Psychotropic Medications and the Risk of Sudden Cardiac Death During an Acute Coronary Event

Study Questions:

What is the role of psychotropic drugs as a triggering factor of sudden cardiac death (SCD) during an acute coronary event?

Methods:

The use of medication was compared between victims of SCD and survivors of an acute coronary event in a case–control study including a consecutive series of victims of SCD (n = 1,814, mean age 65 ± 11 years) verified to be due to an acute coronary event at medico-legal autopsy, and consecutive series of patients surviving an acute myocardial infarction (AMI; n = 1,171, mean age 66 ± 12 years). The medication history was obtained from autopsy/hospital records and interviews with relatives of SCD victims and AMI patients. Logistic regression analysis was used to assess the risk of SCD related to different psychotropic medications after adjustment for demographic risk factors, such as male gender, a history of angina pectoris, hypertension, diabetes, a history of prior AMI, hypercholesterolemia, and the use of cardiovascular medications (i.e., lipid-lowering therapy, statins, nitroglycerin, acetylsalicylic acid, beta-blockers, calcium-channel blockers, diuretics, angiotensin-converting enzyme inhibitors, or AT2-antagonists and flecainide, amiodarone, or sotalol).

Results:

The use of antipsychotics (9.7 vs. 2.4%; odds ratio, [OR] 4.4; 95% confidence interval [CI], 2.9-6.6; p < 0.001) and antidepressants (8.6 vs. 5.5%; OR, 1.6; 95% CI, 1.2-2.2; p = 0.003) was more common in the SCD than AMI group, but the use of benzodiazepines did not differ between the groups (11.7 vs. 13.2%; p = 0.270). The use of antipsychotics remained as a significant risk factor for SCD after adjustment for confounding variables (OR, 3.4; 95% CI, 1.8-6.5; p < 0.001). Combined use of phenothiazines and any antidepressant was associated with a very high risk of SCD (OR, 18.3; 95% CI, 2.5-135.3; p < 0.001).

Conclusions:

The authors concluded that the use of psychotropic drugs, especially combined use of antipsychotic and antidepressant drugs, is strongly associated with an increased risk of SCD at the time of an acute coronary event.

Perspective:

This study suggests that the use of psychotropic drugs was more common among the victims of SCD compared with survivors of AMI, and combined use of both antipsychotic and antidepressant drugs was associated with a very high risk of SCD during a coronary event. The causal relationship between the use of psychotropic drugs and SCD during an ischemic event was further supported by an observation of higher doses of antipsychotic drugs among the victims of SCD as well as a special circadian rhythm of SCD among those using psychotropic drugs with a higher incidence during the night hours. Since patients using both antipsychotic and antidepressant drugs seem to be at a very high risk of dying suddenly during a coronary event, this combination should be avoided, especially in those patients who carry other cardiovascular risk factors.

Clinical Topics: Dyslipidemia, Prevention, Homozygous Familial Hypercholesterolemia, Novel Agents, Hypertension

Keywords: Antipsychotic Agents, Benzodiazepines, Myocardial Infarction, Psychotropic Drugs, Diuretics, Phenothiazines, Risk Factors, Hypercholesterolemia, Calcium Channel Blockers, Survivors, Incidence, Cardiovascular Agents, Death, Case-Control Studies, Cardiology, Cardiovascular Diseases, Hypertension


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