Antipsychotic drugs and QT interval prolongation

Current Findings and Potential Mechanisms of KarXT (Xanomeline-Trospium) in Schizophrenia Treatment

Standard schizophrenia treatment involves antipsychotic medications that target D2 dopamine receptors. However, these drugs have limitations in addressing all symptoms and can lead to adverse effects such as motor impairments, metabolic effects, sedation, sexual dysfunction, cognitive impairment, and tardive dyskinesia. Recently, KarXT has emerged as a novel drug for schizophrenia. KarXT combines xanomeline, a muscarinic receptor M1 and M4 agonist, with trospium, a nonselective antimuscarinic agent. Of note, xanomeline can readily cross blood-brain barrier (BBB) and, thus, enter into the brain, thereby stimulating muscarinic receptors (M1 and M4). By doing so, xanomeline has been shown to target negative symptoms and potentially improve positive symptoms. Trospium, on the other hand, is not able to cross BBB, thereby not affecting M1 and M4 receptors; instead, it acts as an antimuscarinic agent and, hence, diminishes peripheral activity of muscarinic receptors to minimize side effects probably stemming from xanomeline in other organs. Accordingly, ongoing clinical trials investigating KarXT's efficacy in schizophrenia have demonstrated positive outcomes, including significant improvements in the Positive and Negative Syndrome Scale (PANSS) total score and cognitive function compared with placebo. These findings emphasize the potential of KarXT as a promising treatment for schizophrenia, providing symptom relief while minimizing side effects associated with xanomeline monotherapy. Despite such promising evidence, further research is needed to confirm the efficacy, safety, and tolerability of KarXT in managing schizophrenia. This review article explores the current findings and potential mechanisms of KarXT in the treatment of schizophrenia.

Predictors for prolonged qt intervals in acute antipsychotic poisoned patients

Background

Acute antipsychotic poisoning is correlated to a high prevalence of qt interval prolongation.

Aim

This study aimed to evaluate early qt interval prolongation predictors in acute antipsychotic-poisoned patients.

Methodology

This prospective cohort study enrolled 70 symptomatic patients with acute antipsychotic poisoning. Sociodemographic data, toxicological, clinical, investigation, and outcomes were collected and analyzed. The estimation of the corrected qt interval (QTc) was performed using Bazett's method. Primary outcome was normal or abnormal length of QTc interval. Secondary outcomes included duration of hospital stay, complete recovery and mortality. The corrected qt interval was analyzed by univariate and multivariate logistic regression analysis.

Results

Patients were divided into groups A (normal QTc interval up to 440 msec; 58.6% of cases) and B (prolonged QTc interval ≥ 440 msec; 41.4% of cases). Patients in group B had significantly high incidences of quetiapine intake, bradycardia, hypotension, hypokalemia, and long duration of hospital stay. By multivariate analysis, quetiapine [Odd's ratio (OR): 39.674; Confidence Interval (C.I:3.426-459.476)], bradycardia [OR: 22.664; C.I (2.534-202.690)], and hypotension [OR: 16.263; (C.I: 2.168-122.009)] were significantly correlated with prolonged QTc interval.

Conclusion

In acute antipsychotic poisoning, quetiapine, bradycardia, and hypotension are early clinical predictors for prolonged QTc interval.

Antipsychotic polypharmacy and adverse drug reactions among adults in a London mental health service, 2008-2018

BACKGROUND

Antipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions (ADRs). Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2 + antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of ADRs: QT interval prolongation, hyperprolactinaemia, and increased body weight [body mass index (BMI) ⩾ 25].

METHODS

We extracted anonymised EHR data. Patients aged 16 + receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively.

RESULTS

We identified 35 409 observations of antipsychotic prescribing among 13 391 patients. Compared with antipsychotic monotherapy, APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% CI 1.87-3.24) and of registering a BMI > 25 (adjusted odds ratio 1.75; 95% CI 1.33-2.31) in the period following the APP prescribing.

CONCLUSIONS

Our observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity.

Evaluation of rosuvastatin-induced QT prolongation risk using real-world data, in vitro cardiomyocyte studies, and mortality assessment

Drug-induced QT prolongation is attributed to several mechanisms, including hERG channel blockage. However, the risks, mechanisms, and the effects of rosuvastatin-induced QT prolongation remain unclear. Therefore, this study assessed the risk of rosuvastatin-induced QT prolongation using (1) real-world data with two different settings, namely case-control and retrospective cohort study designs; (2) laboratory experiments using human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM); (3) nationwide claim data for mortality risk evaluation. Real-world data showed an association between QT prolongation and the use of rosuvastatin (OR [95% CI], 1.30 [1.21-1.39]) but not for atorvastatin (OR [95% CI], 0.98 [0.89-1.07]). Rosuvastatin also affected the sodium and calcium channel activities of cardiomyocytes in vitro. However, rosuvastatin exposure was not associated with a high risk of all-cause mortality (HR [95% CI], 0.95 [0.89-1.01]). Overall, these results suggest that rosuvastatin use increased the risk of QT prolongation in real-world settings, significantly affecting the action potential of hiPSC-CMs in laboratory settings. Long-term rosuvastatin treatment was not associated with mortality. In conclusion, while our study links rosuvastatin use to potential QT prolongation and possible influence on the action potential of hiPSC-CMs, long-term use does not show increased mortality, necessitating further research for conclusive real-world applications.

