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Paula McVay
Posted on Friday, July 09, 2004 - 06:17 pm:   

Dr Kanters,
I have a 15 year old son with schizoaffective disorder. After numerous med trials (starting at age 6)the only antipsychotic that helps him is clozaril. He is also on trileptal and topamax.
With his last hospitalization, which lasted 3 monts, it was discoverd that he has borderline long QTc. They were doing EKG's twice a week. His most current one was 478. The range has been from the 450's (only 2 a couple of months ago) up to 488. They generally stay in the high 470's to 480's. They tried inderol which he couldn't tolerate. I have repeatedly asked about beta blockers but for some reason they are hesitant to use them. Do you have any information in regards to the QT and psychtropic meds? He has side effects to all of them but this one is the only one that has helped with the sucidal tendencies,psychosis and very aggressive behavior. He is still hallucinating, but not severely. He was discharged yesterday, mostly due to insurance problems. The psychiatric doctor was in constant contact with the pediatric cardiologist. I have done so much research on long QT and the antipsychotics I feel like a walking medical referance book. His potassium and magnesium levels are normal. He does have a cousin who died of Long QT when she was 20, but this seems to be medication induced and also dose related.
Your opinion would be invaluable to me.
Thank you for your time.
Paula McVay
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Dr. Jorgen Kanters
Username: Jorgen

Registered: 08-2003
Posted on Tuesday, July 13, 2004 - 08:18 am:   

Dear Paula

A specific answer is impossible to give. That needs acces to all detailed information and examining your son.

Many antipsychotics has QT prolongating effects. It is difficult to say whereas your son QT prolongation is due to the drugs alone or hes having LQTS in combination with the drugs.

What was his QT interval before the drugs?

I have a few LQTS patients on antipsychotics despite their QT prolonging effects. One have to evaluate which problems are the worst for the patients, and in my cases its definitely the psychiatric problems and not their Long QT Syndrome. Then the benefits outweights the risk.

The death of his cousin rises suspicion of inherited Long QT. I dont know if it was on your side or on the father of your sons side. If it is inherited either you or the father much be affected as a gene carrier. What does yours ECG show?

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Paula McVay
Posted on Monday, July 19, 2004 - 05:53 am:   

Dr Kanters,
Thank you for your response. This is my 2nd attempt to write back to you. I spoke with the modorater and he thinks I entered my name wrong or something.
Regardless, Jared is back in the hospital after only 3 days home. He had and extreme psychotic breakdown and became very violent. His doctor said I had to call the police. It took him 4 hours to settle down, despite 2 shots of valium and 1 of thorazine. I told them not to give him thorazine.
The cousin who died of long QT is on his fathers side. Jareds brothers QTc is normal. Mine is 436. Im going to try to get his father go get one but this could be tricky as he is a paranoid schizophrenic and will ultimatly blame the whole thing on me. Also my daughter had one done a couple of months ago which I just found out today. I am going to have her get a copy of hers. He had to be taken to the hospital by ambulance and it took 4 policemen to contain him. I was so afraid the emotional toll on him would cause problems.
Also, how come they dont want long QT sufferes to not swim? Is it the physical exertion or the holding of the breath. Any ideas on that? No onehere seems to know. It the only sport Jared enjoys.
Once again thanks for your input. I dont expect miracles from you but hope you might have some information and insite that I havnt come accross. Not trying to put you under any presser. We do have as appointment with a cardiac specialist who specizes in the electrical side of cardiolog. I cant remember the exact name of her specialty. This will be on Aug. 6th.
Again, Thank you.
Best,
Paula McVay
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Paula Mcvay
Posted on Sunday, July 25, 2004 - 07:24 am:   

This board is too difficult to commmunicate with. I dont want to repeat myself and surely it will save the doc time.
Paula
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Dr. Jorgen Kanters
Username: Jorgen

Registered: 08-2003
Posted on Monday, August 02, 2004 - 01:31 pm:   

It seems that your kid has Long QT syndrome and his father is the carrier, since the cousin is on his side. In that case all of your other childs with the same father has 50% chance to have Long QT syndrome.

Furthermore it seems that Long Qt Syndrome in this case is a minor problem compared to the schizophrenia.

The treatment for schizophrenia can worse LQTS, but seems nessecary from what you have written.

betablocker therapy could be used, but only if your son tolerate it.

Eventually you could discuss an Implantable Cardioverter Defibrillator with your electrophysiologist
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chandrika Joshi
Posted on Friday, September 02, 2005 - 02:04 am:   

Dear Dr Kanters,
Are there any antipsychotic medications that a person suffering from long QT Syndrome take ( which are safe)?

