What are the cardiac side effects and precautions of Aripiprazole (Abilify)?

From the Guidelines

Aripiprazole is not associated with QTc prolongation or torsade de pointes, making it a safer option compared to other antipsychotics in terms of cardiac side effects. The most significant cardiac concerns with aripiprazole include orthostatic hypotension and tachycardia. Before starting aripiprazole, patients should undergo baseline ECG assessment, especially those with pre-existing cardiovascular disease, family history of QT prolongation, or those taking other medications that affect cardiac conduction 1. Regular monitoring of vital signs and ECGs is recommended during treatment, particularly when using higher doses (above 20mg daily). Patients should be educated about symptoms requiring immediate attention, such as palpitations, dizziness, fainting, or chest pain. Dose adjustments may be necessary for patients with cardiac risk factors, and aripiprazole should be used cautiously in elderly patients who are more susceptible to orthostatic hypotension.

Some key points to consider when prescribing aripiprazole include:

• Aripiprazole has a better cardiac safety profile compared to other antipsychotics, with no association with QTc prolongation or torsade de pointes 1
• Orthostatic hypotension and tachycardia are potential cardiac side effects of aripiprazole
• Baseline ECG assessment and regular monitoring of vital signs and ECGs are recommended during treatment
• Patients with pre-existing cardiovascular disease, family history of QT prolongation, or those taking other medications that affect cardiac conduction require closer monitoring
• Dose adjustments may be necessary for patients with cardiac risk factors, and aripiprazole should be used cautiously in elderly patients 1

In terms of management, if significant cardiac symptoms develop, dose reduction or medication change should be considered in consultation with a healthcare provider. It is essential to weigh the benefits and risks of aripiprazole in patients with cardiac risk factors and to closely monitor them for any adverse effects. Overall, aripiprazole is a relatively safe option for patients with cardiac concerns, but careful monitoring and precautions are still necessary to minimize the risk of cardiac side effects.

From the FDA Drug Label

Aripiprazole may cause orthostatic hypotension, perhaps due to its α1-adrenergic receptor antagonism. The incidence of orthostatic hypotension-associated events from short-term, placebo-controlled trials of adult patients on oral aripiprazole (n=2467) included (aripiprazole incidence, placebo incidence) orthostatic hypotension (1%, 0.3%), postural dizziness (0.5%, 0.3%), and syncope (0.5%, 0.4%); of pediatric patients 6 to 18 years of age (n=732) on oral aripiprazole included orthostatic hypotension (0.5%, 0%), postural dizziness (0.4%, 0%), and syncope (0.2%, 0%) Aripiprazole should be used with caution in patients with known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure, or conduction abnormalities), cerebrovascular disease, or conditions which would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medications)

The cardiac side effects of Aripiprazole include:

• Orthostatic hypotension: Aripiprazole may cause a decrease in blood pressure when changing position, which can lead to lightheadedness or fainting.
• Syncope: Fainting may occur due to orthostatic hypotension.
• Postural dizziness: Dizziness when standing up from a sitting or lying position.

Precautions for patients with cardiac conditions:

• Aripiprazole should be used with caution in patients with known cardiovascular disease, such as history of myocardial infarction or ischemic heart disease, heart failure, or conduction abnormalities.
• Patients with cerebrovascular disease or conditions that predispose them to hypotension should also use aripiprazole with caution 2.

From the Research

Cardiac Side Effects of Aripiprazole

• QT interval prolongation has been reported in patients taking aripiprazole, particularly in overdose situations 3, 4
• QRS widening has also been observed in cases of aripiprazole overdose 3
• Atrioventricular block has been reported in a case of aripiprazole overdose 4
• Ventricular trigeminy and supraventricular tachycardia have been described in patients treated with aripiprazole 4

Precautions for Aripiprazole Use

• Patients at high risk for torsade should be monitored closely, as aripiprazole's cardiac safety has not been fully assessed in this population 5
• Baseline and steady-state electrocardiogram is recommended in patients at high risk for torsade due to marked QTc prolongation 5
• Aripiprazole is considered a low-risk antipsychotic regarding cardiac safety in healthy patients, but caution is still advised 5, 6
• Genetic testing may be relevant, as CYP2D6 poor metabolizers may be at increased risk of prolonged toxicity 3

Studies on Cardiac Effects of Aripiprazole

• A study in children and adolescents found no significant differences in PR, QRS, RR, and QT(c) intervals after aripiprazole therapy 7
• A systematic review with a meta-analytic approach found that aripiprazole has limited affinity for the delayed rectifier potassium current and is associated with a low risk of QTc prolongation 5
• A review of aripiprazole's pharmacology and clinical use found that it appears to be well tolerated, with no significant cardiac rhythm disturbances reported 6