QTc Prolongation and Psychotropic Medications: Complex Clinical Cases and Impact of Ethnicity, Sex, Environment and Other Determinants

Psychiatrists routinely prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for Torsades de Pointes (TdP), a polymorphic ventricular tachycardia that can result in sudden cardiac death (SCD). The corrected QT interval (QTc) on the 12-lead electrocardiogram (ECG) is the most widely accepted benchmark of TdP risk and a major drug safety benchmark by the US Food and Drug Administration. Evaluation of the QTc and associated risk factors for TdP has become a routine part of clinical practice in consultation-liaison psychiatry. While genetic variants and female sex are well-known risk factors for TdP, the impact of ethnicity, environment, and other psychosocial determinants on prevalence of sudden cardiac death requires more consideration by the CL psychiatrist.

This fully interactive workshop is targeted to participants of all stages of learning and experience. The workshop will build on the core concepts that have been presented in prior ACLP Pre-Conferencet Skills Courses by utilizing complex clinical case examples that consider various determinants of health. Though we have presented on this topic as a Skills Course in the past several years, we chose to submit as a workshop this year to make the learning experience available to all meeting attendees.

We will begin with a brief review of the QT interval and an update on psychotropic medications that prolong the QTc. This review will include updates in the literature from the past year, including evidence for newly approved medications, a focus on droperidol (increasingly used again), and a step-by-step overview of QT measurement, heart rate correction, and clinical application. Using audience polling, discussion and a series of new clinical cases we will then discuss the approach to risk stratification and mitigation for use of psychotropic medications in patients at risk for TdP and SCD. Cases will highlight the impact of environmental-biopsychosocial determinants of health on the risk of SCD and high-yield strategies for various practice settings and patient populations. High risk populations include patients with: pregnancy, opioid use disorder treated with methadone, implanted cardiac devices, known mutations of genes associated with SCD, end-stage renal disease receiving hemodialysis, treatment in resource-poor clinical settings, and severe medical/surgical illness requiring intensive level of care. Cases will become increasingly complex as the learner becomes more confident. The workshop will conclude with a Q&A with the panel of speakers.

Participants will have the opportunity to take a pre- and post-test to assess baseline and acquired knowledge, skill and comfort with the topic.

Agenda:

Pre-Test (at workshop entry)

Introduction (5 minutes) Dr. Funk

Brief Update on QTc and ECG (10 minutes) Dr. Celano

Brief Update on Medications (10 minutes) Dr. Beach

Interactive Clinical Cases using Audience Polling (45 minutes) Drs. Beach, Celano and Funk

Interactive Q&A and Discussion (20 minutes) Drs. Beach, Celano and Funk

Post-Test (post-workshop on your own)