Torquere is Latin for ‘to twist’ and gave rise to ‘torque’ in English and, in French, to ‘torsade’ a ‘twisted fringe, cord or ribbon’. Torsade de pointes (TdP) is a ballet sequence in which the dancer twists around her ‘pointes’ (dancing en pointe means ‘on the tip’ and is a classical ballet technique, usually performed using special shoes called pointes). Dessertenne used this phrase to describe a distinctive form of ventricular tachycardia in an elderly woman, because the electrical axis of the ventricular complexes varied cyclically giving the electrocardiogram (ECG) a twisted appearance (Figure 1) [1]. Similar polymorphic ventricular tachycardia had previously been identified as the cause of loss of consciousness during quinidine therapy (‘quinidine syncope’) [2]. TdP can be fatal and occurs in several clinical settings associated with prolongation of the ventricular action potential, notably drug treatment and inherited abnormalities of cardiac ion channels [3]. Prolongation of the ventricular action potential is recognized non-invasively by QT segment prolongation on the ECG (a useful but tricky surrogate end-point for risk of clinically important TdP – see below).We have commented previously on druginduced QT prolongation and its importance in drug development [4–7]. Several antidysrhythmic drugs, for example disopyramide and procainamide, as well as quinidine, cause TdP including some (flecainide, encainide and D-sotalol) that have increased mortality in randomized controlled trials [8, 9].Several non-cardiac drugs can also, albeit less frequently cause TdP. These include domperidone (in high dose intravenously – see below), methadone, arsenic trioxide, and several antihistamines, antipsychotic drugs and antiinfective drugs [3]. Not only do drugs differ in their potential to cause TdP, but several patient factors also strongly influence the risk [3]. One of the strongest of these is female sex [10] perhaps because testosterone, which shortens QT interval [11], is lower in women than in men. Several other susceptibility factors can be understood in terms of their influence on cardiac repolarization. These include poor left ventricular function, hypokalaemia, severe hypomagnesaemia and genetic polymorphisms in cardiac ion channels associated with inherited long QT syndromes (LQTS). Drug–drug interactions are clinically important, notably the interaction between ketoconazole (a potent inhibitor of CYP3A) and terfenadine [12], which contributed to the withdrawal of terfenadine from the market after several years of use, including over the counter sales. Diet (especially fruit juice consumption) also influences drug disposition in complex ways [13] underscoring the difficulties for regulators concerned about the potential for low frequency but severe drug harms.
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