Guidelines for the Management of QTc

Prolongation in Adults Prescribed Antipsychotics

When to do an ECG:
 History of CVD, family history of CVD
 Where clinical examination reveals irregular pulse BASELINE ECG
 If patient taking certain medicines which are known to cause ECG Should be done for ALL patients commencing
antipsychotic medication
abnormalities (e.g. erythromycin, fluconazole, tricyclic anti-depressants,
methadone, domperidone, anti-arrhythmics – see BNF or
https://crediblemeds.org for further information) NORMAL QTc:
 The patient is on high dose antipsychotic therapy (HDAT) Women: < 470ms Men: <440ms
 No action required
 The patient has factors which may predispose to arrhythmias including:  Repeat ECG at least annually if
o Electrolyte abnormalities – hypokalaemia, hypocalcaemia, clinically indicated*
hypomagnesaemia;
o Systemic disease – liver disease, renal disease, hypothyroidism.
QTc ABNORMAL > 500ms QTc ABNORMAL < 500ms
 STOP suspected causative drug Consider:
Notes for consideration: Syncope / pre-syncope = emergency & need for  Decreasing the dose of drug
ECG monitoring (cardiac arrest monitoring)
 Stress/anxiety can affect an ECG & it may be necessary to manage the  URGENT referral to cardiologist  Or switching to an alternative drug with
less risk of ↑ QTc (Aripiprazole)
patient’s anxiety and repeat the ECG
 Electrolyte imbalances may need correcting
 Consider the risks associated with switching antipsychotics Repeat ECG
 Patients should be warned to avoid other QTc prolonging medications
(prescribed or over-the-counter types)
If ABNORMAL – If NORMAL –
Refer to Cardiologist Repeat at least annually if
For specialist cardiology advice contact your local on call cardiologist clinically indicated*
References
It is recommended that you have the following information prior to seeking  The Maudsley Prescribing Guidelines 2015
 Summary of Product Characteristics available at www.medicines.org.uk
advice:  NICE Guidelines CG178 – Psychosis and Schizophrenia in Adults -
March 2014
1. What medications have been prescribed for the patient’s mental health  Lester UK Adaptation Positive Cardiometabolic Health Resource 2016
 Psychotropic Drug Directory 2016
condition?
2. What other medications is the patient taking (comprehensive list)?
3. Has the patient experienced any faintness, near collapse or collapse
Effect of antipsychotics on QTc
episodes? No effect Low Moderate High
4. Is the patient known to have any cardiac history / conditions? (at therapeutic doses)
5. What was the patient’s heart rate and QTc (rate corrected QT-interval from  Aripiprazole  Clozapine  Chlorpromazine  High Dose
(note: yellow card  Flupentixol  Quetiapine Antipsychotic
the automatic report at the top of the tracing) before starting therapy? reports of torsade de
pointes and QT
 Olanzapine  Amisulpride Therapy (HDAT)
6. What is the patient’s latest heart rate and QTc measurement? prolongation)  Prochlorperazine  Haloperidol
7. Biochemistry results (within last two weeks): sodium, potassium, urea,  Zuclopenthixol  Risperidone  Pimozide
creatinine, eGFR [+ magnesium level if potassium (< 3.5mm/L]; FBC results  Lurasidone  Sulpiride
 Paliperidone
8. Do you have alternative medication options open to you if the current regime  Fluphenazine
needs to be changed because of excessive prolongation in the QT-interval?  Asenapine

The cardiologist will need to have a copy of the relevant ECG(s) for the
discussion