Cited by 112Cardiac electrophysiology and arrhythmiasCardiac Arrhythmias and TreatmentsCardiac pacing and defibrillation studies

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Giant T–U Waves Precede Torsades de Pointes in Long QT Syndrome

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Kirchhof, Paulus, Franz, Michael R., Bardai, Abdennasser, Wilde, Arthur M.·2009·Journal of the American College of Cardiology

DOI 10.1016/j.jacc.2009.03.043

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Abstract

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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Inter-individual variability and modeling of electrical activity: a possible new approach to explore cardiac safety?
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
Ventricular rate adaptation: A novel, rapid, cellular-based in-vitro assay to identify proarrhythmic and torsadogenic compounds
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
Clinical Practice Guideline
Willems, S., Wegner, F. K., & Eckardt, L. (2025) · Deutsches Ärzteblatt international · doi:10.3238/arztebl.m2025.0082 · Cited by 5
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
“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?”
Influential
Confirmation 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
Pseudo-colouring an ECG enables lay people to detect QT-interval prolongation regardless of heart rate
Alahmadi, A., Davies, A., Vigo, M., & Jay, C. (2020) · PLoS ONE · doi:10.1371/journal.pone.0237854 · Cited by 5
“In fact, specific T-wave patterns can aid detection of LQTS [43], and large T-U waves are known to precede TdP [44].”
Background
Electrocardiographic Parameters Indicating Worse Evolution in Patients with Acquired Long QT Syndrome and Torsades de Pointes
Kukla, 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
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
“The U wave has also been shown to be a potential marker of Torsade de Pointes [4].”
Background
Wearable 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
QT interval prolongation during ECG evolution in takotsubo cardiomyopathy poses a threat of torsade de pointes to predisposed patients
Sacha, J., Wester, A., Hordyński, G., & Pluta, W. (2013) · Herz · doi:10.1007/s00059-013-3756-8 · Cited by 4
Torsades: adjacent and triggering electrocardiographic events
Childers, R. (2010) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2010.06.013 · Cited by 4
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
Suppression of amiodarone‐induced torsade de pointes by landiolol in a patient with atrial fibrillation‐mediated cardiomyopathy
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
“In our patient, we observed “giant (negative) T- U waves” (Kirchhof et al., 2009) 6 days after starting intravenous administration of amiodarone (Figure 2).”
Background
Use 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
“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…”
BackgroundInfluential
The Clue Is in the U Wave: Torsades de Pointes Ventricular Tachycardia in a Hypokalemic Woman on Methadone
Fitzpatrick, J. K., & Goldschlager, N. (2018) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2017.09.007 · Cited by 3
2018 Korean Heart Rhythm Society Guidelines for Antiarrhythmic Drug Therapy in Non-valvular Atrial Fibrillation
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
“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].”
Personalized, intuitive & visual QT-prolongation monitoring using patient-specific QTc threshold with pseudo-coloring and explainable AI
Alahmadi, A., Davies, A., Vigo, M., & Jay, C. (2023) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2023.09.012 · Cited by 3
Multi-Beat Averaging Reveals U Waves Are Ubiquitous and Standing Tall at Elevated Heart Rates Following Exercise
Al-Karadi, M. S., & Langley, P. (2020) · Sensors · doi:10.3390/s20144029 · Cited by 3
Frequenz- und Rhythmuskontrolle bei Vorhofflimmern
Weipert, K. F., Erkapic, D., & Schmitt, J. (2015) · Herz · doi:10.1007/s00059-014-4201-3 · Cited by 3
Recommendations for the management of COVID 19 patients regarding proarrhythmic effects of some current treatments, specifically if these patients suffer from arrhythmias, and for those receiving antiarrhythmic therapy.
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
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
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
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
Electrocardiographic measures of repolarization heterogeneity are not predictive for Torsades de Pointes among undifferentiated patients with prolonged QTc: A case control study
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
Cardiología (ESC) Desarrolladas con la contribución especial de European Heart Rhythm Association (EHRA) Aprobado por European Association for Cardio-Thoracic Surgery (EACTS)
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
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
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
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
“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
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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
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
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
Cardiac Action Potential Prolongation Induced by Isolated Thioridazine Enantiomers
Jensen, A. S. (2014) · doi:10.13052/rp-9788793237421 · Cited by 1
“This includes T wave morphology changes, U wave amplitude increase, and QT interval prolongation (19, 20).”
Premature atrial contractions with multiple patterns of aberrant conduction followed by torsade de pointes in a patient with polymyalgia rheumatica
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
“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.”
Background
Torsade de pointes
Sünbül, M., Erdoğan, O., & Mutlu, B. (2013) · Herz · doi:10.1007/s00059-012-3711-0 · Cited by 1
Accurate Dysrhythmia Monitoring in Adults
Bourgault, A. M., Seckel, M. A., & Kramlich, D. L. (2016) · Critical Care Nurse · doi:10.4037/ccn2016767 · Cited by 2
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
“(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.”
Long QT begets long QT
Viskin, S. (2022) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.15736 · Cited by 1
“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)”
Method
Other ECG Patterns of Risk
de Luna, A. B. (2012) · doi:10.1002/9781118392041.ch24
Inherited Heart Diseases
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
Beat-to-Beat Corrected QT Analysis Detects Corrected QT Prolongation in 50 Consecutive Telemetry-Monitored Patients
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.
ORCID: Kirchhof, Paulus
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)
DOI: 10.1016/j.jacc.2009.03.043
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: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 1476 d)
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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Giant T–U Waves Precede Torsades de Pointes in Long QT Syndrome

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