Genetic Biomarkers of Antipsychotic-Induced Prolongation of the QT Interval in Patients with Schizophrenia

Antipsychotics (AP) induced prolongation of the QT interval in patients with schizophrenia (Sch) is an actual interdisciplinary problem as it increases the risk of sudden death syndrome. Long QT syndrome (LQTS) as a cardiac adverse drug reaction is a multifactorial symptomatic disorder, the development of which is influenced by modifying factors (APs' dose, duration of APs therapy, APs polytherapy, and monotherapy, etc.) and non-modifying factors (genetic predisposition, gender, age, etc.). The genetic predisposition to AP-induced LQTS may be due to several causes, including causal mutations in the genes responsible for monoheme forms of LQTS, single nucleotide variants (SNVs) of the candidate genes encoding voltage-dependent ion channels expressed both in the brain and in the heart, and SNVs of candidate genes encoding key enzymes of APs metabolism. This narrative review summarizes the results of genetic studies on AP-induced LQTS and proposes a new personalized approach to assessing the risk of its development (low, moderate, high). We recommend implementation in protocols of primary diagnosis of AP-induced LQTS and medication dispensary additional observations of the risk category of patients receiving APs, deoxyribonucleic acid profiling, regular electrocardiogram monitoring, and regular therapeutic drug monitoring of the blood APs levels.

Evaluation of deep convolutional neural networks for in situ hybridization gene expression image representation

High resolution in situ hybridization (ISH) images of the brain capture spatial gene expression at cellular resolution. These spatial profiles are key to understanding brain organization at the molecular level. Previously, manual qualitative scoring and informatics pipelines have been applied to ISH images to determine expression intensity and pattern. To better capture the complex patterns of gene expression in the human cerebral cortex, we applied a machine learning approach. We propose gene re-identification as a contrastive learning task to compute representations of ISH images. We train our model on an ISH dataset of ~1,000 genes obtained from postmortem samples from 42 individuals. This model reaches a gene re-identification rate of 38.3%, a 13x improvement over random chance. We find that the learned embeddings predict expression intensity and pattern. To test generalization, we generated embeddings in a second dataset that assayed the expression of 78 genes in 53 individuals. In this set of images, 60.2% of genes are re-identified, suggesting the model is robust. Importantly, this dataset assayed expression in individuals diagnosed with schizophrenia. Gene and donor-specific embeddings from the model predict schizophrenia diagnosis at levels similar to that reached with demographic information. Mutations in the most discriminative gene, Sodium Voltage-Gated Channel Beta Subunit 4 (SCN4B), may help understand cardiovascular associations with schizophrenia and its treatment. We have publicly released our source code, embeddings, and models to spur further application to spatial transcriptomics. In summary, we propose and evaluate gene re-identification as a machine learning task to represent ISH gene expression images.

QTc interval prolongation in the patients with primary biliary cholangitis

Background

The QT interval prolongation was associated with fatal arrhythmias and cardiac death. However, there were not adequate data to clarify the situation of QT interval prolongation in primary biliary cholangitis (PBC) patients. The aim of this study was to clarify the rate and the associated risk factors of corrected QT (QTc) interval prolongation in PBC patients.

Methods

From January 2016 to December 2020, PBC patients were retrospectively enrolled. The rate of QTc interval prolongation was surveyed and the associated risk factors were clarified by univariate and multivariate analyses.

Results

Among the 189 PBC patients, 24.3% (46/189) had the QTc interval prolongation. The univariate analysis showed that age, Child‐Pugh classification, creatinine, international normalized ratio (INR), and platelet (PLT) were associated with QTc interval prolongation in the PBC patients. The multivariate analysis further showed only age (p = .028) and Child‐Pugh classification (p = .035) were the associated risk factors. It had the highest risk of QTc interval prolongation (as high as 64.3%) in the patients who were more than 62.5 years old and with Child‐Pugh C.

Conclusion

The QTc interval prolongation was frequent in PBC patients, especially in the patients with decompensated cirrhosis. The rate of QTc interval prolongation was as high as 64.3% in the PBC patients who were more than 62.5 years old and classified as Child‐Pugh C.

Cardiac toxicity from bisphenol A exposure in human-induced pluripotent stem cell-derived cardiomyocytes

Bisphenol A (BPA) is a well-known endocrine-disrupting chemical that is widely used in a variety of products, including plastics, medical equipment and receipts. Hence, most people are exposed to BPA through the skin, via inhalation and via the digestive system, and such exposure has been linked to cardiovascular diseases including coronary artery disease, hypertension, atherosclerosis, and myocardial infarction. However, the underlying mechanisms of cardiac dysfunction caused by BPA remain poorly understood. In this study, we found that BPA exposure altered cardiac function in human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). Acute BPA exposure in hiPSC-CMs resulted in reduced field potential, as measured by multielectrode array (MEA). Furthermore, we observed that BPA dose-dependently inhibited I_Ca, I_Na or I_Kr channels. In addition, BPA exposure dose-dependently inhibited calcium transients and contraction in hiPSC-CMs. Our findings suggest that BPA exposure leads to cardiac dysfunction and cardiac risk factors such as arrhythmia.

Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review

AIMS

To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations.

METHOD

A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table.

RESULTS

Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary."

CONCLUSION

A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.

Effects of norquetiapine, the active metabolite of quetiapine, on cloned hERG potassium channels

Quetiapine is an atypical antipsychotic drug that is widely used for the treatment of schizophrenia. It is mainly metabolized by a cytochrome P450 system in the liver. Norquetiapine is a major active metabolite in humans with a pharmacological profile that differs distinctly from that of quetiapine. We used the whole-cell patch-clamp technique to investigate the effects of norquetiapine on hERG channels that are stably expressed in HEK cells. Quetiapine and norquetiapine inhibited the hERG tail currents at -50mV in a concentration-dependent manner with IC₅₀ values of 8.3 and 10.8μM, respectively, which suggested equal potency. The block of hERG currents by norquetiapine was voltage-dependent with a steep increase over a range of voltages for channel activation. However, at more depolarized potentials where the channels were fully activated, the block by norquetiapine was voltage-independent. The steady-state inactivation curve of the hERG currents was shifted to the hyperpolarizing direction in the presence of norquetiapine. Norquetiapine did not produce a use-dependent block. A fast application of norquetiapine inhibited the hERG current elicited by a 5s depolarizing pulse to +60mV, which fully inactivated the hERG currents, suggesting an inactivated-state block. During a repolarizing pulse wherein the hERG current was slowly deactivated, albeit remaining in an open state, a fast application of norquetiapine rapidly and reversibly inhibited the open state of the hERG current. Our results indicated that quetiapine and norquetiapine had equal potency in inhibiting hERG tail currents. Norquetiapine inhibited the hERG current by preferentially interacting with the open and/or inactivated states of the channels.

