What are the management options for a patient with bradycardia, QTc interval prolongation, and PR interval prolongation, taking Abilify (aripiprazole) with hypertension?

From the Guidelines

The patient's Abilify (aripiprazole) should be discontinued immediately due to its potential contribution to QTc interval prolongation and cardiac conduction abnormalities, as recommended by the European Heart Journal study 1. The management of a patient with bradycardia, QTc interval prolongation, and PR interval prolongation, taking Abilify (aripiprazole) with hypertension, requires a comprehensive approach.

• Discontinuation of aripiprazole is crucial, as it may be exacerbating the cardiac conduction abnormalities, particularly the QTc prolongation, as suggested by the study 1.
• An alternative antipsychotic with less cardiac impact should be considered after cardiology consultation, such as lurasidone (Latuda) or brexpiprazole (Rexulti).
• A comprehensive cardiac evaluation, including an electrolyte panel (particularly potassium, magnesium, and calcium), thyroid function tests, and an echocardiogram, is essential to identify any underlying cardiac conditions.
• Temporary cardiac monitoring is necessary, especially if the bradycardia is symptomatic (heart rate <50 bpm with dizziness or syncope) or if the QTc is severely prolonged (>500 ms), as recommended by the study 1.
• For hypertension management, beta-blockers should be avoided as they can worsen bradycardia; instead, consider calcium channel blockers like amlodipine (5-10 mg daily) or ACE inhibitors like lisinopril (10-20 mg daily) that won't exacerbate conduction issues.
• Any medications that prolong QTc interval should be avoided, including certain antibiotics, antidepressants, and antiemetics, as suggested by the study 1.
• Electrolyte imbalances should be corrected promptly, maintaining potassium >4.0 mEq/L and magnesium >2.0 mg/dL, to prevent further cardiac complications. The QTc interval should be evaluated before initiation of treatment and during titration of dose, as recommended by the study 1, to minimize the risk of arrhythmias.
• Concomitant treatment with more than one drug with the propensity of prolonging the QT interval should be avoided if possible, as recommended by the study 1.
• If cardiac risks are identified, the cardiac risk factors should be optimized and/or a drug with a more favourable risk profile should be preferred if possible in the clinical situation, as suggested by the study 1.

From the Research

Management Options for Bradycardia, QTc Interval Prolongation, and PR Interval Prolongation

• The patient's condition, characterized by bradycardia (heart rate of 40), QTc interval prolongation, and PR interval prolongation, while taking Abilify (aripiprazole) and having hypertension, requires careful management.
• According to 2, aripiprazole has been found to have a low risk of cardiac safety in healthy patients, but its use in patients at high risk for torsade, such as those with marked QTc prolongation, warrants caution and monitoring.
• In the absence of signs of 3rd degree heart block, management should focus on addressing the bradycardia and QTc interval prolongation, as well as controlling hypertension.
• The study 3 highlights the importance of accurate interpretation of a 12-lead EKG, assessment of hemodynamic stability, and time-sensitive pharmacologic or procedural intervention in managing cardiac emergencies.

Considerations for Aripiprazole Use

• As noted in 2, while aripiprazole is considered a low-risk antipsychotic regarding cardiac safety, its use in patients with pre-existing cardiac conditions or those at high risk for torsade requires baseline and steady-state electrocardiogram monitoring.
• The lack of thorough QT (TQT) studies with aripiprazole and the absence of data in patients at high risk for torsade suggest that caution should be exercised when prescribing this medication to such patients.

Monitoring and Intervention

• Close monitoring of the patient's heart rate, QTc interval, and PR interval is essential to promptly identify any changes or worsening of their condition.
• As indicated in 3, effective management includes accurate interpretation of a 12-lead EKG, assessment of hemodynamic stability, and time-sensitive pharmacologic or procedural intervention.
• In the event of hemodynamic instability or worsening cardiac function, consultation with a cardiologist and consideration of alternative treatments or interventions, such as pacing or medication adjustments, may be necessary, as suggested by 3.