QT Prolongation and Ventricular Pre-Excitation in Psychiatric Illness: Have We Pre-Excited our Colleagues?

A 27-year-old male patient presented with acute psychosis complicated by a prolonged corrected QT (QTc) interval in the setting of Wolff-Parkinson-White (WPW) pattern. The patient required antipsychotic medications that are high risk for prolonging the QTc interval and putting the patient at risk for torsades de pointes (TdP).

The key questions were as follows: 1) How does WPW affect the QTc interval? 2) Does the prolongation of the QTc interval seen in pre-excitation confer increased risk for TdP? and 3) How should patients with WPW and psychiatric illnesses be risk stratified when considering pathway ablation?

Early cardiology involvement allowed safe, early antipsychotic medication initiation. A multidisciplinary team approach resulted in a strategy of early catheter ablation because of the risk for pre-excited atrial fibrillation during future electroconvulsive therapy.

Despite broad awareness of the relationship between a prolonged QT interval and TdP, QT prolongation does not always reflect primary ventricular abnormalities that predispose to TdP, allowing the safe administration of antipsychotic agents in patients who need them.