Which psychiatric medications increase troponin T levels?

Psychiatric Medications That Increase Troponin T Levels

Clozapine is the psychiatric medication most strongly associated with troponin T elevation due to its potential to cause cardiotoxicity and myocarditis. 1, 2

Specific Psychiatric Medications Associated with Troponin Elevation

• Clozapine has been documented to cause myocarditis and cardiomyopathy, which can lead to elevated troponin T levels. This potentially life-threatening complication, though rare (incidence of 3%), requires immediate attention 2

• Antipsychotics with high risk of QT prolongation may indirectly lead to troponin elevation through cardiac complications:

  • Thioridazine (especially at doses ≥600 mg) 1, 3
  • Pimozide 4
  • Sultopride 4
  • Droperidol 4
  • Haloperidol (to a lesser extent) 4, 3
  • Chlorpromazine (to a lesser extent) 4

• Among atypical antipsychotics, the risk hierarchy for cardiac effects that may lead to troponin elevation is:

  • Highest risk: Sertindole (withdrawn from market) 4
  • Moderate risk: Ziprasidone 4
  • Lower risk: Risperidone 4
  • Minimal risk: Quetiapine, olanzapine, and clozapine (regarding QT prolongation specifically, though clozapine has other cardiac risks) 4

• SSRIs:

  • Citalopram at doses exceeding 40 mg/day can cause QT prolongation that may lead to cardiac complications and subsequent troponin elevation 1

Mechanisms and Monitoring

• Psychiatric medications can increase troponin T levels through several mechanisms:

  • Direct cardiotoxicity (as with clozapine) 2
  • QT interval prolongation leading to arrhythmias 1, 4
  • Tachycardia, which is a common side effect of many antipsychotics 2

• Risk factors that increase the likelihood of troponin elevation with psychiatric medications:

  • Concomitant use of other QT-prolonging medications 1
  • Electrolyte abnormalities (particularly hypokalemia and hypomagnesemia) 4
  • Bradycardia 4
  • Congenital long QT syndrome 4
  • Underlying cardiac pathology 4
  • Use of medications that inhibit the hepatic metabolism of antipsychotics 4

Clinical Implications and Recommendations

• Baseline ECG and troponin measurement should be obtained before initiating treatment with antipsychotics known to have cardiac effects, particularly clozapine 1

• For patients on clozapine who develop fever, tachycardia, or other signs of systemic inflammatory response, consider troponin measurement to rule out myocarditis 2

• When elevated troponin T is detected in patients on psychiatric medications, it's important to distinguish medication-induced elevation from other causes such as tachyarrhythmia, hypertension, cardiac trauma, heart failure, or severe non-cardiac conditions 1

• Be aware that patients with schizophrenia on antipsychotic medications have higher rates of cardiac arrest and ventricular arrhythmia than control populations (rate ratios 1.7 to 3.2) 3

Important Caveats

• False elevations of troponin T (but not troponin I) can occur in patients with skeletal myopathies due to cross-reaction of the cTnT immunoassay with skeletal muscle troponin isoforms 5

• When evaluating troponin elevation in psychiatric patients, consider measuring both troponin T and troponin I, as troponin I is less likely to be falsely elevated in non-cardiac conditions 5

• Serial troponin testing in patients with myopathies can meet criteria for myocardial infarction despite absence of actual cardiac injury 5