Prolonged Q-T interval

[mmfd]

Hi, thanks for taking my question.  I have familial DCM with an EF of 45%, up from 15%.  My LV is now 65 mm.  I also have a long long history of NSVT and SVT.  I had an unsuccessful ICD implant attempt in Aug. 2002.   This was from a left persistent superior vena cava, and congenital tortuous vessels on the right side. I have been taking Amiodarone 200 mg./day since then.  On my last Holter I only had 1000 PVC's/24 hours, which was my best ever!  Now my Q-T was found to be 650 msec with 560 corrected for my rate of 51.  At night my heart rate goes down in the high 30's.  I also take the usual meds like Coreg, Lisinipril, Lasix etc.  I have mild pulmonary hypertension.  My questions:  what are my options??  The cardiologist is holding the Amiodarone til the end of the week, and then I will take 100 mg./day.  How long does it normally take for the Q-T to return to normal?  What do we do if it doesn't??  What other drugs could I take to replace the Amiodarone?  Would it be worthwhile trying another ICD placement at another center, like CCF?  I am supposed to go to Europe in 3 weeks, is the risk too great?  Should I have another T-wave alternans test?  Both that I've had, had indeterminate results.  It seems like there just isn't an easy solution.....

[CCF-M.D.-MJM]

Hi MMFD,

This is a very complicated question.  First, why do you need a ICD?  Using the results of SCD-HeFT, there was little if any benefit for people with EF >35% short of confounding factors like cong. long QT syndrome with a family history of sudden death, personal history of sudden death, sustained ventricular tachycardia/ventricular fibrillation, etc.  Do any of these apply?  The SCD-HeFT trial also showed no survival benefit to amiodarone.  It may help reduce the incidence of VT, but there is not proven survival benefit.  Do you need to be on amiodarone?

The cardiologist is holding the Amiodarone til the end of the week, and then I will take 100 mg./day. How long does it normally take for the Q-T to return to normal?

It may takes days to weeks for your QT to return to normal, assume the prolonged QT is from the amiodarone.

What do we do if it doesn't??

If it doesn't normalize and you have no evidence of arrhythmias, you would continue to hold the amiodarone and any other QT prolong agents and wait.

What other drugs could I take to replace the Amiodarone?

I am still not sure why you are on the amiodarone and am not sure that it needs replaced.  You may have an indication for it, I am just not sure what it is based on what you wrote above.

Would it be worthwhile trying another ICD placement at another center, like CCF?

Again, you currently do not have an indication for ICD based on what you wrote above.  (Although I recognize there is probably more to your story then you wrote above).

I am supposed to go to Europe in 3 weeks, is the risk too great?

I would hope your QT normalizes by then, but even then, I don't feel comfortable -- based on what I know about your history --commenting on this question.

Should I have another T-wave alternans test?

I don't think a T wave alternans tests offers any more information in your current situation.

I hope this helps answer your question.  It sounds like you have made some significant improvements from your EF of 15%.  Good luck!

[Rick9897]

What did you leave out of your story.  I agree with the MD.  If I had an EF of 45%, I would not have been eligible for an ICD.  With a EF  of 15%, you would have been eligible for a bi-V pacer and possibly an ICD if they could easily induce VT and VF.  I take amiodarone to prevent the return of AF which would not allow me to be A+V sequencially paced but amiodarone does not increase survival in the face of VT or VF.  That was very evident in the recent studies.  Anyway, I think you are extremely lucky that you have improved so much.  You are almost normal which is great.  

Didn't you post these questions once before...not too long ago. I recall reading something similar.

[mmfd]

I don't know what to say.  The ICD placement was indicated back in 2002 with my history and such a low EF of 15%.  I was not a candidate for the bi-v since I didn't have and still don't have a BBB.  Plus they couldn't have placed the device anyway!  Today, with an EF so much higher, I am not obviously  a  candidate for an ICD while taking Amiodarone.  I had hemodynamically unstable arrhy. with BP dropping to 70 palp.  Three cardiologists at that time said I needed one, so I trusted their opinion!  As for taking the Amiodarone now, this is a good question and one I had thought about.  I haven't seen the EP since I went on it in the fall of 2002 and the recent studies were not out then.  Time to see him I suspect!!  The regular cardiologist has been managing my case.  Yes, it is wonderful that my EF has risen so much, since initially they said I was transplant material, and had no hope of recovery.  Just goes to show!  However, the EF isn't the only indicator of recovery.  I still don't feel normal by any means and it is important to listen to the patient, something that doctor's forget.  Oh, and no, the Q-T problem is new and I have not posted on this board regarding it.  I did post on another board though a couple of days ago, if that helps.

[Rick9897]

I was told that amiodarone is not effective for VT and VF.  The only reason I am on it is for the atrial fib.  It seems to me that you ought to have EP studies to see if they can induce VT or VF and go from there.  You are a candidate for an ICD if your EF is 30% or less and they can easily induce the VT/VF.  The Madet I and Madet II studies provide the guidelines for inserting the device.  Insurance will not pay for it unless they can induce it.  Although I understand that it may be approved for cardiomyopathy with an EF 30% or less without EP studies by next year.