The Journal of Emergency Medicine, Vol. 54, No. 1, pp.

8–15, 2018
Ó 2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2017.08.073

Original
Contributions

PREVALENCE AND OUTCOME OF HIGH-RISK QT PROLONGATION RECORDED IN

THE EMERGENCY DEPARTMENT FROM AN INSTITUTION-WIDE QT
ALERT SYSTEM

Heather N. Anderson, MD,* J. Martijn Bos, MD, PHD,† Kristina. H. Haugaa, MD, PHD,† Bruce W. Morlan, MS,‡
Robert F. Tarrell, MS,§ Pedro J. Caraballo, MD,jj and Michael J. Ackerman, MD, PHD*†{
*Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, †Department of
Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester,
Minnesota, ‡Department of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, §Department of Statistics, Mayo Clinic,
Rochester, Minnesota, jjDepartment of Internal Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, and
{Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota
Reprint Address: Michael J. Ackerman, MD, PHD, Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice
Sudden Death Genomics Laboratory, Mayo Clinic, Guggenheim 501, 200 First Street SW, Rochester, MN 55905

, Abstract—Background: QT prolongation is an indepen-
dent risk factor for sudden death, stroke, and all-cause
mortality. However, additional studies have shown that in
certain settings, QT prolongation may be transient and a
result of external factors. Objective: In this study, we evalu-
ated the clinical characteristics and outcomes of patients
seen in the emergency department (ED) with QT prolonga-
tion. Methods: Between November 2010 and June 2011, 7522
patients had an electrocardiogram (ECG) obtained during
their evaluation in the ED. Clinical, laboratory, and therapeu-
tic information was collected for all patients with QT prolonga-
tion (i.e., $ 500 ms and QRS < 120 ms). Potential QT-inciting
factors (drugs, electrolyte disturbances, and comorbidities)
were synthesized into a pro-QT score. Results: Among the
7522 patients with an ECG obtained in the ED, a QT alert
was activated in 93 (1.2%; mean QTc 521 ± 34 ms). The major-
ity of ED patients (64%) had more than one underlying condi-
tion associated with QT prolongation, with electrolyte
disturbances in 51%, a QT prolonging condition in 56%,
and QT-prolonging drugs in 77%. Thirty-day mortality was
13% for patients with QT prolongation noted in the ED.
Conclusions: One percent of patients evaluated with an ECG
in the ED activated our prolonged QTc warning system, with
most demonstrating > 1 QT-prolonging condition. Thirty-day
mortality was significant, but it requires further investigation
to determine whether the QTc simply provided a non-
invasive indicator of increased risk or heralded the presence
of a vulnerable host at risk of a QT-mediated sudden
dysrhythmic death. Ó 2017 Elsevier Inc. All rights reserved.

This work was supported by the Mayo Clinic Windland Smith , Keywords—QT prolongation; emergency department;
Rice Comprehensive Sudden Cardiac Death Program. risk factor; monitoring
Michael J. Ackerman is a consultant for Boston Scientific,
Gilead Sciences, Invitae, Medtronic, MyoKardia, and St. Jude
Medical. Mayo Clinic and Michael J. Ackerman have received
royalties from Transgenomic with respect to their FAMILION-
INTRODUCTION
LQTS and FAMILION-CPVT genetic tests from 2004 to 2015.
None of the disclosures pertain to this study and none of the
companies provided financial support for this study. The re- Prolongation of the QT interval on electrocardiogram
maining authors disclose no conflicts. (ECG) is associated with increased risk of all-cause

RECEIVED: 28 February 2017; FINAL SUBMISSION RECEIVED: 11 August 2017;

