Document Type : Original Article
Authors
- . Farzad Gheshlaghi 1
- . Mozhgan Karbalayi Mehrizi 2
- . Ahmad Yaraghi 1
- . Ali Mohammad Sabzghabaee 3
- . Forough Soltaninejad 4
- . Nastaran Eizadi-Mood 1
1 Department of Clinical Toxicology, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Toxicology, Noor General University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
3 Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Pulmonary, Shahrekord University of Medical Sciences, Shahrekord, Iran
Abstract
Objective: Tricyclic antidepressant (TCA) poisoning is among highly prevalent and potentially
dangerous toxicities. ST‑T changes are observed in the electrocardiogram (ECG) of most
of TCA poisoned patients. We aimed to study ST‑T segment changes in TCA toxicity and
its probable relationship with other ECG findings.
Methods: This retrospective study was carried out in Noor and Ali Asghar University
Hospital, Isfahan (Iran) in 2012. Patients with TCA toxicity based on the patients’ history
who had not consumed any cardio-active drugs and did not have a past medical history of
cardiovascular disease in the recent 5 years, were randomly selected and investigated. Their
demographic and medical data on admission including ECG, age, sex, type and amount of
ingested TCA, poisoning severity score, QRS changes, QT interval, heart axis position and
R‑wave were all recorded. ST‑T changes and their relation with other ECG parameters have
been determined using statistical analysis.
Findings: Medical records of 272 patients were analyzed. In symptomatic patients, ST change
prevalence was 40.8% and T change prevalence was 9.5%. In asymptomatic patients, the
frequency of ST and T changes were 4.8% and 0.8%, respectively (P < 0.05). The most common
ST and T changes in baseline (on admission) ECG were non‑significant elevation (15.4%),
significant elevation (11%) in pre‑cordial leads, and T‑wave flattening (6.6%). A statistically
significant correlation was documented between ST segment changes with QRS and R‑wave
in aVR. The correlation between T‑wave changes and R‑wave in aVR lead was also significant.
Conclusion: ST‑T changes in TCA poisoned patients are more prevalent in symptomatic
patients. Obviously for a more definite conclusion, it is necessary to design a prospective study
with the control group. This may facilitate a better understanding of ST‑T segment changes.
Keywords
1. Wing YK. Recent advances in the management of depression
and psychopharmacology. Hong Kong Med J 2000;6:85‑92.
2. Bebarta VS, Maddry J, Borys DJ, Morgan DL. Incidence
of tricyclic antidepressant‑like complications after
cyclobenzaprine overdose. Am J Emerg Med 2011;29:645‑9.
3. Choy CH, KitchellAK, KamCW. Lethal tricyclic antidepressant
overdose. Hong Kong J Emerg Med 2001;8:101‑5.
4. Dart RC, Caravati EM, McGuigan MA. Medical Toxicology,
3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2004.
p. 1914.
5. Kobayashi K, Miyajima M, Tanaka T, Kumagai K, Hirose Y,
Hori Y, et al. Tricyclic antidepressant overdose rescued by
percutanenous cardiopulmonary support: Report of two cases.
Chudoku Kenkyu 2011;24:46‑50.
6. Burns E. Tricyclic overdose (sodium‑channel blocker toxicity).
Available from: http://www.lifeinthefastlane.com/ecg‑library/
basics/tca‑overdose/. [Last accessed on 2013 Sep 07].
7. Fasoli RA, Glauser FL. Cardiac arrhythmias and ECG
abnormalities in tricyclic antidepressant overdose. Clin Toxicol
1981;18:155‑63.
8. Kiran HS, RavikumarYS, Jayasheelan MR, Prashanth. Brugada
like pattern in ECG with drug overdose. J Assoc Physicians
India 2010;58:120‑2.
9. Rechlin T. Decreased R‑R variation: Acriterium for overdosage
of tricyclic psychotropic drugs. Intensive Care Med
1995;21:598‑601.
10. Liebelt EL, Francis PD, Woolf AD. ECG lead aVR versus
QRS interval in predicting seizures and arrhythmias in
acute tricyclic antidepressant toxicity. Ann Emerg Med
1995;26:195‑201.
11. Taherinia A, Heidarpour A. ST elevation in tricyclic
antidepressants toxicity: A case report. Iran Heart J
2012;13:43‑5.
12. Yanowitz FG. ST segment abnormalities. Available from: http//
www.library.med.utah.edu/kw/ecg/ecg_ outline/Lesson10/
index.html. [Last accessed on 2013 Sep 07].
13. Daviglus ML, Liao Y, Greenland P, Dyer AR, Liu K, Xie X,
et al. Association of nonspecific minor ST‑T abnormalities with
cardiovascular mortality: The Chicago Western Electric Study.
JAMA 1999;281:530‑6.
14. Masoumi G, Eizadi‑Mood N, Akbari M, Sohrabi A,
Khalili Y. Pattern of poisoning in Isfahan. J Isfahan Med Sch
2012;29:2003‑10.
15. Persson HE, Sjöberg GK, Haines JA, Pronczuk de Garbino J.
Poisoning severity score. Grading of acute poisoning. J Toxicol
Clin Toxicol 1998;36:205‑13.
16. Shah VN, Karavadara NR, Shah DS, Shah BK.
Gatifloxacin‑induced prolongation of QTc interval. Research
letter. Indian J Pharmacol 2006;38:60‑1.
17. Micro EKG‑Mad scientist software. Available from:http://www.
madsci.com/manu/ekg_part.htm#The_ST_Segment. [Last
accessed on 2013 Sep 07].
18. Dianat S, Zarei MR, Hassanian‑Moghaddam H,
Rashidi‑Ranjbar N, Rahimian R, Rasouli MR. Tricyclic
antidepressants intoxication in Tehran, Iran: Epidemiology
and associated factors. Hum Exp Toxicol 2011;30:283‑8.
19. Prutkin JM. ECG tutorial: ST and T wave changes.
In: Goldberger AL, editors. UpToDate. Waltham, MA:
UpToDate; 2013.
20. Chan CY, Waring WS. Images in cardiovascular medicine.
Tricyclic cardiotoxicity treated with sodium bicarbonate.
Circulation 2007;115:e63‑4.
21. Sigurdsson E, Sigfusson N, Sigvaldason H, Thorgeirsson G.
Silent ST‑T changes in an epidemiologic cohort study – A
marker of hypertension or coronary heart disease, or both: The
Reykjavik study. J Am Coll Cardiol 1996;27:1140‑7.
)