Psychopathology Related to Energy Drinks: A Psychosis Case Report

Energy drinks (ED) are nonalcoholic beverages that have caffeine as their most common active substance. The rapid expansion of ED consumption has created concern in the scientific community as well as in the public opinion. We report a psychotic episode probably triggered by ED abuse in a young adult without previous psychotic disorders. We have reviewed the literature regarding the relationship between caffeine, energy drinks, and psychopathology. Few articles have been published about mental health effects of energy drinks and caffeine abuse. Nevertheless, this relationship has been suggested, specifically with anxiety disorders, manic episodes, suicide attempts, psychotic decompensation, and substance use disorder. ED consumption could represent a global public health problem because of the potential severe adverse effects in mental and physical health. To our knowledge, this article is probably the first case of psychosis related to ED abuse in an individual without previous psychotic disorders.

Cardiotoxicity of antiemetic drugs in oncology: An overview of the current state of the art

PURPOSE

Cardiac complications in cancer patients have been a significant medical problem in the last few years. Cardiosafety profile of most novel approved drugs, in cancer patients, is required by regulatory authorities. Risk of proarrhythmic effect associated with a new drug, in fact, is usually evaluated with specific studies conducted in agreement with ICHE14 guidelines. In this overview, we detailed the cardio safety profile of antiemetic drugs. In particular, we focused on data of 5HT3-RA drugs used for prevention of chemotherapy-induced nausea and vomiting in the oncology setting.

METHODS

A literature search was conducted using the PubMed database to identify studies reporting arrhythmic complications of antiemetic drug used in oncology.

RESULTS AND CONCLUSION

Most of the antiemetic drugs have been approved by regulatory authorities when ICHE14 guidelines were not issued, so the cardiotoxicity of those drugs has been defined with the post-marketing authorization pharmacovigilance activity. We reviewed the cardiotoxicity data of major antiemetic and adjuvant agents, providing a general overview and recommendations about their use in medical oncology.

Efeitos cardiotóxicos resultantes da interação da risperidona com diuréticos tiazídicos

Antipsicóticos atípicos têm sua ação em doses que podem produzir efeitos colaterais importantes. A risperidona é o antipsicótico atípico de nova geração mais utilizado na atualidade e seu uso está associado a tratamento de esquizofrenia, transtornos psicóticos, episódios de mania e nos distúrbios de comportamento, entre outros. Os efeitos adversos mais importantes estão relacionados ao sistema nervoso central e autônomo, sistema endócrino e sistema cardiovascular. Neste último, pode haver efeitos inotrópicos negativos e alterações no eletrocardiograma, como prolongamento do intervalo QT, podendo causar taquicardia e arritmias. Relatamos um caso de um homem de 48 anos com história de delírio persecutório após ser ameaçado no trabalho, que estava sendo tratado com risperidona e paroxetina. Por não haver melhora, suas doses foram aumentadas e o paciente apresentou alargamento do intervalo QTc, com diminuição da amplitude da onda T e aumento da onda U, e hipocalemia. Além disso, o paciente era hipertenso e estava em uso de hidroclorotiazida. A risperidona tem o potencial de bloquear o componente rápido do canal cardíaco de potássio e isso prolonga o processo de repolarização dos ventrículos, podendo causar torsade de pointes, morte súbita e arritmias. Já a hidroclorotiazida causa hipocalemia, provocando alterações na contração e relaxamento do miocárdio. Houve interação medicamentosa grave entre duas drogas com potencial arritmogênico, o que levou às alterações no eletrocardiograma e produziu sintomas danosos ao paciente. A troca do antipsicótico atípico para um típico e da hidroclorotiazida por um diurético que não causa hipocalemia trouxe melhoras ao paciente.

Use of atypical antipsychotics in the elderly: a clinical review

The use of atypical antipsychotic drugs in the elderly has become wider and wider in recent years; in fact, these agents have novel receptor binding profiles, good efficacy with regard to negative symptoms, and reduced extrapyramidal symptoms. However, in recent years, the use of both conventional and atypical antipsychotics has been widely debated for concerns about their safety in elderly patients affected with dementia and the possible risks for stroke and sudden death. A MEDLINE search was made using the words elderly, atypical antipsychotics, use, schizophrenia, psychosis, mood disorders, dementia, behavioral disorders, and adverse events. Some personal studies were also considered. This paper reports the receptor binding profiles and the main mechanism of action of these drugs, together with their main use in psychiatry and the possible adverse events in elderly people.

Use and safety of antipsychotics in behavioral disorders in elderly people with dementia

In recent years, the use of antipsychotics has been widely debated for reasons concerning their safety in elderly patients affected with dementia. To update the use of antipsychotics in elderly demented people, a MEDLINE search was conducted using the following terms: elderly, conventional and atypical antipsychotics, adverse events, dementia, and behavioral and psychotic symptoms in dementia (BPSD). Owing to the large amounts of studies on antipsychotics, we mostly restricted the field of research to the last 10 years. Conventional antipsychotics have been widely used for BPSD; some studies showed they have an efficacy superior to placebo only at high doses, but they are associated with several and severe adverse effects. Atypical antipsychotics showed an efficacy superior to placebo in randomized studies in BPSD treatment, with a better tolerability profile versus conventional drugs. However, in 2002, trials with risperidone and olanzapine in elderly patients affected with dementia-related psychoses suggested the possible increase in cerebrovascular adverse events. Drug regulatory agencies issued specific recommendations for underlining that treatment of BPSD with atypical antipsychotics is "off-label." Conventional antipsychotics showed the same likelihood to increase the risk of death in the elderly as atypical agents, and they should not replace the atypical agents discontinued by Food and Drug Administration warnings. Before prescribing an antipsychotic drug, the following are factors to be seriously considered: the presence of cardiovascular diseases, QTc interval on electrocardiogram, electrolytic imbalances, familiar history for torsades des pointes, concomitant treatments, and use of drugs able to lengthen QTc. Use of antipsychotics in dementia needs a careful case-by-case assessment, together with the possible drug-drug, drug-disease, and drug-food interactions.

