A History of SVT is NOT a Contraindication for Rexulti (Brexpiprazole)
A history of supraventricular tachycardia does not contraindicate the use of Rexulti (brexpiprazole), as this atypical antipsychotic has not been associated with QT prolongation or serious cardiac arrhythmias. 1
Evidence Supporting Safety in Patients with SVT History
Brexpiprazole's Favorable Cardiac Safety Profile
Low-quality evidence from randomized controlled trials demonstrates that brexpiprazole does not increase QT interval, distinguishing it from other atypical antipsychotics that carry arrhythmogenic risk 1
Brexpiprazole belongs to the same class as aripiprazole, which has similarly not been associated with QT prolongation or torsades de pointes, making it a preferred choice when antipsychotic therapy is needed in patients with cardiac concerns 2
Contrast with Higher-Risk Antipsychotics
Among antipsychotics, ziprasidone and thioridazine carry the highest risk for QT prolongation, followed by quetiapine, risperidone, and haloperidol 2
Risperidone and quetiapine are associated with QT prolongation and greater odds of torsades de pointes, particularly in overdose situations 1
The European Heart Journal guidelines specifically note that antipsychotics should be avoided in patients with ventricular arrhythmias or high VT risk, but this caution applies primarily to QT-prolonging agents, not brexpiprazole 2
Clinical Decision-Making Algorithm
When Antipsychotic Therapy is Required:
First-line choice: Brexpiprazole, aripiprazole, or olanzapine - these agents do not prolong QT interval in licensed doses 1
Avoid: Ziprasidone, thioridazine, quetiapine, and risperidone - particularly in patients with any arrhythmia history 1
Exercise caution with haloperidol - despite less QT prolongation than ziprasidone, it causes more torsades de pointes and sudden cardiac death, especially when given intravenously 2
Important Caveats
SVT itself is typically not associated with structural heart disease and involves abnormal electrical pathways in the atria or AV node, not ventricular tissue 3, 4
The primary cardiac concerns with antipsychotics relate to ventricular arrhythmias (torsades de pointes) from QT prolongation, not supraventricular arrhythmias 2, 1
Risk stratification for QT-prolonging medications should focus on: female gender, age >65 years, baseline QTc >500 ms, electrolyte abnormalities, prior sudden cardiac death, or concurrent QT-prolonging medications 2
Practical Recommendation
Proceed with brexpiprazole in patients with SVT history without additional cardiac monitoring beyond standard clinical practice, as the medication does not affect cardiac conduction or repolarization in ways that would exacerbate supraventricular arrhythmias 1. If the patient has additional risk factors for ventricular arrhythmias (prolonged baseline QTc, electrolyte disturbances, multiple QT-prolonging drugs), obtain baseline ECG and monitor appropriately, but SVT history alone does not warrant these precautions 2.