Refining detection of drug-induced proarrhythmia: QT interval and TRIaD

被引:148
作者
Shah, RR
Hondeghem, LM
机构
[1] Med & Healthcare Prod Regulatory Agcy, London, England
[2] Katholieke Univ Leuven, Dept Pharmacol, Louvain, Belgium
关键词
dispersion of repolarization; instability of repolarization; proarrhythinia; QT prolongation; reverse use dependency; torsades de pointes; triangulation of action potential; TRIaD;
D O I
10.1016/j.hrthm.2005.03.023
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
QT interval prolongation is so frequently associated with torsades de pointes (TdP) that it has come to be recognized as a surrogate marker of this unique tachyarrhythmia. However, not only does TV not always follow QT interval prolongation, but UP can occur even in the absence of a prolonged QT interval. Worse still, even shortening of the QT interval may be associated with serious arrhythmias (particularly ventricular tachycardia [VT] and ventricular fibrillation [VF]). It appears increasingly probable that the distinction between various ventricular tachyarrhythmias may be arbitrary. and drug-induced UP, polymorphic VT, VT, catecholaminergic polymorphic VT, and VF may represent discrete entities within a spectrum of drug-induced proarrhythmia. Although they are differentiated by the coupling interval and the duration of QT interval, they appear to share it common Substrate: a set of disturbances of repolarization characterized by Triangulation. Reverse use dependency, electrical Instability of the action potential. and Dispersion (TRIaD). It is becoming increasingly evident that augmentation of TRIaD, rather than changes in the duration of QT interval, provides the proarrhythmic substrate. In contrast, when not associated with an increase of TRIaD, QT interval prolongation can be an antiarrhythmic property. Electrophysiologically. augmentation of TRIaD can be explained by inhibition of hERG (human ether-a-go-go related gene) channel. Because drug-induced disturbances in repolarization commonly result from inhibition of hERG channels or I-Kr, hERG blockade and the resulting prolongation of QT interval are important properties of a drug to he studied. However, these need only be a concern if associated with TRIaD. More significantly. TRIaD so often precedes prolongation of action potential duration or QT interval and ventricular tachyarrhythmias that it should be considered a marker of proarrhythmia until proven otherwise, even in the absence of QT interval prolongation. Detecting drug-induced augmentation of TRIaD may offer an additional, more sensitive, and accurate indicator of the broader proarrhythmic potential of a drug than may QT interval prolongation alone.
引用
收藏
页码:758 / 772
页数:15
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