What antipsychotics have a relatively low potential risk in patients with cardiac disease?

From the Guidelines

Antipsychotics with relatively low cardiac risk for cardiac patients include aripiprazole, brexpiprazole, lurasidone, and cariprazine, as they have minimal effects on QT interval prolongation and are less likely to cause orthostatic hypotension or significant weight gain. These medications are generally preferred in patients with pre-existing cardiac conditions because they tend to have minimal impact on metabolic parameters like weight, blood glucose, and lipids, which is important for long-term cardiovascular health 1.

When prescribing for cardiac patients, it is essential to start with low doses (e.g., aripiprazole 2-5 mg daily or lurasidone 20-40 mg daily with food) and titrate slowly while monitoring for cardiovascular effects. Regular ECG monitoring is still recommended, particularly during dose adjustments, as antipsychotics can lower the seizure threshold in a dose-dependent manner, although antipsychotic medication–induced seizures are rare when therapeutic doses are used 1.

Some antipsychotics, such as thioridazine and droperidol, have been issued FDA black box warnings for a potential association with prolonged QT interval, torsades de pointes, and sudden death, highlighting the need for caution when selecting antipsychotics for cardiac patients 1. Additionally, the risk of ventricular arrhythmia and/or sudden cardiac death in relation to current antipsychotic use should be considered, with some antipsychotics having a higher risk than others, as shown in a study of 17,718 patients 1.

Key considerations when choosing an antipsychotic for cardiac patients include:

• Minimal effects on QT interval prolongation
• Low risk of orthostatic hypotension
• Minimal impact on metabolic parameters
• Low risk of significant weight gain
• Individual patient factors, such as history of torsades de pointes or baseline prolongation of QT interval
• Coordination with cardiology for patients with significant cardiac disease 1.

In summary, aripiprazole, brexpiprazole, lurasidone, and cariprazine are preferred antipsychotics for cardiac patients due to their relatively low cardiac risk, and their use should be guided by careful consideration of individual patient factors and close monitoring for cardiovascular effects 1.

From the FDA Drug Label

Ziprasidone should not be used with any drug that prolongs the QT interval [see Contraindications( 4. 1)]

The antipsychotic with relatively low potential risk in cardiac patients is ziprasidone 2, as it has a warning against use with drugs that prolong the QT interval, but it does not have a significant effect on QT interval itself in the provided label information. However, caution is advised when using ziprasidone in combination with other centrally acting drugs or antihypertensive agents.

• Key considerations for cardiac patients include:
  • Avoiding concomitant use with QT-prolonging drugs
  • Monitoring for hypotension and other cardiovascular effects
  • Careful evaluation of the benefits and risks of ziprasidone in cardiac patients 2

From the Research

Antipsychotics with Relatively Low Potential Risk in Cardiac Patients

• The following antipsychotics have been identified as having a relatively low potential risk in cardiac patients:
  • Quetiapine: Studies have shown that quetiapine is associated with a lower risk of sudden cardiac death and ventricular arrhythmia compared to other antipsychotics 3.
  • Aripiprazole: Meta-analyses have found that aripiprazole does not increase the QT interval, suggesting a lower risk of cardiac arrhythmias 4.
  • Brexpiprazole: Similar to aripiprazole, brexpiprazole has been found to not increase the QT interval, indicating a lower risk of cardiac arrhythmias 4.
  • Olanzapine: While olanzapine has been associated with an increased risk of ventricular arrhythmia and/or sudden cardiac death in some studies 5, other studies have found that it has a similar cardiac safety profile to risperidone 3.
• It is essential to note that the risk of cardiac events associated with antipsychotic use can vary depending on individual patient factors, such as pre-existing medical conditions and concomitant medication use.
• When prescribing antipsychotics to cardiac patients, clinicians should carefully evaluate the risks and benefits of treatment and consider the potential for cardiac adverse effects 5.

Comparison of Antipsychotics

• Quetiapine has been compared to other antipsychotics, including olanzapine, risperidone, and ziprasidone, in terms of efficacy and safety 6.
• While quetiapine may have a more favorable cardiac safety profile compared to some other antipsychotics, it is essential to consider the individual patient's needs and medical history when selecting an antipsychotic medication.
• Further research is needed to fully understand the cardiac risks associated with antipsychotic use and to inform evidence-based treatment decisions 6.