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Cardiovascular monitoring in patients prescribed clozapine

Published online by Cambridge University Press:  02 January 2018

William R. Jones
Affiliation:
Yorkshire Centre for Eating Disorders, Leeds, Leeds and York Partnership NHS Foundation Trust, email: wrjones@doctors.org.uk
Usha Narayana
Affiliation:
Bootham Park Hospital, York, Leeds and York Partnership NHS Foundation Trust
Sarah Howarth
Affiliation:
Joanna Shinners is clinical audit lead
Qadeer Nazar
Affiliation:
Lynfield Mount Hospital, Bradford, Bradford District Care Trust
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Abstract

Type
Columns
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2014

Wilson et al Reference Wilson, Hamilton, Callender, MacManus, Howitt and Okpo1 highlight the ongoing issue of poor physical health monitoring in patients prescribed clozapine. We recently presented a survey which investigated standards of physical health monitoring in adult patients (n=98) prescribed clozapine against standards set out by Maudsley Guidelines in which we found similarly high rates (53%) of clozapine augmentation and antipsychotic polypharmacy (details available from the authors on request). Moreover, cardiovascular monitoring was poor with only 30% of patients having had a baseline electrocardiogram prior to initiation of clozapine. Similarly, only 28% had yearly electrocardiogram monitoring performed once clozapine therapy had been established. Of those patients established on clozapine therapy, 34% were found to have asymptomatic sinus tachycardia, which was more commonly seen in patients prescribed additional antipsychotic medication than those prescribed clozapine alone (P<0.001). Clinical actions in response to asymptomatic sinus tachycardia varied enormously, with only 12% of cases having been discussed with local cardiology services.

These findings are of great concern when one considers that clozapine is associated with potentially life-threatening adverse cardiovascular conditions such as myocarditis and cardiomyopathy. Reference Kilian, Kerr, Lawrence and Celermajer2 While tachycardia is commonly seen during the early stages of clozapine treatment, occurring in up to 50% of patients, sustained tachycardia, defined as a heart rate >100 bpm for more than 6 months, can precipitate cardiomyopathy and appears to be an independent risk factor for sudden cardiac death. Reference Shinbane, Wood, Jensen, Ellenbogen, Fitzpatrick and Scheinman3 Reducing clozapine dose and the use of rate-limiting drugs such as beta-blockers have been suggested as potential solutions to this problem, Reference Young, Bowers and Manure4 although these options may not always be clinically appropriate and there appears to be a broad range of approaches in dealing with this.

In response to these findings we have introduced a system whereby initiation of clozapine therapy and its continued prescription by our pharmacy department is contingent on evidence of baseline and continued cardiovascular monitoring. We have also developed a shared care pathway with our local cardiology department ensuring that cardiac monitoring is optimised in this vulnerable patient group and that management of sustained tachycardia is jointly managed by both psychiatric and cardiology services. Information on this shared care pathway is available from the corresponding author.

References

1 Wilson, S, Hamilton, R, Callender, J, MacManus, A, Howitt, S, Okpo, B. Clozapine antipsychotic polypharmacy: audit of use and patient monitoring. Psychiatrist 2013; 37: 322–5.Google Scholar
2 Kilian, JG, Kerr, K, Lawrence, C, Celermajer, DS. Myocarditis and cardiomyopathy associated with clozapine. Lancet 1999; 354: 1841–5.CrossRefGoogle ScholarPubMed
3 Shinbane, JS, Wood, MA, Jensen, DN, Ellenbogen, KA, Fitzpatrick, AP, Scheinman, MM. Tachycardia-induced cardiomyopathy: a review of animal models and clinical studies. J Am Coll Cardiology 1997; 29: 709–15.Google Scholar
4 Young, CR, Bowers, MB, Manure, CM. Management of the adverse effects of clozapine. Schizophrenia Bull 1998; 24: 381–90.CrossRefGoogle ScholarPubMed
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