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ECG abnormalities as predictors in Tricyclic antidepressant overdose

Three Part Question

In [Tricyclic antidepressant overdose] which [ECG abnormalities] are predictive of [seizures and arrythmias]

Clinical Scenario

You are called to the emergency department following the arrival of a 23 year old male electrician who is suspected of ingesting 25 imipramine tablets. You are shown an ECG that was taken shortly after his arrival. You wonder which ECG abnormalities are predictive of complications.

Search Strategy

MEDLINE 1966-April 2007 PubMed Interface
(Antidepressant or tricyclic or amitriptyline or dothiepin or nortriptyline or imipramine or desipramine or protriptyline or clomipramine or doxepin) and (overdose or poisoning or self poisoning or toxic) and (ecg or ekg or electrocardiogram)

Search Outcome

237 studies were found, 1 recent Meta-Analysis and 1 review paper

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Bailey B et al
Papers identified from Medline and Cochrane register for studies that investigated criteria for prediciting outcomes in TCA overdose. Papers assessed by 2 investigators. Studies included if possible to construct 2x2 table from TCA concentration or ECG abnormalities against clinical outcomes. The following diagnostic tests were evaluated (1)TCA concentration (2)QRS>0.10 seconds (3)QTc>430 ms (4)R/S ratio >0.7 (5)Right axis deviation of 120-270 degrees in the terminal 40ms frontal plane QRS vectorMeta analysisNumber of Studies941 studies found, 18 studies were included in the reviewSome studies excluded due to mixed outcomes
Pooled Sensitivity & Specificity to predict DeathQRS=0.81 & 0.62; QTc= 0.50 & 0.68; T40= 0.33 & 0.71 respectively
Pooled Sensitivity & Specificity to predict SeizuresQRS=0.69 & 0.69; T40= 0.50 & 0.72 respectively
Pooled Sensitivity & Specificity to predict Ventricular ArryhthmiasQRS=0.79 & 0.46; QTc= 0.78 & 0.56;T40= 0.33 & 0.71; R/S ratio= 0.47 & 0.97 respectively
Positive & Negative Likelihood ratios for DeathQRS= 2.13 & 0.31; QTc= 1.56 & 0.74; T40= 1.14 & 0.94 respectively
Positive & Negative Likelihood ratios for SeizuresQRS= 3.18 & 0.38; T40= 1.79 & 0.69 respectively
Positive & Negative Likelihood ratios for Ventricular ArryhthmiasQRS=1.46 and 0.46; QTc= 1.77 & 0.39; T40= 1.14 & 0.94; QTc= 1.77 & 0.39; R/S ratio= 15.7 & 0.55 respectively
Thanacoody HK. Thomas SH.
review of known papers and studies regarding ECG changes in tricyclic overdose. including recent meta analysis and case reports.Reviewauthors conclusionQRS prolongation >100ms and Right axis deviation are the most reproducible predictorsSearch strategy not included


There are many studies and case reports of the ECG patterns seen in TCA overdose. These changes include prolonged QRS, QTc interval, right axis deviation, R/S ratio in lead aVR, Brugada pattern.The presence of any ECG changes suggests significant TCA overdose which may lead to cardiovascular or neurological sequalae. The studies assessing these changes as predictors of seizures and arrythmias are presented in the comprehensive review by Thanacoody et al. Although no search strategy is included I can find no additional useful papers.

Clinical Bottom Line

The most reliable ECG predictors of seizure and arrhythmia are QRS prolongation >100ms and Right axis deviation.


  1. Bailey B. Buckley NA. Amre DK A meta-analysis of prognostic indicators to predict seizures, arrhythmias or death after tricyclic antidepressant overdose Journal of Toxicology - Clinical Toxicology 2004; 42(6):877-88
  2. Thanacoody HK. Thomas SH. Tricyclic antidepressant poisoning : cardiovascular toxicity. Toxicol Rev. 2005;24(3):205-14.