Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention

Abstract

Available evidence does not yet allow accurate comparison of the quantitative risk of serious cardiovascular side-effects or sudden cardiac death for all antipsychotics, not least because several agents have not been examined in sufficient detail. Nevertheless, an elevated risk of serious adverse Abstract Cardiac safety of antipsychotic drugs continues to be a concern for both typical and atypical antipsychotics.Risk appears greatest in those with pre-existing cardiac disease but many patients may have occult cardiovascular disease. In addition, several drugs appear to increase the likelihood of diabetes and weight gain, which may have an additive adverse effect. On the basis of risk of sudden cardiac death and risk of QTc prolongation we suggest considering antipsychotics in two categories -higher and lower risk. Of most concern is the use of large cumulative doses of antipsychotics that are sometimes given inadvertently by different prescribers. Clinicians need to be aware how to read an ECG, and how to monitor physical parameters and interpret the significance of QTc prolongation in relation to antipsychotic prescribing. We suggest provisional guidance on antipsychotic monitoring in relation to cardiac safety but acknowledge that future studies will help clarify which antipsychotic drugs and which concomitant risk factors are most important for those with and without established cardiac disease.Nasser Abdelmawla is a specialist registrar in psychiatry. He completed his PhD in psychopharmacology and has an interest in druginduced adverse effects. Alex Mitchell is a consultant in liaison psychiatry at

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

“…8 Because of potential cardiac arrhythmia risk, a baseline ECG is recommended prior to initiating a number of these medications, with periodic ECG monitoring of patients taking the medications, though evidence showing the effectiveness of ECG monitoring is lacking. [1][2][3]18,22,23 Similarly, in patients being considered for methadone, a baseline ECG may help clinicians assess for risk of torsades de pointes, based on the presence and degree of QTc interval prolongation prior to medication initiation. Accurate estimates on the risk of torsades de pointes or sudden cardiac death are not available.…”

Junior doctors' knowledge and practice of electrocardiographic monitoring for high-risk patients receiving antipsychotic medications

“…2 Iatrogenic causes such as the use of high-dose antipsychotics should also be taken seriously. 3 The causative role of psychotropic drugs in the development of sometimes severe and even lifethreatening arrhythmias has been extensively researched. 4 It is now apparent that certain anti- Factors implicated in the prolongation of the QT c interval may be pharmacological or non-pharmacological.…”

Sudden cardiac death and antipsychotics. Part 1: Risk factors and mechanisms

“…Bazett, Friderica). See part 2 of this overview (Abdelmawla & Mitchell, 2006) for further discussion. Advances in Psychiatric Treatment (2006), vol.…”

“…The latter is not necessarily causative, as higher doses might be linked with mortality through a confounding factor such as worse physical health in those with more serious mental health problems. Compared with the overall excess of non-suicide mortality, the number of deaths that might be attributable to medication is small, but most argue that iatrogenic mortality must be taken seriously, with appropriate steps taken towards prevention (Abdelmawla & Mitchell, 2006). Ray et al (2001) conducted a retrospective cohort study of half a million Medicaid patients in the US state of Tennessee between 1988 and 1993, before the introduction of atypical antipsychotics.…”