Giant T–U Waves Precede Torsades de Pointes in Long QT Syndrome
Open accessAbstract
Objectives This study sought to identify electrocardiographic (ECG) criteria that are associated with initiation of torsades de pointes (TdP) in patients with acquired (a-) and congenital (c-) long QT syndrome (LQTS).Background Electrocardiographic criteria used as risk predictors for TdP commonly rely on a prolonged QT interval but rarely consider abnormal T-U waves.Methods We analyzed ECG recordings with TdP from 35 LQTS patients (15 c-LQTS and 20 a-LQTS) and compared them with premature ventricular complexes (PVCs) from 40 patients with normal QT intervals and with PVCs in 24 of the 35 LQTS patients not related to TdP.Results Abnormal T-U waves (6.2 +/- 0.9 mm) directly preceded TdP in 34 of 35 LQTS patients and were larger than T-wave amplitude (2.8 +/- 0.2 mm) in control patients and larger than the largest T-U-wave in LQTS without TdP (4.7 +/- 0.8 mm). The TdP-initiating beat emerged from a T-U-wave in 27 of 35 LQTS patients and in none of 40 control patients. The QRS duration of the first TdP beat (175 +/- 12 ms) was longer than in control PVCs (145 +/- 4 ms) and in PVCs in LQTS patients not related to TdP (138 +/- 22 ms). The QRS angle was less steep before TdP than in other PVCs (all p < 0.05).Conclusions Abnormal, giant T-U waves separate TdP initiation in LQTS patients from PVCs in other heart disease and from other PVCs in LQTS patients. These ECG analyses suggest that early afterdepolarizations initiate TdP and, if present, may help to identify an imminent risk for TdP.
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The presence of abnormal TU waves is a sign of imminent torsades de pointes.
“the presence of 'abnormal TU waves' is a sign of imminent torsades de pointes.652”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [652]
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“Augmented U-waves, or partial/complete T-U wave fusion, where the T and U waves cannot be distinguished, are signi cant risk predictors of TdP [47, 49].”
BackgroundDynamic properties of selected repolarization descriptors
Hnatkova, K., Toman, O., Šišáková, M., Novotný, T., & Malík, M. (2010) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2010.06.003 · Cited by 14 · see citing works
Torsade de Pointes due to Methadone Use in a Patient with HIV and Hepatitis C Coinfection
John, J., Amley, X., Bombino, G., Gitelis, C., Topi, B., Hollander, G. M., & Ghosh, J. (2010) · Cardiology Research and Practice · doi:10.4061/2010/524764 · Cited by 12 · see citing works
“In patients with prolonged QTc, the presence of pathological T-U waves (Figure 6) might be the only warning sign of imminent TdP [1].”
BackgroundLong QT Syndrome Unmasked by Dexmedetomidine: A Case Report
Burns, K. M., & Greene, E. A. (2013) · Congenital Heart Disease · doi:10.1111/chd.12055 · Cited by 12 · see citing works
Karrer, K., Denck, H., Karnicka-Młodkowska, H., Drings, P., Salzer, G. M., Hrabar, B., Liao, M., Sun, Y., Thermann, M., & Chen, D. (1990) · PubMed · Cited by 12 · see citing works
El‐Sherif, N., & Turitto, G. (2015) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12222 · Cited by 11 · see citing works
Goto, M., Sato, M., Kitazawa, H., Takahashi, M., Fuse, K., Saito, A., Okabe, M., & Aizawa, Y. (2014) · Internal Medicine · doi:10.2169/internalmedicine.53.1828 · Cited by 10 · see citing works
“When the action potential duration is excessively prolonged, early after-depolarization is expected to provoke triggered activity and subsequent VF, as observed in congenital or drug-induced QT prolongation (10, 11).”
BackgroundHigh-Density Lipoprotein Shortens the Ventricular Action Potential
Kirchhof, P. F., & Fabritz, L. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2010.12.048 · Cited by 10 · see citing works
Nakayama, M., Saito, A., Kitazawa, H., Takahashi, M., Sato, M., Fuse, K., Okabe, M., Hoshino, K., Tanaka, N., Yamashina, A., et al. (2012) · Internal Medicine · doi:10.2169/internalmedicine.51.6567 · Cited by 9 · see citing works
“Furthermore, Kirchhof et al found that the first TdP beat emerges from abnormal T-U waves which are larger than any other repolarization waves in the available ECGs and are not found before other types of premature ventricular beats (26).”