Electrocardiographic abnormalities as potential contributors to premature mortality in patients with mental illness in a psychiatric day treatment program

Objective: Because patients with mental illness can die prematurely, we sought to determine if undetected cardiovascular disease might be present in a psychiatric day treatment population.

Method: We studied 96 patients in a day treatment program seen between February 2011 and August 2012. Data were obtained through an electronic medical record database. Electrocardiographic diagnoses were assigned by 1 investigator (M.L.). Medications were categorized into classes, and problem lists revealed comorbid diagnoses. Fisher exact test (2-tailed) and analysis of variance were used to compare findings between patient groups. Electrocardiogram (ECG) findings were the primary outcome measure.

Results: Ninety-two ECGs were performed in 37 patients. Of these 37 patients, 70% were women, 65% were 50 years of age or younger, and 54% were people of color. ECGs were performed mainly for chest pain/dyspnea (46%) and overdose/altered mental status (27%). Of these 37 patients, 20 (54%) had abnormal ECGs, 7 (19%) had borderline findings, and 10 (27%) had normal studies. When compared with the larger group of 59 patients without ECG testing, those with abnormal ECGs were more likely to be older (mean age = 47 vs 37 years, P < .001) and have more comorbid conditions (mean no. = 10.0 vs 3.8, P < .0001). The most common abnormalities were conduction disorders (prolonged QRS ≥ 105 ms, or prolonged QTc ≥ 450 ms in men or ≥ 460 ms in women), coronary artery disease, and arrhythmias.

Conclusions: In psychiatric outpatients who underwent ECG testing, mainly for chest pain or altered mental status, over 50% had concerning findings. Older patients with multiple comorbidities were at higher risk of having abnormal ECGs. Generalizability of these findings depends on validation in larger samples in multiple settings.

Prevalence of QTc interval changes in acute psychiatric care: a cross-sectional study

INTRODUCTION

In a case series we examined the prevalence and incidence of QT changes during a 1-week interval in hospitalized patients in a general psychiatry ward during a 6-month period.

METHOD

This cross-sectional study was done on electrocardiographic QT interval of patients admitted to the Psychiatric Department of Taleghani Hospital during a 6-month period excluding subjects with underlying cause of QT prolongation.

RESULTS

Admission and follow-up electrocardiograms of 27 men and 47 women were studied, there was significant QT prolongation during hospitalization (P value 0.001) in approximately 30% of subjects, irrespective of type of administered medication.

CONCLUSION

Pro-arrhythmic changes as reflected in QTc prolongation and QTc dispersion in electrocardiograms are common in patients admitted in psychiatric wards irrespective of type of therapy and should be screened and followed by serial electrocardiograms to minimize untoward cardiac outcomes.

Clarithromycin, QTc interval prolongation and torsades de pointes: the need to study case reports

BACKGROUND

The manufacturers of clarithromycin sought a drug similar in efficacy to erythromycin but with a superior side-effect profile. They generally achieved this outcome, but postmarketing findings identified a series of reports linking clarithromycin to QTc interval prolongation and torsades de pointes (TdP) ultimately leading to a Black Box Warning. We sought to clarify risk factors associated with TdP among case reports of patients receiving clarithromycin linked to QTc interval prolongation and TdP.

METHODS AND RESULTS

In a detailed literature search, we found 15 women, five men, and one boy meeting our search criteria. Among the 17 adults with reported clarithromycin dose and concurrent QTc interval measurement, we found no statistically significant relationship between clarithromycin dose and QTc interval duration. This did not change for the adults who developed TdP. Among adults, major risk factors were female sex (15), old age (11) and heart disease (17). A total of eight adult subjects had all three major risk factors and 14 of the 20 adults had at least two major risk factors. All adult subjects had at least two risk factors besides clarithromycin. A total of four of the 20 adults received cisapride and three received disopyramide. Three adults were considered to suffer from some aspect of the congenital long QT syndrome.

CONCLUSIONS

We believe that the risk factor description for this drug should be refined to emphasize the major risk factors of (1) female sex, (2) old age and (3) heart disease.

Inhibitory effects of psychotropic drugs on the acetylcholine receptor-operated potassium current (IK.ACh) in guinea-pig atrial myocytes

Influences of psychotropic drugs, six antipsychotics and three antidepressants, on acetylcholine receptor-operated potassium current (IK.ACh) were examined by a whole-cell patch clamp method in freshly isolated guinea-pig atrial myocyte. IK.ACh was induced by a superfusion of carbachol (CCh) or by an intracellular application of guanosine 5'-[thio] triphosphate (GTPγS). To elucidate mechanism for anticholinergic action, IC50 ratio, the ratio of IC50 for GTPγS-activated IK.ACh to CCh-induced IK.ACh, was calculated. Antipsychotics and antidepressants inhibited CCh-induced IK.ACh in a concentration-dependent manner. The IC50 values were as follows; chlorpromazine 0.53 μM, clozapine 0.06 μM, fluphenazine 2.69 μM, haloperidol 2.66 μM, sulpiride 42.3 μM, thioridazine 0.07 μM, amitriptyline 0.03 μM, imipramine 0.22 μM and maprotiline 1.81 μM. The drugs, except for sulpiride, inhibited GTPγS-activated IK.ACh with following IC50 values; chlorpromazine 1.71 μM, clozapine 14.9 μM, fluphenazine 3.55 μM, haloperidol 2.73 μM, thioridazine 1.90 μM, amitriptyline 7.55 μM, imipramine 7.09 μM and maprotiline 5.93 μM. The IC50 ratio for fluphenazine and haloperidol was close to unity. The IC50 ratio for chlorpromazine, clozapine, thioridazine, amitriptyline, imipramine and maprotiline was much higher than unity. The present findings suggest that the psychotropics studied suppress IK.ACh. Chlorpromazine, clozapine, thioridazine, amitriptyline, imipramine, maprotiline and sulpiride are preferentially acting on muscarinic receptor. Fluphenazine and haloperidol may act on G protein and/or potassium channel.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