ACCEPTED: 16 August 2017

8
High-Risk QT Prolongation in ED
mortality, and has been studied extensively in patients with
cardiac disease (1–3). Given this association, heightened
awareness and concern for QT prolongation has
developed throughout the various fields of medicine.
However, additional studies have shown that in certain
settings, QT prolongation may be transient and a result
of external factors (4). This finding is particularly relevant
in the emergency department (ED) setting, where patients
present with a variety of complaints and practitioners are
tasked with determining a diagnosis and prognostic assess-
ment quickly. The ED is also an area where ECGs are
obtained commonly. In light of acuity often accompanied
by a wide array of pathology, it is difficult for providers to
determine the relevance of isolated QT prolongation (5).
The prevalence of QT prolongation in the ED is poorly
understood, especially with regard to predisposing factors
contributing to this entity. This study was designed to
further analyze the surreptitious finding of QT prolonga-
tion among patients evaluated in our institution’s ED (6).
This has been studied in postoperative populations, but
not in the ED (7,8). Herein, we describe the prevalence,
underlying causes, and outcomes of patients presenting
to the ED with QT prolongation with regard to QT-
associated comorbidities, electrolyte disturbances, and
use of QT-prolonging medication.
MATERIALS AND METHODS
Study Design, Setting, and Population
This study is a retrospective review of patients identified
through an institution-wide, electronic medical record
(EMR)–based QT alert system from November 2010 to
June 2011. This system screens all ECGs obtained in the
inpatient, outpatient, and ED settings at our institution.
A total of 86,107 ECGs in 52,579 unique patients were
performed during the time period mentioned. This study
was reviewed and approved by the Institutional Review
Board.
Study Protocol: Institution-Wide QT Alert System
The QT alert system automatically analyzes each ECG
performed at our institution through an algorithm devel-
oped to identify ECGs with significant prolongation of
the QT interval (6). Briefly, for adult patients, ECGs
with QRS duration # 120 ms, heart rate (HR) < 100
beats/min, and QTc $ 500 ms prompted a QT-alert. If
the QRS was > 120 ms and HR < 100 beats/min, the
QTc must be $ 550 ms to prompt an alert. If the HR
was $ 100 beats/min, the ECG was not evaluated further
within the algorithm.
In children (< 18 years of age), ECGs with QRS
duration # 120 ms, HR < 150 beats/min, and
9
QTc $ 470 ms met the threshold for a QTc alert. In
ECGs with QRS > 120 ms and a HR < 150 beats/min, a
QT alert was prompted for a QTc $ 550 ms. If the HR
was > 150 beats/min, the ECG was not evaluated further
through the algorithm. QTc thresholds were set at values
well beyond the 99th percentile for their respective age
categories in an effort to enhance the signal-to-noise ratio
and minimize the chances of alert fatigue (9). These QTc
alert levels were also considered to represent an action-
able degree of QTc prolongation because the risk of
dysrhythmic episode is increased beyond these pediatric
and adult thresholds. To prevent notification delays, aside
from the standard electronic, EMR message, alerts
triggered by patients seen in the ED also led to a phone
call to the emergency physician making them aware of
the QT prolongation. Electronic analysis of the QT inter-
val occurs immediately at the time that the ECG is ob-
tained; however, all ECGs are also reviewed by a
technician and, if requested, a cardiologist, and a manual
QT alert can be triggered if it is believed that significant
QT prolongation is present, but did not trigger through
the automated alert system. All pediatric ECGs are al-
ways reviewed by a pediatric cardiologist.
ECG Review
A cardiologist (KHH) blinded to the electronic ECG mea-
surements reviewed all ECGs included in this study. The
QT interval was measured manually in the lead showing
the most clearly demarcated T-wave offset (generally
lead II) as a mean of three consecutive beats. Haugaa
et al. previously reported approximately 93% concordance
(with 6 10 ms) between the computer-derived and manu-
ally calculated QTc (6). The manually calculated QTc was
used if the two values differed by > 10 ms. The QTc was
adjusted manually to higher values in 4.2% (48 of 1145)
and to lower values in 3.4% (39 of 1145). Every ECG
was also evaluated for presence of bundle branch block,
ventricular pacing, atrial fibrillation, atrial flutter, supra-
ventricular tachycardia, ST-T wave changes indicative of
ischemia, and left ventricular hypertrophy by Sokolow
and Lyon and Cornell voltage criteria, as these could
impair accurate measurement of the QTc (10,11). ECGs
with these abnormalities were excluded from analysis
and the remaining ECGs were defined as
electrocardiographically isolated QT prolongation.
Data Collection and Measurements
For patients with isolated QT prolongation, clinical, labora-
tory, and therapeutic data were collected from the EMR.
The main ED-rendered diagnosis for each patient encounter
was recorded and grouped into 1 of 10 categories (cardio-
vascular, infectious, pulmonary, renal/diabetes mellitus,
10 H. N. Anderson et al.

