& 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Psychosomatics 2014:]:]]]–]]]
Letters to the Editor
What Psychiatrists Need to Know About Pacemakers and Defibrillators TO THE EDITOR: In the September-October issue of Psychosomatics, Brojmohun et al.1 undertook the important but daunting task of proposing what psychiatrists should know about cardiac devices such as pacemakers and defibrillators. Their discussion particularly targeted assessing cardiac repolarization in the setting of cardiac devices and the risk of torsades de pointes with psychotropic medications. In so doing, Brojmohun et al. confronted a complex interface between psychiatry and cardiology. The article presented an algorithmic approach to managing psychiatric drugs in those with cardiac devices, which is rich in high-yield clinical information, such as searching for baseline risk factors, attention to concomitant culprit medications, and monitoring serum electrolytes. Some aspects of their algorithm surprisingly surpassed what most consultation-liaison psychiatrists would consider their scope of practice, even recognizing the considerable variation of knowledge and skills within the field. For example, independently ascertaining the basic cardiac device type and, if applicable, pacemaker setting are novel tasks for most psychiatrists. Furthermore, estimation of the duration of cardiac repolarization is fraught with complexity, both in normal and widened QRS complexes. QT interval assessment, the most common means of assessing cardiac repolarization, is vulnerable to measurement error and Psychosomatics ]:], ] 2014
confounded by heart rate and diurnal variation. Measurement challenges are magnified in the setting of a wide QRS or pacemaker. Most practitioners likely rely on electrocardiogram automated QTc measurement and therefore lack practice in manual and alternative methods of QT interval measurement. Beyond the most commonly used Bazett formula for heart rate correction, Brojmohun et al. described other ways to correct the QT interval for heart rate and the use of alternative assessments of repolarization including in the setting of widened QRS (corrected JT interval and peak-to-end duration of the T wave). Yet, would most psychiatrists feel comfortable applying these independently? Some of these alternative methods of assessing cardiac repolarization have been mostly confined to research use and as already identified by Beach et al.2 are yet to gain clinical acceptance. Moreover, studies show that even cardiologists and internists can struggle greatly with measuring and identifying long QT interval. In a study of patients with long QT syndrome, 4 80% of arrhythmia experts but only o 50% of cardiologists and o 40% of noncardiologists (internists, neurologists, pediatricians, emergency room and intensive care specialists, and gastroenterologists) calculated the QTc correctly.3 Similarly, a practitioner survey study found that only 60% of physician respondents (most identified as cardiologists) could accurately assess the QT interval within 20 ms.4 We are grateful for the thoughtful review by Brojmohun et al. that
illuminated an approach to the complex clinical scenario involving cardiac devices and psychotropic medications, especially from the consultation-liaison perspective. Their systematic clinical approach and suggestion of practitioner awareness and proficiency of QT intervals and cardiac devices is valuable. Although a select few may be comfortable with more advanced QT interval measurement approaches and discerning types of cardiac device, these are likely a minority as this is a highly specialized skill. We would thus like to underscore that it is equally important to recognize one's individual limitations and be aware when referral and collaboration with a cardiologist with expertise in arrhythmias is warranted. We hope that the breadth of coverage Brojmohun et al. provided on this topic may serve as a refresher for some, a reference for others, and a reminder of the importance of interdisciplinary collaboration to provide first-rate care. Thomas G. Salter, M.D. Departments of Psychiatry and Internal Medicine, University of Iowa, Iowa City, IA Jess G. Fiedorowicz, M.D., Ph.D. Departments of Psychiatry and Internal Medicine, Carver College of Medicine, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
References 1. Brojmohun A, Lou JY, Zardkoohi O, Funk MC: Protected from torsades de pointes? What psychiatrists need to know about pacemakers and defibrillators Psychosomatics 2013; 54
www.psychosomaticsjournal.org
1
Letters to the Editor (5):407–417. /http://www.ncbi.nlm.nih. gov/pubmed/23756118S 2. Beach SR, Celano CM, Noseworthy Pa, Januzzi JL, Huffman JC: QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics 2013; 54(1):1–13. /http://www. ncbi.nlm.nih.gov/pubmed/23295003S
2
www.psychosomaticsjournal.org
3. Viskin S, Rosovski U, Sands AJ, et al: Inaccurate electrocardiographic interpretation of long QT: the majority of physicians cannot recognize a long QT when they see one. Heart Rhythm 2005; 2(6):569–574. /http://www.ncbi.nlm.nih. gov/pubmed/15922261S
4. LaPointe NMA, Al-Khatib SM, Kramer JM, Califf RM: Knowledge deficits related to the QT interval could affect patient safety. Ann Noninvasive Electrocardiol 2003; 8(2):157–160. /http://www.ncbi.nlm.nih.gov/pubmed/ 12848798S