Sudden cardiac death and antipsychotic medications: literature review

The review summarises the evidence from international publications on sudden cardiac death (SCD) in psychiatric patients receiving neuroleptics. Modern SCD definitions are presented, together with the relevant epidemiological data. The pathogenesis of fatal cardiac arrhythmias, caused by cardiotoxic effects of antipsychotic medications, is discussed. Electrocardiographic changes, in particular QT interval changes, as well as risk factors of SCD and main principles of its prevention, are described in detail.

Mind and heart: heart rate variability in major depressive disorder and coronary heart disease - a review and recommendations

OBJECTIVE

There is a reciprocal association between major depressive disorder (MDD) and coronary heart disease (CHD). These conditions are linked by a causal network of mechanisms. This causal network should be quantitatively studied and it is hypothesised that the investigation of vagal function represents a promising starting point. Heart rate variability (HRV) has been used to investigate cardiac vagal control in the context of MDD and CHD. This review aims to examine the relationship of HRV to both MDD and CHD in the context of vagal function and to make recommendations for clinical practice and research.

METHODS

The search terms 'heart rate variability', 'depression' and 'heart disease' were entered into an electronic multiple database search engine. Abstracts were screened for their relevance and articles were individually selected and collated.

RESULTS

Decreased HRV is found in both MDD and CHD. Both diseases are theorized to disrupt autonomic control feedback loops on the heart and are linked to vagal function. Existing theories link vagal function to both mood and emotion as well as cardiac function. However, several factors can potentially confound HRV measures and would thus impact on a complete understanding of vagal mechanisms in the link between MDD and CHD.

CONCLUSIONS

The quantitative investigation of vagal function using HRV represents a reasonable starting point in the study of the relationship between MDD and CHD. Many psychotropic and cardiac medications have effects on HRV, which may have clinical importance. Future studies of HRV in MDD and CHD should consider antidepressant medication, as well as anxiety, as potential confounders.

Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management

Historically, treatment for schizophrenia focused on sedation. The advent of the typical antipsychotics resulted in treatment aimed specifically at the underlying disease, but these agents were associated with numerous adverse effects, and were not particularly effective at treatment of the negative symptoms of schizophrenia. As a result, numerous atypical agents have been developed over the past 2 decades, including several agents within the past 5 years. Overdose of antipsychotics remains quite common in Western society. In 2010, poison control centres in the US received nearly 43,000 calls related to atypical antipsychotics alone. Due to underreporting, the true incidence of overdose with atypical antipsychotics is likely much greater. Following overdose of an atypical antipsychotic, the clinical effects observed, such as CNS depression, tachycardia and orthostasis are largely predictable based on the unique receptor binding profile of the agent. This article, which focuses on the atypical antipsychotics commonly used in the treatment of schizophrenia, discusses the features commonly encountered in overdose. Specifically, agents that result in QT prolongation and the corresponding potential for torsades de pointes, as well as unique features encountered with the various medications are discussed. The diagnosis of this overdose is largely based on history. Routine use of drug screens is unlikely to be beneficial. The primary goal of management is aggressive supportive care. Patients with significant CNS depression with associated loss of airway reflexes and respiratory failure need advanced airway management. Hypotension should be treated first with intravenous fluids, with the use of direct acting vasopressors reserved for persistent hypotension. Benzodiazepines should be used for seizures, with barbiturates used for refractory seizures. Intravenous magnesium can be administered for patients with a corrected QT interval exceeding 500 milliseconds.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance

These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.

Analysis of efficacy and side effects in CATIE demonstrates drug response subgroups and potential for personalized medicine

OBJECTIVE

This study aims to improve understanding of antipsychotic non/response and assess the potential for personalized schizophrenia treatment.

METHODS

We used data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Efficacy measures included the Positive and Negative Syndrome Scale (PANSS) and neurocognitive functioning. Side effect measures included weight, lipids, glucose, heart rate and QT prolongation. Latent class analysis was conducted for each of the five drugs on the individual treatment effects to study whether there were subgroups of drug responders. The posterior probabilities of belonging to a particular response group were correlated across drugs to examine if patients not responding to one drug are likely to respond to a different drug and whether response to one drug may help to predict response to another drug.

RESULTS

We identified four qualitatively distinct response groups: Optimal Responders, Average Responders, Global Responders and Non-Responders. Different patterns of correlations with demographics and clinical variables across classes provided further support for the validity of these groups. The low correlations between posterior probabilities of the same response groups across drugs implied that patients generally belonged to different response groups for different drugs.

CONCLUSIONS

Our results demonstrate the existence of subgroups of patients characterized by distinct patterns of drug response. Further, findings suggest that patients who experience a poor response to one drug may be an optimal responder to another antipsychotic. Taken together these findings demonstrate the potential to personalize schizophrenia treatment and highlight the importance of identifying better predictors of drug response.