gastrointestinal, neurologic, malignancy, psychiatric, intox- uation in the ED. Overall, 470 of 52,579 (0.9%) patient-
ication, trauma/postoperative). In addition, comorbidities specific ECGs were noted to have electrocardiographi-
associated with QT prolongation were also recorded (6). cally isolated QT prolongation. Among the 7522 patients
Mortality data were obtained from vital status of the with an ECG obtained in the ED, a QT alert was activated
EMR for all patients and where possible, cause of death in 93 (1.2%). Of the 470 patients with electrocardio-
was determined and recorded based on information from graphically isolated QT alerts, 93 patients had their QT
the EMR and outside correspondence. alert originate in the ED (20%).
Electrolyte disturbances were documented; specifically Demographics of the 93 ED patients with QT prolonga-
hypokalemia, hypomagnesemia, and hypocalcemia. The tion are outlined in Table 1. The ED cohort had a median
electrolyte levels were obtained only if collected within age of 67 years (interquartile [IQR] range 52–77 years)
48 h before the ECG or within 48 h after the ECG was and slightly more than half were female. The QTc for pa-
performed. If multiple levels were available, the closest tients with an alerted QTc in the ED was 521 6 34 ms.
value before the ECG was recorded. Hypokalemia Follow-up ECGs from the ED visit were available for 78
(< 3.6 mmol/L), hypomagnesemia (< 1.7 mg/dL), and patients (84%). Fifty-three (67%) demonstrated resolution
hypocalcemia (< 4.65 mg/dL) were defined based on our of QT prolongation (median follow-up time was 5 days
institution’s reference values. [IQR 2–129 days]), while 25 (32%) continued to demon-
All medications up to 7 days before the alerted ECG strate prolongation on subsequent studies.
were recorded and QT-prolonging medications were
defined by presence on the Credible Meds QT drug list, Risk Factors
which is a peer-reviewed electronic resource based on
scientific literature and United States (US) Food and Figure 1 shows the distribution of QT-prolonging risk
Drug Administration updates (12). For patients in the factors for patients with a QT alert in the ED. Patients in
ED, outpatient medications and medications received in the ED were most likely to have more than one
the ED before ECG were recorded separately. QT-prolonging risk factor in more than one of the three
categories (medications, comorbidities, electrolyte distur-
Pro-QTc Score bances). This represented 64% of the ED population.
Sixteen percent were exposed to medications alone, 13%
The pro-QT score is a tool for describing the QT- had only QT-prolonging comorbidities, and 7% had
prolonging risk factors in a patient and was first described electrolyte disturbances only. Patients in the ED often
by Haugaa et al. in 2013 (6). It currently serves as a nu- had multiple QT-prolonging risk factors compared to
merical description of the patients’ clinical phenotype, patients evaluated in non-ED locations (n = 377, data not
but has not been validated at this time (6). Patients are
given 1 point for each QT-prolonging diagnosis, electro- Table 1. Emergency Department Cohort Demographics
and Summary of QT-Prolonging Risk Factors
lyte disturbance, and QT-prolonging medication. The
pro-QTc score was calculated for each patient in this Factor ED Cohort (n = 93)
study utilizing clinical, laboratory, and therapeutic data.
Age, y, median (IQR) 67 (52–77)
For patients seen in the ED, a pro-QTc score was calcu- Female, n (%) 55 (59)
lated both on presentation to the ED (pre-ED) and upon Caucasian, n (%) 89 (96)
ED discharge (post-ED). QRS duration, ms, mean 6 SD (95% CI) 95 6 12 (92–98)
QTc, ms, mean 6 SD (95% CI) 521 6 34 (514–528)
LQTS, n (%) 0 (0)
Statistical Analysis Pro-QTc score, mean 6 SD (95% CI) 3.0 6 1.6 (2.7–3.3)
Deaths, n (%; 95% CI) 36 (39; 29–49)
Electrolyte disturbances, n (%) 48 (51)
Data were analyzed via c2 test for nominal data and Hypokalemia 34 (37)
unpaired Student’s t-test for comparison of mean values. Hypomagnesemia 20 (22)
Log-rank analysis was used to compare Kaplan-Meier Hypocalcemia 24 (26)
QT-prolonging condition, n (%) 52 (56)
curves. A p value < 0.05 was considered statistically signif- Cardiovascular 19 (21)
icant. Postoperative 0 (0)
Diabetes mellitus 11 (12)
Intoxication 7 (8)
RESULTS Neurologic (post-stroke/seizure) 6 (7)
Renal 4 (4)
Demographics QT-prolonging drugs, n (%) 71 (77)

