Managing cardiovascular disease risk in patients treated with antipsychotics: a multidisciplinary approach

Figures & data

Table 1 Risk factors for prolonged QTc

Hypokalemia^Citation27

Hepatitis C^Citation27

HIV^Citation27

T-wave abnormalities on ECG^Citation27

Female sex^Citation28

Age 70 and older^Citation29,Citation30

Agitation^Citation31

Use of multiple QTc-prolonging medications^Citation32

Abbreviations: QTc, corrected QT segment; ECG, electrocardiogram; HIV, human immunodeficiency virus.

Table 2 Summary of clinical guidelines for antipsychotic medications and ECG changes

High risk medications	Initial monitoring guidelines	Treatment guidelines
Ziprazidone Avoid if: • Prolonged QT syndrome • Arrhythmia • Recent MI • Uncompensated heart failure • On QT-prolonging drugs (see www.torsades.org)	Check electrolytes and ECG • Prior to treatment with agents noted on left in the presence of other risk factors • Prior to ziprasidone in setting of diuretics or chronic diarrhea (APA)	Recheck ECG • After significant dose change of agents on left • Development of risk factors on left • Addition of other QTc-prolonging drugs (see www.torsades.org)
Thioridazine, mesoridazine, pimozide Avoid If: • Known heart disease • History of syncope • Family history of sudden death at < 40 years old • Prolonged QTc (APA)	Check ECG • If the antipsychotic agent’s product characteristics suggest it • If specific cardiovascular risks are identified (eg, high blood pressure or risk factors on left) • History of cardiovascular disease • The patient is admitted to the hospital (NICE)	Assess: • If QTc >500 msec• If QTc increase of 60 msec from baseline Action: • Reduce or discontinue the agent • If agitation or psychosis still present, treatwith alternative methods (benzodiazepines,mood stabilizers, ECT) Recheck electrolytes regularly • For patients on diuretics or with other risksfor electrolyte disturbances Refer for cardiovascular evaluation • For symptoms of possible arrhythmia,including dizziness, syncopal episodes, andpalpitations (APA)

Abbreviations: ECG, electrocardiogram; MI, myocardial infarction; QTc, corrected QT segment; APA, American Psychiatric Association; NICE, National Institute for Health and Care Excellence; ECT, electroconvulsive therapy; msec; milliseconds.

Figure 1 Metabolic and weight gain treatment and monitoring algorithm.

Abbreviations: BMI, body mass index; HbA1c, glycosylated hemoglobin.

Table 3 Weight gain by agent

Short term trials	% subjects gaining ≥7% body weight
Aripiprazole (bipolar mania monotherapy)^Citation58	2.2
Lurasidone (bipolar depression monotherapy)^Citation60	2.4
Ziprazidone(bipolar disorder 20–40 mg BID)^Citation59	2.4
Ziprazidone(bipolar disorder 60–80 mg BID)^Citation59	4.4
Lurasidone (schizophrenia)^Citation60	4.8
Aripiprazole (major depressive disorder adjuvant)^Citation58	5.2
Paliperidone (6 mg/day)^Citation61	6
Paliperidone (3 mg/day)^Citation61	7
Quetiapine (bipolar depresion)^Citation62	8
Aripiprazole (schizophrenia)^Citation58	8.1
Risperidone (up to 8 mg/day)^Citation63	8.7
Paliperidone (9 or 12 mg/day)^Citation61	9
Ziprazidone (schizophrenia)^Citation59	10
Iloperidone (10–16 mg/day)^Citation65	12
Asenapine^Citation64	14.7
Iloperidone (20–24 mg/day)^Citation65	18
Quetiapine (bipolar mania monotherapy)^Citation62	21
Olanzapine^Citation66	22
Quetiapine (schizophrenia)^Citation62	23

Abbreviation: BID, twice daily.

Table 4 Weight gain by agent

Long term trials	% subjects gaining ≥7% body weight
Ziprazidone (schizophrenia 20–40 mg BID)^Citation59	5.6
Ziprazidone (schizophrenia 60–80 mg BID)^Citation59	20
Clozapine^Citation67	35
Olanzapine monotherapy in adults^Citation66	64
Olanzapine monotherapy in adolesence^Citation66	89

Abbreviation: BID, twice daily.

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