Sudden cardiac death after treatment with low dose risperidone in combination with cotrimoxazole

Risperidone as an antipsychotic drug raises the risk of serious ventricular tachyarrhythmias and sudden cardiac death; co-administered with other potentially arrhythmogenic drugs the risk escalates. There are some electrocardiographic markers which may help predict such events.

CASE REPORT

We describe a 47-year-old woman with acute psychosis, who died suddenly subsequent to refractory ventricular arrhythmia, while on low dose risperidone combined with cotrimoxazole.

CONCLUSION

This case report suggests that use of risperidone even at a low dose and in an apparently healthy individual is associated with a heightened risk of lethal ventricular tachyarrhythmia. Therefore, clinicians should always be aware of such awkward effect. It is recommended to obtain baseline electrocardiogram in all patients and follow up electrocardiograms in selected patients when considering such therapy in order to avoid fatal outcomes.

Probable quetiapine-mediated prolongation of the QT interval

PURPOSE

QT prolongation can occur with both first- (FGA) and second-generation antipsychotics (SGA). QT prolongation was identified in an adult patient who presented to the emergency room with schizophrenia, fluid and electrolyte imbalances, and pneumonia. Quetiapine, an SGA, was a component of the pharmacotherapy regimen. Based on the Naranjo adverse drug reaction probability scale rating criteria, a probable causal association was made.

METHODS

PubMed and Ovid were searched using the terms antipsychotic, psychotropic, QT interval, corrected QT interval (QTc) prolongation, and quetiapine. References were examined for additional articles related to antipsychotic drugs and the QT interval.

DISCUSSION

In this patient, the use of quetiapine was identified as a contributing factor in QT prolongation. Prior QT prolongation was experienced with ziprasidone, another SGA. The antidepressant and dose remained consistent throughout the inpatient course of treatment. Other risk factors in this patient included hypokalemia, dehydration, pneumonia, age, gender, and concurrent usage of an antidepressant. Dual psychiatric diagnoses, preexisting cardiovascular disease, and electrolyte disturbances may increase this risk potential.

CONCLUSION

Psychiatric patients may be more at risk of cardiovascular complications, such as QT interval prolongation. The pharmacist can help evaluate risk factors and provide input into the care of all patients, particularly those identified as at risk.

Safety of the electroconvulsive therapy-ziprasidone combination

In clinical practice, a nonnegligible proportion of patients with mood or psychotic disorders undergo electroconvulsive therapy (ECT) concomitantly with pharmacotherapy. Ziprasidone, a combined serotonin and dopamine receptor antagonist, is a second-generation antipsychotic agent with a lower incidence of extrapyramidal motor symptoms and prolactin elevation and a safer profile of adverse effects on plasma lipids, glucose levels, and body weight than other antipsychotics. To the best of our knowledge, there are as yet no available reports on the safety of the ECT-ziprasidone combination. We report here on a series of 8 female inpatients who underwent ECT while receiving ziprasidone (20-80 mg/d) as part of their regimen. Seven patients were treated for major depressive episode in the context of unipolar major depressive disorder (n = 5) or of bipolar disorder I (n = 2), whereas 1 patient was treated for exacerbation of schizophrenic symptoms. In all cases, the combination was well tolerated with only minimal adverse effects and unremarkable changes in corrected QT interval.

A case of torsades de pointes induced by severe QT prolongation after an overdose of eperisone and triazolam in a patient receiving nifedipine

INTRODUCTION

Eperisone hydrochloride is a centrally acting muscle relaxant, and triazolam is a short-acting benzodiazepine. Although commonly prescribed, cardiotoxicity induced by a single overdose of either drug is comparatively rare. A patient receiving nifedipine developed torsades de pointes (TdP) because of prolongation of the corrected QT (QTc) interval after an overdose of eperisone hydrochloride and triazolam.

CASE REPORT

A 60-year-old man receiving nifedipine was admitted in a comatose condition 3 h after ingesting 5,000 mg of eperisone and 2.5 mg of triazolam. Electrocardiogram showed sinus rhythm with prolongation of the QTc interval (820 ms). The serum electrolyte levels were as follows: potassium, 3.8 mEq/L; magnesium, 2.4 mg/dL. The serum drug concentrations were high: eperisone, 15,360 ng/mL; triazolam, 110.8 ng/mL. A temporary cardiac pacemaker was implanted immediately after the development of TdP, 11 h after the ingestion. The serum triazolam concentration normalized on day 2. The QTc interval and eperisone concentration normalized on day 6.

CONCLUSION

Eperisone and triazolam overdose can cause life-threatening cardiotoxicity. Electrocardiographic monitoring and serial determination of QTc interval are likely the best way to observe these patients and evaluate the risk of cardiotoxicity.

QTc interval in a sample of long-term schizophrenia inpatients

This naturalistic study attempted to determine the prevalence of prolonged QTc interval in a relatively large population of inpatients hospitalized with chronic schizophrenia, and to explore QTc relationship with demographic variables, metabolic parameters and prescribed treatments. All inpatients from a Spanish long-term psychiatric hospital were cross-sectionally investigated to determine the prevalence of QTc prolongation and metabolic syndrome. The sample with a DSM-IV diagnosis of schizophrenia included 171 Caucasian inpatients, all of Spanish origin. A prolonged QTc interval was defined as >450 ms in men and >470 ms in women. The relationships between QTc and other continuous variables were assessed using a linear regression model with QTc as the dependent variable. Only 10 patients (6%) had a prolonged QTc interval; one case was possibly explained by hypokalemia. Three patients (2%) had a QTc > 500 ms. Gender, old age (> or = 50 years old), current smoking, systolic blood pressure, HDL cholesterol and history of arrhythmia were found to have significant effects on QTc interval in a linear regression analysis. After controlling for significant variables, the mean QTc interval was not significantly influenced by antipsychotic dose, type of antipsychotic treatment, the use of depot antipsychotics, or the number of different antipsychotics prescribed. Our study focused on long-term schizophrenia inpatients with frequent antipsychotic polypharmacy and high antipsychotic doses, and suggested that after excluding the case with hypokalemia length of QTc was associated with history of arrhythmias and with metabolic factors, while the effects of antipsychotic compound or class were not so evident.

