Hydroxychloroquine (HCQ) and chloroquine (CQ) are well-established medications used in treating rheumatic and dermatologic diseases. Recently these medications, and their potential for cardiac toxicity, have gained attention due to their experimental use in early 2020 for treating COVID-19 infections. A new white paper published Oct. 26 in Arthritis & Rheumatology summarizes the current understanding of HCQ/CQ cardiac toxicity, describes the risks for corrected QT interval (QTc)–prolongation and torsade de pointes (TdP), and addresses areas of priority for future research.

Based on a nonsystematic literature review conducted by a working group of experts spanning rheumatology, dermatology and cardiology, the white paper found clear, invaluable benefits of HCQ and CQ in the management of systemic lupus erythematosus and rheumatoid arthritis. However, the medications were associated with risks of prolonged QTc and TdP in some patients – albeit the risks were low in comparison to the benefits of the medications.

According to the report, clinicians should be made aware of the potential risks, especially for patients taking HCQ/CQ over longer periods of time, and should consider risk and benefit assessment prior to initiation of any medication. The authors also note that while “current data do not support institution of specific recommendations regarding how to avoid these adverse effects” some options to consider include a baseline ECG in patients with multiple risk factors as well as follow-up ECG and screening for cardiac symptoms in patients with prolonged QTc or those receiving HCQ/CQ in combination with other QTc-prolonging therapies.

Looking ahead, the white paper urges “additional research to allow better understanding of the cardiovascular risk and safety profile of these therapies used in the management of rheumatic and cutaneous disease.” For example, retrospective studies to evaluate QTc intervals in patients with rheumatic disease before and after treatment with HCQ or CQ, along with long-term studies addressing regular cardiac monitoring including ECG, could provide important insights into risks and benefits.  

“The short-lived effort to use HCQ for COVID-19 infections had the unintended and beneficial consequence of refocusing rheumatologists and cardiologists on addressing the potential of cardiovascular toxicity in patients taking antimalarials for inflammatory diseases,” said Richard A. Kovacs, MD, MACC, past president of the ACC. “The American College of Rheumatology should be congratulated for providing this new information to their members on practical ways to assess the cardiovascular risks of these widely used and highly beneficial drugs.”

Clinical Topics: Arrhythmias and Clinical EP, Cardio-Oncology, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Novel Agents, Statins

Keywords: Pharmaceutical Preparations, Heart Disease Risk Factors, Risk Assessment, Electrocardiography, Long QT Syndrome, Cardiology, Lupus Erythematosus, Systemic, Arthritis, Rheumatoid, Rheumatic Diseases, Risk Factors, Dermatology, COVID-19, Cardiovascular Diseases, Cardiotoxicity, Cardiologists, Torsades de Pointes, Rheumatologists, Rheumatology, Chloroquine, Retrospective Studies, Antimalarials, Hydroxychloroquine

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