IQR = interquartile range; LQTS = long QT syndrome; CI =

Of 52,579 individual patients who received ECGs, 7522 confidence interval; ED = emergency department; SD = standard
patients (14%) had their ECG performed during an eval- deviation.
High-Risk QT Prolongation in ED
Figure 1. Frequency of QT risk factors in emergency depart-
ment (ED) population. Pie chart showing the frequency of risk
factors in the ED population for each of the risk factors alone
(electrolytes, comorbidities, medications) or multiple
QT-prolonging factors.
shown) (64% vs. 43%; p = 0.0003), while they were less
likely to have QT prolongation due to comorbidities
(13% vs. 24%; p = 0.02) or QT-prolonging medications
(16% vs. 28%; p = 0.02) alone.
Details of QT-prolonging risk factors are shown in
Table 1. Overall, electrolyte disturbances were seen in
48 (51%) of ED patients, a QT-prolonging condition in
52 (56%) of patients and QT-prolonging drugs in 77%
of patients. Patients who presented to the ED with intox-
ication represented a significant percentage of the
patients with QT prolongation in the ED (8%) and
many patients with QT prolongation in the ED were noted
to be on QT-prolonging drugs (77%).
Fifty-one percent of patients in the ED had at least one
electrolyte disturbance, with some having up to two
(18 patients [20%]) or all three (6 patients [6%]) electro-
lyte abnormalities (hypokalemia, hypomagnesemia, and
hypocalcemia).
The presence of QT-prolonging medications was a
significant contributor to the pro-QTc score in patients in
the ED. Seventy-seven percent of patients in the ED were
taking one or more QT-prolonging medications and the
percentage of patients with polypharmacy was higher in
the ED setting (20% vs. 12%). Of this cohort, 13 patients
received medication in the ED before the ECG, with the
most common medication being ondansetron (6 patients),
followed by a first-generation antihistamine (4 patients),
and a fluoroquinolone antibiotic (3 patients). The remaining
patients were on daily outpatient medications with the
potential to cause QT prolongation. The most common
outpatient medications were antidepressants/antipsychotics
(47 patients [50%]) with the majority being on a selective-
serotonin reuptake inhibitor (29 patients). Other medica-
tions included antibiotics (fluoroquinolones, macrolides)
and cardiac medications (i.e. amiodarone).
11
Pro-QTc Score
The pro-QTc score provides a summary score of all QT
aggravating risk factors for each patient. The mean score
for ED patients was 3.0 6 1.6. The pre-ED QTc score
was slightly lower than the post-ED score, 2.8 6 1.6
vs. 3.0 6 1.6 (p = 0.01).
Mortality
All-cause mortality for ED patients (mean follow-up
224 days, range 1–530 days) with an alerted ECG was
39% (95% confidence interval 29–49%), which was
significantly higher than patients without an alert seen
in the ED during the same time period (36 of 93
[39%] vs. 2005 of 7429 [27%]; p < 0.001; Figure 2B).
More importantly, short-term mortality—defined as
10-day and 30-day mortality—was significantly higher
for alerted patients in the ED (9% 10-day mortality
and 13% 30-day mortality) compared to non-alerted
ED patients (2.1% and 3.7%; p = 0.008 and
p < 0.001; Figure 2A). Of those in the alerted ED cohort
that died within 30 days, 4 died from cardiac causes,
including 2 from congestive heart failure, 1 after aortic
valve replacement, and 1 from an ST-elevation myocar-
dial infarction. For the remaining cases, a cause of death
could not be determined. Mortality was 37% for patients
with a pro-QT score $ 4 and 21% for those with a score
< 4, but this did not reach statistical significance
(p = 0.09).
No patients in the ED group presented to the ED
carrying the diagnosis of long QT syndrome (LQTS).
However, 1 patient in the ED was in fact diagnosed
with LQTS after her QT alert. This 13-year-old female
presented to the ED with a chief complaint of chest
pain. Her initial ECG was significant for a QTc of
600 ms (Figure 3A). With regard to potential risk factors
for prolonged QT, the patient was on a medication found
on the Credible Meds QT drug list (citalopram) and also
had hypokalemia documented on her ED evaluation
(pro-QTc score 2). The patient was admitted to the gen-
eral pediatrics hospital service due to chest pain and QT
prolongation. Initially, the patient was thought to have
acquired QT prolongation secondary to the two identified
risk factors, but QT prolongation persisted despite
discontinuation of citalopram and electrolyte normaliza-
tion (Figure 3B). Cardiology was consulted after
admission and genetic testing was initiated because of
extreme QT prolongation and an elicited history of
possible LQT-triggered syncopal events. She was
diagnosed subsequently with genotype-positive LQT1
(KCNQ1-G179S), treated with b-blockers, and is
followed in the LQTS clinic with no documented
LQT-triggered events since diagnosis.
12
Figure 2. Survival in the emergency department (ED) population. Thirty-day (A) and overall (B) survival curves in the ED population
with QT prolongation.
DISCUSSION
QT prolongation has been described previously as a risk