Whole genome association study identifies polymorphisms associated with QT prolongation during iloperidone treatment of schizophrenia

Administration of certain drugs (for example, antiarrhythmics, antihistamines, antibiotics, antipsychotics) may occasionally affect myocardial repolarization and cause prolongation of the QT interval. We performed a whole genome association study of drug-induced QT prolongation after 14 days of treatment in a phase 3 clinical trial evaluating the efficacy, safety and tolerability of a novel atypical antipsychotic, iloperidone, in patients with schizophrenia. We identified DNA polymorphisms associated with QT prolongation in six loci, including the CERKL and SLCO3A1 genes. Each single nucleotide polymorphism (SNP) defined two genotype groups associated with a low mean QT change (ranging from -0.69 to 5.67 ms depending on the SNP) or a higher mean QT prolongation (ranging from 14.16 to 17.81 ms). The CERKL protein is thought to be part of the ceramide pathway, which regulates currents conducted by various potassium channels, including the hERG channel. It is well established that inhibition of the hERG channel can prolong the QT interval. SLCO3A1 is thought to play a role in the translocation of prostaglandins, which have known cardioprotective properties, including the prevention of torsades de pointes. Our findings also point to genes involved in myocardial infarction (PALLD), cardiac structure and function (BRUNOL4) and cardiac development (NRG3). Results of this pharmacogenomic study provide new insight into the clinical response to iloperidone, developed with the goal of directing therapy to those patients with the optimal benefit/risk ratio.

The potential relationship between QTc interval prolongation and ziprasidone treatment: three cases

QTc interval prolongation may appear as a consequence of both typical and atypical antipsychotic treatments. Ziprasidone, which is effective in treating schizophrenia, is associated with QTc prolongation. Although the prolongation of QTc with ziprasidone treatment is often pronounced, there is a scarce number of cases reported about the relationship between ziprasidone and QTc prolongation. Of the three cases presented in this case series, two cases showed values exceeding 0.50 s with ziprasidone treatment.

Cellular mechanism of the QT prolongation induced by sulpiride

In this study, the authors investigated the electrophysiological effect of sulpiride on cardiac repolarization using conventional microelectrode recording techniques in isolated canine Purkinje fibers and a whole-cell patch clamp technique in transiently transfected cells with the hERG, KCNQ1/KCNE1, KCNJ2, and SCN5A cDNA and in rat cardiac myocytes for I(Ca). In studies of action potential duration, 10 microM, 100 microM, 300 microM, and 1 mM sulpiride prolonged action potential duration in a concentration-dependent manner. In studies of cardiac ion channels, sulpiride did not significantly affect I(Na), I(Ca), I(Ks), I(K1), except for I(Kr). Sulpiride dose-dependently decreased the hERG tail current. It is considered that the prolonged action potential duration by sulpiride was mainly the result of inhibition of the hERG channel. The data suggest that the clinical use of sulpiride is reasonable within therapeutic plasma concentrations, but all patients taking this drug should be cautiously monitored for clinical signs of long-QT syndrome and severe arrhythmia.

High prevalence of hypokalemia in acute psychiatric inpatients

BACKGROUND

Hypokalemia is an easily identifiable, clinically important but commonly neglected condition in psychiatric patients. This study intended to examine the prevalence of hypokalemia and its clinical correlates in acute psychiatric inpatients.

METHOD

This retrospective study was conducted over a 6 month period in 2008. The case notes, computerized records and laboratory results of all patients who were consecutively admitted to the acute psychiatric wards in a University-affiliated regional psychiatric unit were studied.

RESULT

Three hundred forty-seven patients out of 440 admissions were studied. Hypokalemia, as defined by serum potassium level of less than 3.5 mmol/L, was found in 20.5% of patients with a higher prevalence in psychotic patients (27.7%). The mean potassium level of psychotic patients was lower than that of the overall study population (3.72 vs. 3.81 mmol/L, P<.05). White cell counts among the hypokalemic patients were higher than those without hypokalemia (7.8 vs. 7.1 x 10(9)/L, P=.02).

CONCLUSION

Hypokalemia was common among acute psychiatric inpatients. Both agitation and the use of antipsychotics were postulated to contribute to the high prevalence of hypokalemia among acutely ill psychiatric patients.

Metabolic and Cardiac Side Effects of Second-generation Antipsychotics: What Every Clinician Should Know

In 2007, 5 of the 7 second-generation antipsychotics were listed in the Top 200 Drugs prescribed by retail sales in the United States. Cardiovascular disease is the leading cause of natural death in individuals with schizophrenia. Second-generation antipsychotics have been implicated with metabolic and cardiovascular adverse effects, and it is important for nonpsychiatric practitioners to be familiar with the monitoring parameters recommended for these agents. This article discusses the risk of weight gain, hyperglycemia, hyperlipidemia, hyperprolactinemia, and cardiovascular concerns associated with second-generation antipsychotic agents. It also discusses the proposed mechanisms for each of these adverse effects. Furthermore, it reviews suggested monitoring parameters to help manage cardiovascular disease in this patient population, and to improve the gap that exists between mental health care and physical health care in the schizophrenic population.

Effects of concomitant amiodarone and haloperidol on Q-Tc interval prolongation

PURPOSE

The effects of concomitant amiodarone and haloperidol on Q-Tc interval prolongation were studied.