BackgroundAhn, J.-Y., Chu, H., Leem, J., & Yun, J.-M. (2024) · Medicine · doi:10.1097/md.0000000000038441 · Cited by 8 · see citing works
Alahmadi, A., Davies, A., Vigo, M., & Jay, C. (2018) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocy183 · Cited by 8 · see citing works
Alahmadi, A., Davies, A., Royle, J., Vigo, M., & Jay, C. (2019) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3290605.3300353 · Cited by 7 · see citing works
Refractory Hypotension and “Ventricular Fibrillation” With Large U Waves After Overdose
Cole, J. B., Stellpflug, S. J., & Smith, S. W. (2016) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2016.2065 · Cited by 7 · see citing works
Tan, V. H., Duff, H. J., Kuriachan, V. P., & Gerull, B. (2014) · Heart & Lung · doi:10.1016/j.hrtlng.2014.07.004 · Cited by 7 · see citing works
Guennec, J. L., Thireau, J., Ouillé, A., Roussel, J., Roy, J., Richard, S., Richard, S., Martel, E., & Champéroux, P. (2016) · Scientific Reports · doi:10.1038/srep37948 · Cited by 6 · see citing works
Green, J. R., Diaz, G. J., Limberis, J. T., Houseman, K. A., Su, Z. G., Martin, R. L., Cox, B. F., Kantor, S., & Gintant, G. A. (2011) · Journal of Pharmacological and Toxicological Methods · doi:10.1016/j.vascn.2011.03.005 · Cited by 6 · see citing works
Willems, S., Wegner, F. K., & Eckardt, L. (2025) · Deutsches Ärzteblatt international · doi:10.3238/arztebl.m2025.0082 · Cited by 5 · see citing works
In-hospital haloperidol use and perioperative changes in QTc-duration
Blom, M. T., Jansen, S., de Jonghe, A., Munster, B. C. V., de Boer, A., de Rooij, S. E., Tan, H. L., & van der Velde, N. (2015) · The journal of nutrition health & aging · doi:10.1007/s12603-015-0465-4 · Cited by 5 · see citing works
“In the present follow-up study, we therefore aimed to address the following questions: (1) how does QTc-duration change perioperatively? (2) does low-dose haloperidol influence these changes? (3) which clinical variables are associated with potentially dangerous QTc-prolongation?”
InfluentialConfirmation of maximal hyperemia by the incremental dose of intracoronary papaverine
Nakayama, M., Tanaka, N., Yamashita, J., & Iwasaki, K. (2020) · Cardiovascular Intervention and Therapeutics · doi:10.1007/s12928-020-00641-x · Cited by 5 · see citing works
Alahmadi, A., Davies, A., Vigo, M., & Jay, C. (2020) · PLoS ONE · doi:10.1371/journal.pone.0237854 · Cited by 5 · see citing works
“In fact, specific T-wave patterns can aid detection of LQTS [43], and large T-U waves are known to precede TdP [44].”
BackgroundKukla, P., Jastrzębski, M., Fijorek, K., Stec, S. M., Bryniarski, L., Czarnecka, D., & Baranchuk, A. M. (2016) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12355 · Cited by 5 · see citing works
The U wave in atrial fibrillation
Langley, P., Bourke, J. P., & Murray, A. (2015) · Computing in cardiology · doi:10.1109/cic.2015.7411040 · Cited by 4 · see citing works
“The U wave has also been shown to be a potential marker of Torsade de Pointes [4].”
BackgroundWearable electrocardiogram devices in patients with congenital long QT syndrome: The SMART-QT study
Delinière, A., Bessière, F., Placide, L., Pasquié, J., Haddad, C., Tirel, S., Mokhtar, H., Morel, É., Gardey, K., Dulac, A., et al. (2024) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2024.02.010 · Cited by 4 · see citing works
Sacha, J., Wester, A., Hordyński, G., & Pluta, W. (2013) · Herz · doi:10.1007/s00059-013-3756-8 · Cited by 4 · see citing works
Torsades: adjacent and triggering electrocardiographic events
Childers, R. (2010) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2010.06.013 · Cited by 4 · see citing works
The Effect of Moxibustion Treatment for Cardiac Arrhythmia : A Systematic Review
Lee, B., Hwang, J., & Kwon, J.-N. (2019) · 대한한의학회지 · doi:10.13048/jkm.19030 · Cited by 4 · see citing works
Takahashi, K., Yamashita, M., Sakaue, T., Enomoto, D., Uemura, S., Okura, T., Ikeda, S., Takemoto, M., Utsunomiya, Y., & Hyodo, T. (2021) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12842 · Cited by 4 · see citing works
“In our patient, we observed “giant (negative) T- U waves” (Kirchhof et al., 2009) 6 days after starting intravenous administration of amiodarone (Figure 2).”
