QT Prolongation and Ventricular Pre-Excitation in Psychiatric Illness

CLINICAL CONDITION: A 27-year-old male patient presented with acute psychosis complicated by a prolonged corrected QT (QTc) interval in the setting of Wolff-Parkinson-White (WPW) pattern. The patient required antipsychotic medications that are high risk for prolonging the QTc interval and putting the patient at risk for torsades de pointes (TdP). KEY QUESTIONS: The key questions were as follows: 1) How does WPW affect the QTc interval? 2) Does the prolongation of the QTc interval seen in pre-excitation confer increased risk for TdP? and 3) How should patients with WPW and psychiatric illnesses be risk stratified when considering pathway ablation? OUTCOME: Early cardiology involvement allowed safe, early antipsychotic medication initiation. A multidisciplinary team approach resulted in a strategy of early catheter ablation because of the risk for pre-excited atrial fibrillation during future electroconvulsive therapy. TAKE-HOME MESSAGE: Despite broad awareness of the relationship between a prolonged QT interval and TdP, QT prolongation does not always reflect primary ventricular abnormalities that predispose to TdP, allowing the safe administration of antipsychotic agents in patients who need them.