Torsade de pointes. Mechanisms and management

Torsade de pointes is a polymorphic ventricular tachycardia showing a peculiar electrocardiographic pattern characterised by a continuous twisting in QRS axis around an imaginary baseline. An abnormally prolonged QT interval is actually associated with torsade de pointes and it is constantly observed in the sinus beats preceding the onset of the arrhythmic event. Prolongation of ventricular repolarisation associated with the development of torsade de pointes can be observed in many clinical conditions, commonly referred to as prolonged QT syndromes, which can be divided into two major groups: (a) idiopathic long QT syndrome (LQTS), which include the Jervell-Lange-Nielsen and the Romano-Ward syndromes; and (b) acquired prolonged QT syndromes, which are largely iatrogenic and may follow treatment with antiarrhythmic drugs, tricyclic antidepressants, phenothiazines or macrolide antibiotics, and may be associated with metabolic disturbances (hypokalaemia, hypocalcaemia and hypomagnesaemia). Clinical studies have provided criteria for the definition and guidelines for the management of torsade de pointes, while the electrophysiological mechanisms responsible for its onset are still unclear. Two pathogenetic hypotheses have been proposed to account for the electrophysiological mechanisms underlying the condition: (a) re-entry due to a dispersion of refractory periods; and (b) triggered activity initiated by either early or delayed after-depolarisations. Both mechanisms are supported by clinical and experimental observations but a conclusive answer is not yet available.