What are the cardiac effects of glycopyrrolate (glycopyrrolate)?

From the Guidelines

Glycopyrrolate can cause cardiac effects, including tachycardia, by blocking the parasympathetic influence on the heart, and its use is recommended with caution in patients with pre-existing cardiac conditions, as evidenced by its use in the titration method for electroconvulsive therapy to protect the heart from vagally induced bradycardia or arrhythmia 1. To minimize cardiac risks, glycopyrrolate is often used in conjunction with other methods to determine the adequate dose of electrical impulse in electroconvulsive therapy, such as the "half age method" or the "titration method" 1. Some key points to consider when using glycopyrrolate include:

• The medication can cause tachycardia by blocking muscarinic acetylcholine receptors, preventing the vagus nerve from exerting its normal slowing effect on the sinoatrial node
• Patients may experience palpitations, and in some cases, the medication can precipitate supraventricular tachycardias or worsen existing arrhythmias
• Glycopyrrolate can also cause slight blood pressure elevation in some patients
• These cardiac effects are generally more pronounced at higher doses and in elderly patients who may have underlying cardiovascular disease
• Patients with pre-existing cardiac conditions such as coronary artery disease, heart failure, or certain arrhythmias should use glycopyrrolate with caution, and dose adjustments may be necessary, as recommended in the context of electroconvulsive therapy 1. Healthcare providers should monitor cardiac function in patients receiving this medication, especially when initiating therapy or adjusting dosages, to minimize the risk of cardiac complications 1.

From the FDA Drug Label

ADVERSE REACTIONS: ... tachycardia; palpitation; ... cardiac arrhythmias (including bradycardia, ventricular tachycardia, ventricular fibrillation); cardiac arrest; hypertension; hypotension; ... heart block and QTc interval prolongation associated with the combined use of glycopyrrolate and an anticholinesterase. The cardiac effects from glycopyrolate include:

• Tachycardia
• Palpitation
• Cardiac arrhythmias (including bradycardia, ventricular tachycardia, ventricular fibrillation)
• Cardiac arrest
• Hypertension
• Hypotension
• Heart block (associated with combined use of glycopyrrolate and an anticholinesterase)
• QTc interval prolongation (associated with combined use of glycopyrrolate and an anticholinesterase) 2

From the Research

Cardiac Effects of Glycopyrrolate

• Glycopyrrolate has been shown to have decreased cardiac effects compared to atropine in certain medical procedures, such as carotid angioplasty and stenting 3.
• A study found that prophylactic glycopyrrolate reduced hemodynamic instability during carotid angioplasty and stenting, with lower incidence of postoperative bradycardia and hypotension compared to atropine 3.
• In geriatric patients, glycopyrrolate was found to minimize cardiac muscarinic activity after reversal of neuromuscular blockade, with a 16% incidence of new postoperative cardiac dysrhythmias, all of which occurred in patients with pre-existing cardiovascular disease 4.
• A long-term safety study of glycopyrrolate in patients with moderate-to-severe COPD found no significant differences in major adverse cardiovascular events or cardiac complications compared to a long-acting β2-agonist 5.
• Glycopyrrolate pre-treatment before phenylephrine infusion during spinal anaesthesia for caesarean delivery was found to increase heart rate and cardiac output, but also decreased accuracy of blood pressure control and increased the incidence of hypertension 6.
• The pharmacology, toxicology, and clinical safety of glycopyrrolate have been reviewed, with findings suggesting that the benefits of glycopyrrolate generally outweigh the risks in chronic use indications that require muscarinic receptor antagonism 7.

Key Findings

• Glycopyrrolate has been found to have a more favorable cardiac profile compared to atropine in certain medical procedures.
• The incidence of cardiac dysrhythmias with glycopyrrolate is generally low, but may be higher in patients with pre-existing cardiovascular disease.
• Glycopyrrolate may increase heart rate and cardiac output, but also decrease accuracy of blood pressure control and increase the incidence of hypertension in certain situations.
• The long-term safety of glycopyrrolate has been established in patients with moderate-to-severe COPD.

Cardiac Considerations

• Glycopyrrolate may be a suitable alternative to atropine in medical procedures where cardiac effects are a concern.
• Patients with pre-existing cardiovascular disease should be monitored closely for cardiac dysrhythmias when receiving glycopyrrolate.
• Blood pressure control should be carefully managed when using glycopyrrolate, particularly in situations where phenylephrine infusion is used.