BackgroundUse of the Surface Electrocardiogram to Define the Nature of Challenging Arrhythmias
Singh, D. K., & Peter, C. T. (2016) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2015.10.021 · Cited by 3 · see citing works
“Increases in transmural dispersion of repolarization combined with the formation of EADs form the basis of arrhythmic substrate in TDP.10 It is hypothesized that EADs exceeding the activation threshold can result in action potential formation and ultimately PVC’s that occur during the vulnerable period of ventricular…”
BackgroundInfluentialFitzpatrick, J. K., & Goldschlager, N. (2018) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2017.09.007 · Cited by 3 · see citing works
Kang, K., Shim, J., Ahn, J., Lee, D. I., Kim, J., Joung, B., & Choi, K. (2018) · Korean Journal of Medicine · doi:10.3904/kjm.2018.93.2.140 · Cited by 3 · see citing works
“즉, 이러한 약제 복용 중 QT 간격이 500 ms 이상 또는 기저 심전 도보다 60 ms 이상 증가하거나 새로운 U파 발생시 Torsades de pointes 발생의 위험신호이므로 항부정맥제 감량 또는 중 단을 고려해야 한다[64,96-98].”
Alahmadi, A., Davies, A., Vigo, M., & Jay, C. (2023) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2023.09.012 · Cited by 3 · see citing works
Al-Karadi, M. S., & Langley, P. (2020) · Sensors · doi:10.3390/s20144029 · Cited by 3 · see citing works
Frequenz- und Rhythmuskontrolle bei Vorhofflimmern
Weipert, K. F., Erkapic, D., & Schmitt, J. (2015) · Herz · doi:10.1007/s00059-014-4201-3 · Cited by 3 · see citing works
Av, A., Oseroff, O., Sansalone, R., Zhelyakov, E. G., Cappato, R., Snezhitskiy, V. А., Канорский, С. Г., Abzalieva, S. A. S., Belenkov, Y. N., Karpenko, Y., et al. (2020) · Kardiologiia · doi:10.18087/cardio.2020.10.n1283 · Cited by 3 · see citing works
Prevention of Torsade de Pointes during the Pharmacologic Treatment of Atrial Fibrillation
Mitamura, H. (2010) · Journal of Arrhythmia · doi:10.1016/s1880-4276(10)80030-4 · Cited by 2 · see citing works
CORONAVIRUS DISEASE (COVID-19) TREATMENT ALGORITHMS IN PATIENTS WITH QT INTERVAL PROLONGATION
Kalatsei, L. V., Snezhitskiy, V. А., & Av, A. (2020) · Journal of the Grodno State Medical University · doi:10.25298/2221-8785-2020-18-2-203-210 · Cited by 2 · see citing works
Acquired (Drug-Induced) Long and Short QT Syndromes
Shah, R., & Gussak, I. (2013) · Springer eBooks · doi:10.1007/978-1-4471-4978-1_6 · Cited by 2 · see citing works
Marill, K. A., Lopez, S. N., Hark, D., Spahr, J., Muthal, K., Xue, J. Q., Rowlandson, G. I., & Liu, S. W. (2022) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.15735 · Cited by 2 · see citing works
Camm, A. J., Kirchhof, P. F., Ernst, S., Gelder, I. C. V., Hindricks, G., Heidbüchel, H., Colonna, P., Goette, A., Hohloser, S. H., Kolh, P. H., et al. (2010) · Cited by 2 · see citing works
Looking for Virtuous Promiscuity: Electrocardiographic Evidence of Multichannel Drug Block
Haigney, M. C. (2014) · Clinical Pharmacology & Therapeutics · doi:10.1038/clpt.2014.165 · Cited by 1 · see citing works
The Year of 2009 in Electrocardiology
Stern, S. (2010) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2010.00394.x · Cited by 1 · see citing works
The Role of Antiarrhythmics in Atrial Fibrillation
Rhee, K. (2016) · Korean Journal of Medicine · doi:10.3904/kjm.2016.90.3.198 · Cited by 1 · see citing works
“간격 연장이 일어날 수 있지만 이와 연관된 다형심실빈맥 (torsades de pointes)은 매우 드문 것으로 알려져 있다[28].”