factor for all-cause mortality and more specifically, cardio-
vascular mortality (6,13–15). However, the phenotype,
risk factors, and mortality associated with this finding in
the population of patients seen in the ED are unclear. A
previous study from 2009 found 5% of patients did not
survive to discharge among > 500 patients with QTc
prolongation seen in a tertiary hospital ED (16). The
most common predisposing conditions for QT prolonga-
tion in this study were structural heart disease, renal fail-
ure, and stroke; however, the difference between those
patients with multiple risk factors vs. isolated risk factors
for QTc prolongation was not described. In contrast, our
study describes the phenotype and outcomes for patients
seen in the ED setting with QT prolongation.
Significance of QT Prolongation in the ED
Our data demonstrate that QT prolongation represents a
significant burden within the ED, with 1% of all
Figure 3. Initial and follow-up electrocardiograms (ECGs) for
patient diagnosed with long QT syndrome (LQTS). Initial (A)
ECG on presentation to the emergency department and
follow-up (B) 24 h after admission in patient subsequently
diagnosed with LQTS.
H. N. Anderson et al.
ED-obtained ECGs prompting a QT alert. Moreover,
20% of all QT alerts at our institution originate in the
ED. The ED is an area in which providers are required
to move between patients and tasks quickly and to triage
patients most at risk. The QT alert system is crucial in this
type of environment to help providers recognize those
patients with QT prolongation. It is important to identify
this cohort because they are at higher risk of morbidity
and mortality, and also to allow for the opportunity to
modify risk factors that contribute to QT prolongation.
Two types of risk factors commonly identified in ED pa-
tients with QT prolongation are electrolyte disturbances
and QT-prolonging medications, both of which are modi-
fiable. It is important to remember that QT-prolonging
medications may be part of the outpatient regimen for
the patient or medications commonly provided in the
ED setting (i.e., ondansetron or diphenhydramine).
Pro-QTc Score
Haugaa et al. demonstrated that the pro-QTc score was an
age- and sex-independent predictor of mortality (6). The
correlation between pro-QT score and mortality was
noted to be dose-dependent in that as the pro-QT
increased, so did mortality. Specifically, a score $ 4 pre-
dicted mortality with a hazard ratio of 1.72. Among pa-
tients seen in the ED, we observed an average pro-QT
score of 2.8 and 35% of patients had a score $ 4
(maximum 6) upon arrival to the ED. Overall, medica-
tions were shown to be the main contributor to pro-QTc
score in all settings and, consistent with this finding, med-
ications were noted to contribute significantly to the pro-
QTc score in the ED setting (6). In fact, 77% of patients
were exposed to at least one QT-prolonging medication
and up to as many as seven different medications. Of
concern, among those with an alerted ECG, there was
an increase in the post-ED pro-QTc score, which was ac-
counted for entirely by the administration of medications
with known QT-prolonging potential. No QT-triggered
dysrhythmias occurred in the acute setting in our study;
High-Risk QT Prolongation in ED
however, the administration of such medications to
patients with pre-existing QT prolongation certainly ex-
poses these patients to an increased risk for events.
Although the degree of QT prolongation is less for non-
cardiac medications, the risk of sudden cardiac death has
been shown to be higher than for cardiac medications
(17,18). Atypical antipsychotics and antibiotics, many
of which are known for their QT-prolonging potential,
were seen regularly on medication profiles for ED patients
(19,20). Importantly, intoxication with medications
known to prolong the QT interval was seen at a
significantly higher rate in the ED patients compared to
other departments, which is important to consider when
evaluating these patients in the acute setting. In all, this
study demonstrates that QT-prolonging drugs are the
most frequent cause of a QT alert in the ED setting, with
some patients actually receiving additional drugs with
QT-prolonging potential during their ED evaluation.
While treatment of the acute clinical situation may over-
ride the potential risk of drug-induced torsades de pointes,
the QT alert would aid emergency physicians by creating
awareness of the issue and prompt careful evaluation of
potential alternative treatments to mitigate this risk.
Mortality
As noted previously, studies have shown a concerning
association between QT prolongation and all-cause mor-
tality (21,22). Although hypothesized that the ED may be
a setting in which patients may exhibit transient, stress-
related QT prolongation that is not associated with signif-
icant mortality risk, this assumption was not supported by
the results of this study. The high mortality in patients
with QT prolongation in the ED setting is likely multifac-
torial. In the majority of patients, underlying causes/con-
tributors for QT prolongation were identified. In most
