Psychotropic drugs and the ECG: focus on the QTc interval

Abstract

The QT interval measuring depolarisation and repolarisation has, when lengthened, been implicated as a risk factor for the development of torsades de pointes and sudden death, particularly in patients predisposed to these complications due to cardiovascular impairment. Since some of the medications used in psychiatry have been implicated, an extensive review of available literature was made of the major classes, including antipsychotics, antidepressants, lithium, anticonvulsants and benzodiazepines. Further, where no publications were found on a particular medication, the pharmaceutical firms responsible for these items were contacted concerning possibly unpublished data. Results of the survey indicate that there may be difficulty in one of three situations: immediate (in the first minutes to hours after oral or parenteral administration), short-term use of 4 - 12 weeks or long-term use of 6 months. Based on this approach, the greatest concern is directed at the immediate application of haloperidol, droperidol, pimozide and trazodone, the short-term use of thioridazine, pimozide, sertindole, nortriptyline, clomipramine, doxepin and the long-term use of clozapine, olanzapine and carbamazepine. It is of interest that a reduction in QTc is reported with aripiprazole. Among the antidepressants, the tertiary tricyclic antidepressants (imipramine, amitriptyline and doxepin) appear to have a more general impact, while the secondary tricyclic antidepressants (nortriptyline, desipramine) may impact more on children and the elderly. Among other antidepressants, the only reports of torsades de pointes appeared to occur with mirtazapine. It was also of interest to find data showing no effect or reductions in QTc produced by sertraline, citalopram, paroxetine and bupropion in multiple studies. Effects of medications on other heart parameters are also briefly reviewed. In particular, the safety of sertraline in post-MI patients and of bupropion in heart disease patients is highlighted. Little information was available on other classes of medications used in psychiatric disorders. What is available concerning lithium, the anticonvulsants and the benzodiazepines indicates little effect on the QTc, although there may be effects on other cardiovascular parameters.

Opioids and Cardiac Arrhythmia: A Literature Review

“…In a case report, a patient with a history of depression was found unconscious because of overdosing on morphine, diazepam, citalopram, oxycodone and zopiclone at the same time and his initial ECG showed corrected QT interval of 650 ms. However, another study had shown that none of these drugs on their own affect QT interval [80,81]. No relevant studies were found measuring effects of hydromorphone on QT interval.…”

Aripiprazole: A Novel Atypical Antipsychotic Drug With a Uniquely Robust Pharmacology

“…To date, available literature indicates that, aripiprazole demonstrates less risk of EPS, weight gain, raised prolactin levels and prolongation of the QTc interval (1,3,11,28,(32)(33)(34)(35)39,51,59,69). Now that aripiprazole is widely available, there will likely be reports about its safety and tolerability in more "average" patients with schizophrenia.…”

ECG changes in patients on chronic psychotropic medication

“…The highpotency typical and the atypical antipsychotics are less frequently associated with torsades de pointes; however they (especially ziprasidone) have raised much debate and serious concern, which caused the Food and Drug Administration (FDA) to delay approval in some instances. Goodnick et al 19 report that the greatest concern is directed at the immediate use of haloperidol, the short-term use of thioridazine, and the long-term use of clozapine and olanzapine.…”

“…Lithium and the benzodiazepines show little effect on the QTc, although there may be effects on other cardiovascular parameters. 19 Additional risk factors for QT prolongation and torsades de pointes in the psychiatric population include deliberate or accidental antipsychotic overdose, co-morbid substance misuse and, in particular, the effects of high sympathetic arousal during restraint.…”