophysiology. 12 (8): 973–976. doi:10.1046/j.1540-8167.2001.00973.x. ISSN 1045-3873.

[de_RivaWatanabe2015-5] Riva, Marta; Watanabe, Masaya; Zeppenfeld, Katja (2015). "Twelve-Lead ECG of Ventricular Tachycardia in Structural Heart Disease". Circulation: Arrhythmia and Electrophysiology. 8 (4): 951–962. doi:10.1161/CIRCEP.115.002847. ISSN 1941-3149.

[6] ECG found in of https://en.ecgpedia.org/index.php?title=Main_Page

[pmid19252119-7] Koplan BA, Stevenson WG (March 2009). "Ventricular tachycardia and sudden cardiac death". Mayo Clin. Proc. 84 (3): 289–97. doi:10.1016/S0025-6196(11)61149-X. PMC 2664600. PMID 19252119.

[pmid28222965-8] Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S (May 2017). "Ventricular arrhythmias and sudden death in tetralogy of Fallot". Arch Cardiovasc Dis. 110 (5): 354–362. doi:10.1016/j.acvd.2016.12.006. PMID 28222965.

[pmid1638716-9] Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ (August 1992). "Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms". Circulation. 86 (2): 467–74. doi:10.1161/01.cir.86.2.467. PMID 1638716.

[BektasSoyuncu2012-10] Bektas, Firat; Soyuncu, Secgin (2012). "Hypokalemia-induced Ventricular Fibrillation". The Journal of Emergency Medicine. 42 (2): 184–185. doi:10.1016/j.jemermed.2010.05.079. ISSN 0736-4679.

[11] ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

[ThiesBoos2000-12] Thies, Karl-Christian; Boos, Karin; Müller-Deile, Kai; Ohrdorf, Wolfgang; Beushausen, Thomas; Townsend, Peter (2000). "Ventricular flutter in a neonate—severe electrolyte imbalance caused by urinary tract infection in the presence of urinary tract malformation". The Journal of Emergency Medicine. 18 (1): 47–50. doi:10.1016/S0736-4679(99)00161-4. ISSN 0736-4679.

[KosterWellens1976-13] Koster, Rudolph W.; Wellens, Hein J.J. (1976). "Quinidine-induced ventricular flutter and fibrillation without digitalis therapy". The American Journal of Cardiology. 38 (4): 519–523. doi:10.1016/0002-9149(76)90471-9. ISSN 0002-9149.

[pmid250503-14] Dhurandhar RW, Nademanee K, Goldman AM (1978). "Ventricular tachycardia-flutter associated with disopyramide therapy: a report of three cases". Heart Lung. 7 (5): 783–7. PMID 250503.

[15] ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

[ACLS_2003_H_T-16] ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.

[ACLS_2003_EP_HT-17] ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.

[18] ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

[ECC_2005_7.2-19] "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.

[20] Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007

[21] ECG found in wikimedia Commons

[pmid28674475-22] Li M, Ramos LG (July 2017). "Drug-Induced QT Prolongation And Torsades de Pointes". P T. 42 (7): 473–477. PMC 5481298. PMID 28674475.

[SharainMay2015-23] Sharain, Korosh; May, Adam M.; Gersh, Bernard J. (2015). "Chronic Alcoholism and the Danger of Profound Hypomagnesemia". The American Journal of Medicine. 128 (12): e17–e18. doi:10.1016/j.amjmed.2015.06.051. ISSN 0002-9343.

[pmid11330748-24] Khan IA (2001). "Twelve-lead electrocardiogram of torsades de pointes". Tex Heart Inst J. 28 (1): 69. PMC 101137. PMID 11330748.

[25] ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

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Torsades de pointes differential diagnosis

Overview

Differential Diagnosis

References

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