cases, the cause of death was unknown or not determined;
however, in known cases, four were related to cardiac
disease, four were secondary to liver failure, four were
secondary to oncologic disease, two were secondary to
sepsis, and one due to renal disease.
Further, while all-cause mortality between alerted pa-
tients in the ED was not significantly different from alerted
patients elsewhere in our institution, there was a significant
increase in mortality (both overall and short-term) between
alerted patients in the ED and those seen in the same time
period in the ED, whose ECG did not trigger an alert.
While none of the patients had direct evidence of a torsa-
dogenic or ventricular fibrillation–triggered death, herein
the QT alert could be a barometer of morbidity and poten-
tial mortality (6). Elevated pro-QTc score in the ED
patients ($ 4) was associated with an elevated mortality
of 37% overall; however, this was not significantly
different than the patients with scores < 4 (21%).
13
Long QT Syndrome in the ED
Although this is a specialty center for patients with
congenital LQTS, no patient with previously diagnosed
LQTS was seen in the ED during the study period. Howev-
er, 1 patient was diagnosed with LQTS after a QT alert in
the ED. During her evaluation, a pediatric cardiology
consultation was obtained and the patient was admitted
from the ED, as QT prolongation persisted after correction
of QT-aggravating factors. A diagnosis of LQTS was
suspected and subsequently genetically confirmed as
long QT type 1 (LQT1). This chain reaction, started by
the QT alert, enabled the initiation of a LQT1-directed
treatment program. Therefore, it is important for the physi-
cian caring for a patient in the ED with QT prolongation to
look for modifiable risk factors that may be influencing the
QT interval and correct these if possible. Furthermore, if
no such risk factors are present, or the QTc does not
improve with modification, an evaluation for LQTS may
be indicated. It also confirms the importance of follow-
up for patients once they move out of the ED to confirm
normalization of the QT interval.
Limitations
This article describes the largest review of patient with QT
prolongation evaluated in an ED setting. One limitation to
this study is the difficulty in identifying an appropriate
control population with QT prolongation to compare
clinical evaluation and outcomes for patients seen in the
ED. In addition, it must be recognized that this study
was conducted at a single institution with expertise in
LQTS and additional evaluation is needed to determine
application to others centers. However, the mortality in pa-
tients with diagnosed and treated LQTS is extremely low
(23). Further, only one of the patients comprising this
study cohort had LQTS, which, in this case, was diagnosed
after ED evaluation, so it is unlikely that our institution’s
center of excellence status for LQTS confounded this
study in any tangible way. Also, evaluation of mortality
is based on vital status from the EMR and might pose a
slight underestimate from the National Death Index. Addi-
tionally, outcomes and LQT-triggered events/dysrhyth-
mias are limited, even with a large population, due to the
relative rarity of these events and difficulty identifying
which patients have experienced dysrhythmias if they
occur outside the clinical setting.
CONCLUSIONS
Approximately 20% of all QT prolongation on ECGs
obtained at our institution occurred in the ED setting,
illustrating the burden of this abnormality in the ED and
the utility of a system to alert providers to this at-risk
14
population in the busy ED setting. In the majority of cases,
QT prolongation was associated with more than one known
and potentially modifiable QT-prolonging risk factor. One
ED patient was diagnosed with LQTS after her ED-
associated QT alert, highlighting the need for follow-up
once risk factors are treated to ensure that the QT normal-
izes and, if not, to pursue additional evaluation. With regard
to the mortality risk associated with QT prolongation in the
ED, whether the QTc simply provided a non-invasive
indicator of a vulnerable host or heralded the presence of
a vulnerable host at risk of a direct QT-mediated sudden
dysrhythmic death requires further investigation.
Acknowledgments—Heather N. Anderson designed the study,
collected and analyzed data, drafted the initial manuscript,
and approved the final manuscript as submitted. J. Martijn
Bos conceptualized and designed study, revised and reviewed
the manuscript, and approved the final manuscript as submitted.
Kristina. H. Haugaa, Bruce W. Morlan, Robert F. Tarrell, Pedro
J. Caraballo: Drs. Haugaa and Caraballo, Mr. Morlan, and Mr.
Tarrell developed data collection instruments, carried out data
analyses, revised and reviewed the manuscript, and approved
final manuscript as submitted. Michael J. Ackerman conceptu-
alized and designed study, critically revised and reviewed
manuscript, and approved final manuscript as submitted.
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High-Risk QT Prolongation in ED 15