Psychosomatics ]:], ] 2014
Psychosomatics 2014:]:]]]–]]]
Letters to the Editor
What Psychiatrists Need to Know About Pacemakers and Defibrillators TO THE EDITOR: In the September-October issue of Psychosomatics, Brojmohun et al.1 undertook the important but daunting task of proposing what psychiatrists should know about cardiac devices such as pacemakers and defibrillators. Their discussion particularly targeted assessing cardiac repolarization in the setting of cardiac devices and the risk of torsades de pointes with psychotropic medications. In so doing, Brojmohun et al. confronted a complex interface between psychiatry and cardiology. The article presented an algorithmic approach to managing psychiatric drugs in those with cardiac devices, which is rich in high-yield clinical information, such as searching for baseline risk factors, attention to concomitant culprit medications, and monitoring serum electrolytes. Some aspects of their algorithm surprisingly surpassed what most consultation-liaison psychiatrists would consider their scope of practice, even recognizing the considerable variation of knowledge and skills within the field. For example, independently ascertaining the basic cardiac device type and, if applicable, pacemaker setting are novel tasks for most psychiatrists. Furthermore, estimation of the duration of cardiac repolarization is fraught with complexity, both in normal and widened QRS complexes. QT interval assessment, the most common means of assessing cardiac repolarization, is vulnerable to measurement error and Psychosomatics ]:], ] 2014
confounded by heart rate and diurnal variation. Measurement challenges are magnified in the setting of a wide QRS or pacemaker. Most practitioners likely rely on electrocardiogram automated QTc measurement and therefore lack practice in manual and alternative methods of QT interval measurement. Beyond the most commonly used Bazett formula for heart rate correction, Brojmohun et al. described other ways to correct the QT interval for heart rate and the use of alternative assessments of repolarization including in the setting of widened QRS (corrected JT interval and peak-to-end duration of the T wave). Yet, would most psychiatrists feel comfortable applying these independently? Some of these alternative methods of assessing cardiac repolarization have been mostly confined to research use and as already identified by Beach et al.2 are yet to gain clinical acceptance. Moreover, studies show that even cardiologists and internists can struggle greatly with measuring and identifying long QT interval. In a study of patients with long QT syndrome, 4 80% of arrhythmia experts but only o 50% of cardiologists and o 40% of noncardiologists (internists, neurologists, pediatricians, emergency room and intensive care specialists, and gastroenterologists) calculated the QTc correctly.3 Similarly, a practitioner survey study found that only 60% of physician respondents (most identified as cardiologists) could accurately assess the QT interval within 20 ms.4 We are grateful for the thoughtful review by Brojmohun et al. that
illuminated an approach to the complex clinical scenario involving cardiac devices and psychotropic medications, especially from the consultation-liaison perspective. Their systematic clinical approach and suggestion of practitioner awareness and proficiency of QT intervals and cardiac devices is valuable. Although a select few may be comfortable with more advanced QT interval measurement approaches and discerning types of cardiac device, these are likely a minority as this is a highly specialized skill. We would thus like to underscore that it is equally important to recognize one's individual limitations and be aware when referral and collaboration with a cardiologist with expertise in arrhythmias is warranted. We hope that the breadth of coverage Brojmohun et al. provided on this topic may serve as a refresher for some, a reference for others, and a reminder of the importance of interdisciplinary collaboration to provide first-rate care. Thomas G. Salter, M.D. Departments of Psychiatry and Internal Medicine, University of Iowa, Iowa City, IA Jess G. Fiedorowicz, M.D., Ph.D. Departments of Psychiatry and Internal Medicine, Carver College of Medicine, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
References 1. Brojmohun A, Lou JY, Zardkoohi O, Funk MC: Protected from torsades de pointes? What psychiatrists need to know about pacemakers and defibrillators Psychosomatics 2013; 54
www.psychosomaticsjournal.org
1
Letters to the Editor (5):407–417. /http://www.ncbi.nlm.nih. gov/pubmed/23756118S 2. Beach SR, Celano CM, Noseworthy Pa, Januzzi JL, Huffman JC: QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics 2013; 54(1):1–13. /http://www. ncbi.nlm.nih.gov/pubmed/23295003S
2
www.psychosomaticsjournal.org
3. Viskin S, Rosovski U, Sands AJ, et al: Inaccurate electrocardiographic interpretation of long QT: the majority of physicians cannot recognize a long QT when they see one. Heart Rhythm 2005; 2(6):569–574. /http://www.ncbi.nlm.nih. gov/pubmed/15922261S
4. LaPointe NMA, Al-Khatib SM, Kramer JM, Califf RM: Knowledge deficits related to the QT interval could affect patient safety. Ann Noninvasive Electrocardiol 2003; 8(2):157–160. /http://www.ncbi.nlm.nih.gov/pubmed/ 12848798S
Psychosomatics ]:], ] 2014
