Should a Law Enforcement Officer (LEO) with borderline prolonged QTc interval, moderate repolarisation disturbances, and normal sinus rhythm be cleared for full duties despite being asymptomatic?

From the Guidelines

This asymptomatic law enforcement officer (LEO) should not be immediately cleared for full duties without further cardiac evaluation, given the borderline prolonged QTc interval and moderate repolarization disturbances. The ECG findings of repolarization abnormalities in multiple leads could represent several conditions, including possible myocardial ischemia, left ventricular strain, medication effects, or a benign early repolarization variant. While there are no acute ischemic changes, the moderate repolarization disturbances warrant additional investigation before clearing the officer for full duty. I recommend a cardiology consultation with additional testing such as an exercise stress test, echocardiogram, and possibly a 24-hour Holter monitor to rule out significant cardiac pathology, as suggested by 1. The borderline prolonged QTc interval should also be evaluated, as QTc prolongation can increase risk for arrhythmias, particularly during physically demanding or stressful situations that LEOs commonly encounter, as noted in 1 and 1. Only after these evaluations confirm no significant cardiac pathology should the officer return to full duties. This cautious approach is justified because certain cardiac conditions may remain asymptomatic until triggered by extreme physical exertion or stress, potentially leading to sudden cardiac events during duty, highlighting the importance of careful evaluation and consideration of guidelines such as those provided in 1 and 1. Key considerations include:

• The importance of a comprehensive evaluation by a heart rhythm specialist or genetic cardiologist for athletes with suspected or diagnosed cardiac channelopathies, as recommended in 1.
• The need for caution in interpreting QTc intervals, with values <500 ms in the absence of symptoms or familial disease being unlikely to represent LQTS, as discussed in 1.
• The potential risks associated with QT-prolonging drugs and the importance of avoiding them in individuals with prolonged QTc intervals, as highlighted in 1.

From the Research

Law Enforcement Officer Clearance for Full Duties

The decision to clear a Law Enforcement Officer (LEO) with borderline prolonged QTc interval, moderate repolarisation disturbances, and normal sinus rhythm for full duties despite being asymptomatic should be based on the available evidence.

• The studies 2, 3, 4, 5 suggest that prolonged QTc intervals are associated with an increased risk of ventricular arrhythmias, in-hospital mortality, and left ventricular systolic dysfunction.
• A study 2 found a strong significant positive correlation between QTc interval and ventricular arrhythmias (rho = 0.658, p < 0.001) and in-hospital mortality (rho = 0.314, p = 0.04) among STEMI patients.
• Another study 3 found that prolonged QTc intervals were significantly associated with previous myocardial infarction, minimum ST depression, and left ventricular ejection fraction.
• A study 4 found that 70% of patients with propionic acidemia had prolonged QTc intervals, and 40% had reduced left ventricular systolic function.
• However, a study 6 found that initial ECG screening for asymptomatic aircrew revealed extremely low numbers of individuals requiring further investigation, which may suggest that routine ECG screening for asymptomatic individuals may not be necessary.
• A study 5 found that QTc prolongation prior to angiography predicted poor outcome and associated significantly with lower left ventricular ejection fractions and higher left ventricular end-diastolic pressures.

Considerations for LEO Clearance

When considering clearance for full duties, the following factors should be taken into account:

• The LEO's borderline prolonged QTc interval and moderate repolarisation disturbances may increase the risk of ventricular arrhythmias and other cardiac complications.
• The LEO's normal sinus rhythm and asymptomatic status may suggest a lower risk of cardiac complications.
• The available evidence suggests that prolonged QTc intervals are associated with an increased risk of cardiac complications, but the risk may be lower for asymptomatic individuals.