METHODS

All adult patients admitted to a 618-bed tertiary referral teaching hospital between January 1, 2005, and December 31, 2006, who received amiodarone and haloperidol concomitantly were included in this retrospective descriptive analysis. Data collected to assess patients' risk of developing Q-T interval prolongation included age, sex, past medical history, and number of days of concomitant exposure. Data relevant for the assessment of cardiac effects were collected for the time period between 24 hours before and after the administration of haloperidol and included laboratory test values, use of other Q-T interval-prolonging drugs, heart rate, Q-Tc intervals, and clinical documentation of arrhythmia. To determine change in the Q-Tc interval, Q-T and R-R values were recorded using cardiac rhythm strips or electrocardiogram. Nurses' and physicians' records were reviewed to determine if an arrhythmia occurred. Descriptive statistics were used to analyze baseline patient information and Q-Tc interval data.

RESULTS

A total of 49 patients met inclusion criteria, yielding 381 distinct amiodarone-haloperidol exposures. During 138 (36.2%) of 381 haloperidol-amiodarone exposures, patients received at least one additional Q-T interval-prolonging drug. When amiodarone-haloperidol exposures were grouped by the number of concomitant Q-T prolonging drugs, no apparent association was detected between longer Q-Tc intervals and an increased number of concomitant Q-T interval-prolonging drugs.

CONCLUSION

A small, potentially significant Q-Tc interval prolongation, but not ventricular arrhythmia, was observed in adult patients who received a concomitant administration of amiodarone and haloperidol at a tertiary referral teaching hospital.

Sudden cardiac death secondary to antidepressant and antipsychotic drugs

A number of antipsychotic and antidepressant drugs are known to increase the risk of ventricular arrhythmias and sudden cardiac death. Based largely on a concern over QT prolongation and the development of life-threatening arrhythmias, a number of antipsychotic drugs have been temporarily or permanently withdrawn from the market or their use restricted. Some antidepressants and antipsychotics have been linked to QT prolongation and the development of Torsade de pointes arrhythmias, whereas others have been associated with a Brugada syndrome phenotype and the development of polymorphic ventricular arrhythmias. This review examines the mechanisms and predisposing factors underlying the development of cardiac arrhythmias, and sudden cardiac death, associated with antidepressant and antipsychotic drugs in clinical use.

An update on the use of antipsychotics in the treatment of delirium

Objective:

Delirium is the most common neuropsychiatric complication of medical illness, a medical emergency that needs to be identified and treated vigorously. Delirium is too frequently underdiagnosed and untreated in the medical setting, which leads to increased morbidity and mortality, interference in the management of symptoms such as pain, an increased length of hospitalization, increased health care costs, and distress for patients and their caregivers (Inouye, 2006; Breitbart et al., 2002a, 2002b). In this article, we present an update of the use of antipsychotics in management of delirium based on the available literature and our own clinical experience.

Methods:

We reviewed the current literature on the role of antipsychotics in the management of delirium using standard computer-based search methods (e.g., PubMed).

Results:

Antipsychotic medications, including the new atypical antipsychotics, have been demonstrated to effectively manage a wide spectrum of the symptoms of delirium and are an essential component in the multimodal approach to managing delirium.

Significance of results:

The standard approach to managing delirium includes identification and elimination of factors contributing to the delirium in addition to pharmacological and nonpharmacological treatment interventions (Trzepacz et al., 1999). Newer atypical antipsychotics can play an important role in the management of the symptoms of delirium.

[Cardiological monitoring of antipsychotic-treated patients: evaluation and evolution of a hospital protocol]

INTRODUCTION

Following the Agence Française de Sécurité Sanitaire des Produits de Santé (Afssaps) (French Health Authority) recommendations in 2001, which impose the rigorous follow-up (electrocardiogram [ECG] and ionogram) of patients treated with antipsychotics (AP), a monitoring protocol was elaborated and set up in the Caen psychiatric hospital in April 2002. Protocol evaluation compared with fixed aims was performed after two years' follow-up.

AIM OF THE STUDY

This protocol had to answer a triple aim: better identification of patients at risk, ensure in-treatment monitoring, be simple and adapted to daily practice.

INCLUSION CRITERIA

A systematic admission check-up (S0) which includes cardiological and biological controls and after one and six months' treatment control (S1 and S6) were recommended. The major risk factors (RF) researched were long QT interval, bradycardia and hypokaliemia.

RESULTS

The initial monitoring was conducted in 601 patients (that only corresponded to 17% of hospital admission active files during the considered period). Means delays before obtaining an ECG were three times those obtained existing biological check-ups (11 days versus three days after date of admission). Systematic and integrated characterisation controls on admission were not respected. We noted that two-third of patients admitted during this period were hospitalized for only five days, although the mean time to obtain an ECG is of 11 days. This delay (approximately one week) between ECG and biological check-up is not compatible with a complete patient RF evaluation. Respectively, 83 and 68 patients were controlled under treatment at S1 and S6. Only half of the patients were controlled at the one-month (S1) and 16% at the six-months' theoretical dates (S6). These delays are inappropriate, notably with regard to the mean time of hospitalisation (15-17 days). The incidence of major RF was higher in treated (71%) than in non-treated patients. Major RF presence at S0 was not systematically associated with an AP treatment contraindication. The excessive delay before the first ECG could partially explain why this initial check-up was not able to detect a pretreatment contraindication. On the other hand, AP treated patients who presented at least one major RF at S0 were more frequently monitored at S1 than patients who did not (26% versus 13%, p=0.05). Among the 168 patients treated with AP or other drugs prolonging the QT interval at risk, 33 had at least one follow-up. This risk population was not better controlled than the initial cohort.

DISCUSSION

Protocol evaluation is essential to improve its interest and feasibility. If systematic characterisation is simple, its application in practice is very difficult. The second version of the protocol presented here proposes to substitute the systematic ECG characterisation with the classification on admission of patients in "risk groups" that will condition the subsequent monitoring. Risk groups are identified into two RF types: those which are not related to AP treatment and those which are therapeutic attitude is adapted according to initial QTcorrigé (QTc), its progression between S0 and S (seven days) and kaliemia.