Sources of QTc variability: Implications for effective ECG monitoring in clinical practice

Pharmaceuticals that prolong ventricular repolarization may be proarrhythmic in susceptible patients. While this fact is well recognized, schemes for sequential QTc interval monitoring in patients receiving QT-prolonging drugs are frequently overlooked or, if implemented, underutilized in clinical practice. There are several reasons for this gap in day-to-day clinical practice. One of these is the perception that serially measured QTc intervals are subject to substantial variability that hampers the distinction between potential proarrhythmic signs and other sources of QTc variability. This review shows that substantial part of the QTc variability can be avoided if more accurate methodology for electrocardiogram collection, measurement, and interpretation is used. Four aspects of such a methodology are discussed. First, advanced methods for QT interval measurement are proposed including suggestion of multilead measurements in problematic recordings such as those in atrial fibrillation patients. Second, serial comparisons of T-wave morphologies are advocated instead of simple acceptance of historical QTc measurements. Third, the necessity of understanding the pitfalls of heart rate correction is stressed including the necessity of avoiding the Bazett correction in cases of using QTc values for clinical decisions. Finally, the frequently overlooked problem of QT-heart rate hysteresis is discussed including the possibility of gross QTc errors when correcting the QT interval for simultaneously measured short-term heart rate.