To identify the necessity for close monitoring of the QT interval in children and adolescents treated with tricyclics.
Method
Guidelines for permissible ECG changes are reviewed and a case report of a 12-year-old girl with idiopathic long QT syndrome, no history of cardiac disorder, a questionable family history, and normal physical examination and baseline ECG is presented.
Results
Marked increase in QT corrected for heart rate (QTc) occurred on low-dose tricyclic. Possible factors in deaths on desipramine are reviewed.
Conclusion
It is recommended that children and adolescents on tricyclics receive an ECG at baseline and after each dose increase. Recommendations are made regarding ECG parameters and indications for cardiac consultation.
References
1.
SarafK., KleinD., Gittleman-KleinR.Imipramine side effects in children.Psychopharmacologia1974; 37: 265–274.
2.
RyanN.D.Heterocyclic antidepressants in children and adolescents.J Child Adolesc Psychopharmacol1990; 1: 21–31.
3.
ElliottG.R., PopperC.W., FrazierS.H.Tricyclic antidepressants: a risk for 6–9 year olds?J Child Adolesc Psychopharmacol1990; 1: 105–106.
4.
PopperC.W., ElliottG.R.Sudden death and tricyclic antidepressants: clinical considerations for children.J Child Adolesc Psychophaarmacol1990; 1: 125–132.
5.
RiddleM.A., NelsonJ.C., KleinmanC.S.Sudden death in children receiving norpramin: a review of three reported cases and commentary.J Am Acad Child Adolesc Psychiatry1991; 30: 104–108.
6.
RiddleM.A., GellerB., RyanN.Another death in a child treated with desipramine.J Am Acad Child Adolesc Psychiatry1993; 32: 792–797.
7.
ZimnitskyB., PopperC.W.A fifth case of sudder) death in a child taking desipramine.J Child Adolesc Psychopharm (in press).
8.
ElliottG.R., PopperC.W.Tricyclic antidepressants: the QT interval and other cardiovascular parameters.J Child Adolesc Psychopharmacol1990; 1: 187–189.
9.
ParkM.K., GuntherothW.G.How to read pediatric ECGs, second edition.Chicago/London: Year Book Med Pub Inc,1987.
10.
JervellA., Lange-NielsenCongenital deaf-mutism: functional heart disease with prolongation of the QT interval, and sudden death.Am Heart J1957; 54: 103.
WardO.C.New familial cardiac syndrome in children.J Ir Med Assoc1964; 54: 103.
13.
GarsonA., BrickerJ.T., McNamaraD.O.Pediatric cardiology.Philadelphia/London: Lea and Febiger1990; 1: 341–342.
14.
TowbinJ.A.Molecular genetic aspects of the Romano-Ward long QT syndrome.Texas Heart Inst J1994; 21: 42–47.
15.
MossA.J., RobinsonJ.L.Clinical aspects of the idiopathic long QT syndrome. In: HashibaK., MossA.J., SchwartzP.J., editors. QT prolongation and ventricular arrhythmia.New York: Ann NY Acad Sci1992; Vol 644.
16.
MossA.J., SchwartzP.J., CramptonR.S.The long QT syndrome: prospective longitudinal study of 328 families.Circulation1991; 84: 1136–1144.
17.
BeheraM.Jervell and Lange-Nielson syndrome in a middle aged patient.Postgrad Med J1987; 63: 395–396.
18.
DavignonA., RautaharjuP., BoisselleE.Normal ECG standards for infants and children.Ped Cardiol1979/1980; 1: 123–131.
19.
WeintraubR.G., GowR.M., WilkinsonJ.L.The congenital long QT syndromes in childhood.J Am Coll Cardiol1990; 16: 674–680.
20.
GellerB., FarookiZ.Q., CooperT.B.Serial ECG measurements at controlled plasma levels of nortriptyline in depressed children.Am J Psychiatry1985; 142: 1095–1097.
21.
GellerB., CooperT.B., GrahamD.L.Pharmacokinetically designed double-blind placebo controlled study of nortriptyline in 6 - 12-year olds with major depressive disorder.J Am Acad Child Adolesc Psychiatry1992; 1: 34–44.
22.
BiedermanJ., BaldessariniR.J., WrightV.A double-blind, placebo controlled study of desipramine in the treatment of ADD: II serum drug levels and cardiovasclular findings.J Am Acad Child Adolesc Psychiatry1989; 28: 903–911.
23.
RyanN.D., Puig-AntichJ., CooperT.B.Imipramine in adolescent major depression: plasma level and clinical response.Acta Psychiatr Scand1986; 73: 275–288.
24.
SarafK.R., KleinD.F., Gittleman-KleinR.EKG effects of imipramine treatment in children.J Am Acad Child Adolesc Psychiatry1978; 17: 60–69.
25.
WilensT.E., BiedermanJ., BaldessariniR.Electrocardiographic effects of desipramine and 2-OH-desipramine in children, adolescents and adults treated with desipramine.J Am Acad Child Adolesc Psychiatry1993; 32: 798–804.
26.
BiedermanJ., BaldessariniR.J., GoldblattA.A naturalistic study of 24-hour electrocardiographic findings in children and adolescents treated with desipramine.J Am Acad Child Adolesc Psychiatry1993; 32: 805–813.
27.
KapurS., MieczkowskiT., MannJ.J.Antidepressant medications and the relative risk of suicidal attempt and suicide.J Am Med Assoc1992; 268: 3441–3445.
28.
ZipesD.P.Sympathetic stimulation and arrhythmia.N Eng J Med1991; 325: 656–657.
29.
WalshB.T., GiardinaE.V., SloanR.P.Effects of desipramine on autonomic control of the heart.J Am Acad Child Adolesc Psychiatry1994; 33: 191–197.
30.
WagnerK.D., FershtmanM.Potential mechanism of desipramine-related sudden death in children.Psychosomatics1993; 34: 80–83.
