Valerian Root Safety in Prolonged QTc
Valerian root appears safe to use in patients with prolonged QTc interval, as it is not associated with QT prolongation and has a favorable safety profile, though evidence for efficacy in anxiety is limited. 1, 2
Safety Profile in QTc Prolongation
Valerian root does not appear on any guideline lists of QT-prolonging medications and is not mentioned in the ACC/AHA/HRS guidelines for management of patients with ventricular arrhythmias or supraventricular tachycardia as a substance requiring caution in QTc prolongation 3
The herb is well-tolerated with infrequent and benign side effects, achieving a Strength of Recommendation (SOR) grade A for safety 1
Unlike antipsychotics and antiarrhythmics that require careful monitoring in prolonged QTc, valerian does not carry warnings about cardiac conduction effects 3, 4
Evidence for Anxiety and Sleep Disorders
For anxiety disorders, evidence is insufficient to recommend valerian (SOR A), with only one small 4-week RCT (n=36) showing no significant differences between valerian and placebo on HAM-A anxiety scores 1, 5
For insomnia, there is limited evidence suggesting some effectiveness in mild-to-moderate cases (SOR B), though studies show contradictory results and methodological limitations 1
The Cochrane review concluded there is insufficient evidence to draw conclusions about valerian's efficacy compared to placebo or diazepam for anxiety disorders 5
Documented Adverse Effects (Not Cardiac)
While valerian is generally safe, clinicians should be aware of non-cardiac adverse effects:
Hepatotoxicity and nephrotoxicity have been reported with valerian root, along with headaches, chest tightness, mydriasis, abdominal pain, and tremor of hands and feet 2
These effects appear related to chronic or long-term use rather than short-term therapeutic administration 2
Clinical Approach for This Patient Population
The primary concern in prolonged QTc is avoiding medications that further prolong the interval, particularly those exceeding 500 ms or increasing QTc by >60 ms from baseline 3, 4:
Medications requiring strict avoidance include Class III antiarrhythmics (amiodarone, ibutilide), certain antipsychotics (thioridazine, ziprasidone, haloperidol), and macrolide antibiotics 3, 4
Valerian does not fall into these high-risk categories and can be considered if the patient prefers herbal approaches, though efficacy for anxiety remains unproven 1, 5
Safer Evidence-Based Alternatives
If pharmacologic treatment is needed for anxiety in a patient with prolonged QTc:
Benzodiazepines (lorazepam) are safe as they do not prolong QTc and are notably absent from all QT-prolonging medication lists 6
SSRIs and SNRIs can be used with standard monitoring, as they are not prominently featured in QTc prolongation warnings for anxiety treatment 4
Common Pitfalls
Do not assume all herbal products are cardiac-safe: While valerian appears safe for QTc, other supplements may have undocumented cardiac effects 2
Avoid polypharmacy with multiple QT-prolonging agents: The risk exponentially increases when combining medications that individually prolong QTc 4
Monitor electrolytes: Hypokalemia and hypomagnesemia amplify QTc prolongation risk with any medication and should be corrected before initiating treatment 3, 4
Document herbal use: Clinicians should ask patients about herbal medications in a non-judgmental manner, as patients often do not volunteer this information 2