Chandrika
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Dr. Jorgen Kanters
Username: Jorgen

Registered: 08-2003
Posted on Monday, September 05, 2005 - 11:15 am:   

not really. Valium can in extreme situations be used. It does not affect the QT but is really bad as a antipsycotic.

I have several patients on antipsycotics combined with betablockers and that goes well on. One have to ensure that antipsycotics is really needed, but in my cases the psyciartic problem is much worse than the LQTS problem, which justifies the small risk
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Chandrika Joshi
Posted on Monday, September 05, 2005 - 01:27 pm:   

Dr Kanters,

thank you for your response.
She does take benzadiazipines which are not much help. Are any particular antipsychotics which are cleaner even if they are not totally safe.
Also does Bisoprolol( lipid soluble?) cause more psychiatric side effects than atenolol( water soluble).
She was managed well with atenolol but this was recently changed to Bisprolol because of evidence of the former being a better beta blocker. Her delusions and hallucinations seem to have increased. Could it be the drug change?
Chandrika
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Dr. Jorgen Kanters
Username: Jorgen

Registered: 08-2003
Posted on Monday, September 26, 2005 - 09:34 am:   

Atenolol is by some believed to be not as good as other betablockers for LQTS. We use metropolol but bisoprolol is just as good. I dont believe that bisoprolol should have more psychiatric side effects than atenolol
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s k
Posted on Thursday, November 03, 2005 - 05:25 am:   

Dr. Kanters,

I am a resident psychiatrist on a inpatient consult service. I am currently treating a 48yo female patient with a h/o depression, cvas, poorly controlled HTN and DM, who has a baseline has a QTc ranging 480-520 (measured over the past two weeks) of unclear etiology. We have been using benzodiazapines to treat her agitation, however, she has continued to deteriorate (nonverbal, confused, refusing food/oral meds, and presumably delirious +/- psychotic).

We have reached a point where the benefits appear to outweigh the risks in initiating an antipsychotic. I've done quite a bit of reading, but there doesn't seem to be a consensus on monitoring and precautions. Also, I assume we shall have to use either IV or dissovable formulation. Any recommendations would be appreciated. THANKS!
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Dr. Jorgen Kanters
Username: Jorgen

Registered: 08-2003
Posted on Friday, November 04, 2005 - 04:54 pm:   

Even in LQTS it could be nessecary to treat with potential QT prolonging drugs. It is a balance between risk and benefits which has to be evaluated individually.

The QT prolongation could be secondary to heart disease and with the history of hypertension I would suggest an echocardiography. If inherited LQTS could not be ruled out and the indication for antipsychotics is strong what it seems to be, I would monotor for 72h after drug initialization. It would not complete eliminate the risk but reduce it.

I would penetrate further in the history, has the patient syncopes. Are there any family history of sudden death before the age of 40?

A few of mine LQTS patients are either on antidepressants or antopsychotics and despite it is in principle contraindicated it goes fine. However the indication should be good

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Aretha
Posted on Monday, June 12, 2006 - 10:44 pm:   

Dear Dr. Kanters,

Last year my then 3 year old daughter had PVC's during surgery and they lasted over half the day. They put us in PICU and called in a Pediatric Cardiologist. The PVC's stoped as mysteriously as they started and the cardiologist told us it was nothing to worry about and to go on with our lives a normal. Well, last monday night, now 4 years old while putting her to bed she complained of chest pain. Well with her also being Asthmatic I started asking questions. She said it hurt in the middle of her chest and it felt like a swish feeling while making a hand gesture to reflect the same. So off to the ER we went, on the advise of the after hours Pediactric emergency and yes she was having PVC's the same as before, alternating between every other beat then every 4th beat. The refered us back to the cardiologist, who the next day confirmed she was still having the PVC's and her EKG showed QTc (450). Come to find out last years Q wave was 437, over this past week I have learned normal is <440. They are NOW ONLY at my insistance going to have ECG done and another Holter monitor as well.The Holter showed she is still having the PVC's and they are not too worried since she does have a normal rethym mixed in with the PVC's, every other to every 4th beat. My question is, Did they miss somehting last year and could they be missing soemthing now? I am scared to death and fear of her passing out or not waking up in the mornings. As any child is to a mother, she is my life, but more so since I was told I would never have children and we proved them wrong. I know they are not as worried as I am because there are other things so much worse but for me this is the straw that has broken the camels back. At 3 1/2 months old she started having Asthma attacks that we later found out was complicated by Reflux that was going into her lungs. She is 4 years old and has been seen by a Pulmiologist, Gasterologist and now a Cardiologist. I just want them to be sure that they are treating her with a since of ergency.
Thanks for your help and guidance.
Aretha

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