TORSADES DE POINTES SECONDARY TO HYPOKALEMIA AND HYPOMAGNESEMIA: A NEPHRO-CARDIOLOGICAL APPROACH TO DIAGNOSIS AND MANAGEMENT IN THE EMERGENCY DEPARTMENT
Keywords:
torsades de pointes; hypokalemia; hypomagnesemia; long QT; emergency medicine; nephrology; ventricular arrhythmia; Gitelman syndromeAbstract
DOI: https://doi.org/10.46296/yc.v10i19.0966
Abstract
Background: Torsades de pointes (TdP) is a polymorphic ventricular tachycardia associated with QT prolongation and may deteriorate into ventricular fibrillation. Hypokalemia and hypomagnesemia reduce repolarization reserve and frequently coexist with QT-prolonging drugs, gastrointestinal losses, or renal electrolyte-wasting mechanisms. Objective: To synthesize clinical presentation, nephrologic and pharmacologic triggers, electrocardiographic diagnosis, and emergency management strategies reported in case reports and series of TdP associated with hypokalemia and/or hypomagnesemia. Methods: Narrative systematic review conducted according to PRISMA 2020 principles. PubMed/MEDLINE was searched from inception through August 31, 2026, complemented by reference tracking. The primary strategy combined terms for TdP, hypokalemia, hypomagnesemia, and case reports. Cases were eligible when TdP was documented and clinically relevant K+ and/or Mg2+ abnormalities were reported. Reporting quality was appraised using JBI case-report/case-series domains. Results: The focused search retrieved 43 records. Fifteen single-patient reports were retained for structured synthesis. Reference tracking additionally identified a cohort of 48 patients with TdP, used as complementary contextual evidence. Recurrent mechanisms included gastrointestinal losses, diuretics, QT-prolonging drugs, Gitelman syndrome, colistin-induced Bartter-like tubulopathy, hemodialysis, and alcohol-related depletion. Successful treatment consistently combined trigger withdrawal, intravenous magnesium sulfate, intensive potassium correction, defibrillation for unstable episodes, and heart-rate acceleration with pacing or isoproterenol in pause-dependent TdP. Conclusions: Electrolyte-mediated TdP should be managed as a nephrocardiology emergency. Electrical stabilization must be coupled with targeted assessment of renal and extrarenal losses, medication review, and recurrence prevention.
Keywords: torsades de pointes; hypokalemia; hypomagnesemia; long QT; emergency medicine; nephrology; ventricular arrhythmia; Gitelman syndrome.
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