ARTICLE SUMMARY
1. Why is this topic important?
QT prolongation on electrocardiogram (ECG) is an in-
dependent risk factor for sudden death, stroke, and all-
cause mortality. Information regarding the etiology and
outcomes of this often-incidental finding in the unique
population of patients seen the emergency department
(ED) is limited.
2. What does this study attempt to show?
In this study, we sought to evaluate the clinical charac-
teristics and outcomes for ED patients with QT prolonga-
tion identified by Mayo Clinic’s QT alert and provide
action items for the often modifiable causes of the ECG
feature.
3. What are the key findings?
We found that most conditions associated with QT pro-
longation in this unique patient population are identifiable
and, in fact, modifiable. Overall, all-cause mortality for
patients with a QT alert in the ED was 27%. Further, the
QT alert system identified 1 new patient with congenital
long QT syndrome during the time period studied.
4. How is patient care impacted?
Based on these data, ED patients with QT prolongation
require close evaluation for modifiable risk factors that
may prolong the QT interval. In addition, careful consid-
eration must be taken when administering medications in
the ED, as a number of drugs commonly used in the ED
setting carry a risk of QT prolongation. Whether the
QTc simply provides a non-invasive indicator of increased
risk or heralds the presence of a vulnerable host at risk of a
QT-mediated sudden dysrhythmic death requires further
investigation.