Tratamiento farmacológico de la fibrilación auricular. Antiarrítmicos y anticoagulantes orales
Cosı́n-Sales, J., & Olalla, J. J. (2016) · Revista Española de Cardiología Suplementos · doi:10.1016/s1131-3587(16)30012-7 · Cited by 1 · see citing works
Cardiac Syncope with Anoxic Seizure Activity
Talibi, S. S., Douglas, C. A., & Pope, B. (2020) · Case Reports in Emergency Medicine · doi:10.1155/2020/6749382 · Cited by 1 · see citing works
Torsades de pointes associated with inherited channelopathies
Wilde, A. A. M. (2022) · Elsevier eBooks · doi:10.1016/b978-0-12-821446-6.00015-8 · Cited by 1 · see citing works
The U wave in the electrocardiogram. More than an academic curiosity
Carrillo-Esper, R., Carrillo-Córdova, L. D., Carrillo‐Córdova, D. M., & Carrillo-Córdova, C. A. (2015) · Médica Sur · Cited by 1 · see citing works
Cardiac Action Potential Prolongation Induced by Isolated Thioridazine Enantiomers
Jensen, A. S. (2014) · doi:10.13052/rp-9788793237421 · Cited by 1 · see citing works
“This includes T wave morphology changes, U wave amplitude increase, and QT interval prolongation (19, 20).”
Takahashi, K., Yamashita, M., Sakaue, T., Enomoto, D., Uemura, S., Okura, T., Ikeda, S., Takemoto, M., Utsunomiya, Y., Hyodo, T., et al. (2021) · Medicine · doi:10.1097/md.0000000000027286 · Cited by 1 · see citing works
“In the third and fifth TdP events, the QRS complex of the first TdP beat arose from giant negative T-U waves([19,23]); conversely, in the first, second, and fourth TdP events, it did not.”
BackgroundSünbül, M., Erdoğan, O., & Mutlu, B. (2013) · Herz · doi:10.1007/s00059-012-3711-0 · Cited by 1 · see citing works
Accurate Dysrhythmia Monitoring in Adults
Bourgault, A. M., Seckel, M. A., & Kramlich, D. L. (2016) · Critical Care Nurse · doi:10.4037/ccn2016767 · Cited by 1 · see citing works
Highlights of the Year in JACC2009
DeMaria, A. N., Bax, J. J., Ben‐Yehuda, O., Feld, G. K., Greenberg, B., Hall, J. L., Hlatky, M. A., Lew, W. Y. W., Lima, J. A. C., Maisel, A. S., et al. (2010) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2009.12.007 · Cited by 1 · see citing works
“(91) ystematically studied ECG tracings of patients with acuired and congenital LQTS to provide a clinical index of remature ventricular complexes that initiated torsades de ointes, versus those that did not.”
Viskin, S. (2022) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.15736 · Cited by 1 · see citing works
“A similar process is shown in the lower panel: Once the “QT‐begets‐QT” process begins, the amplitude of the postextrasystolic T‐wave increases and becomes bizarre just immediately before the onset of torsade‐de‐pointes.(17)”
Methodde Luna, A. B. (2012) · doi:10.1002/9781118392041.ch24
de Luna, A. D. (2012) · Wiley eBooks · doi:10.1002/9781118392041.ch21
Long QT in stunned myocardium: unrecognised cause of acquired long QT syndrome
Sacha, J. (2014) · Journal of Medical Science · doi:10.20883/medical.e75
Development of Therapeutics for Heart Failure
Udelson, J. E. (2016) · Circulation Heart Failure · doi:10.1161/circheartfailure.116.003045
Davidson, J. E., Agan, D. L., Ballard, D. L., Truong, H. T., Bridgen, C. M., Rubino, S., Sikand, H., & Stein, J. B. (2013) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0b013e318264e0c4
“We propose that this clinical dilemma requires the use of more specific criteria in addition to QTc prolongation such as post pause QT measurement, post pause T-wave amplitude, screening using Schwartz criteria of long QT syndrome, or genetic profiling.(2,4,16) Genetic testing, although promising, is still in its infa…”
Method
- Authors
- Kirchhof, P., Franz, M. R., Bardai, A., & Wilde, A. M.
- Affiliations
- Georgetown University (US)
- University Hospital Münster (DE)
- Amsterdam UMC Location University of Amsterdam (NL)
- Corresponding author
- Franz, Michael R.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2009-07
- Volume
- 54
- Issue
- 2
- Pages
- 143-149
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2128940750
- Cited by
- 112
- References
- 31
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 3 · 2023: 1 · 2022: 6 · 2021: 9 · 2020: 8 · 2019: 4 · 2018: 5 · 2017: 3 · 2016: 12 · 2015: 7 · 2014: 11 · 2013: 8 · 2012: 6
- FWCI
- 6.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- long QT syndrome, torsades de pointes, premature ventricular contractions, early afterdepolarizations, QRS duration, congenital long QT syndrome, acquired long QT syndrome
- MeSH terms
- Adult, Aged, Diagnosis, Differential, Electrocardiography, Female, Follow-Up Studies, Heart Rate, Humans, Long QT Syndrome, Male, Middle Aged, Prognosis, Retrospective Studies, Risk Factors, Torsades de Pointes, Ventricular Premature Complexes
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