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Hussain F, Moazez C, Allen K, Hsu P, Welch K, Febbo J, Rehman M, Garcia M. Myocarditis Presenting as ST-Elevation Myocardial Infarction. Cureus 2023; 15:e47883. [PMID: 38021557 PMCID: PMC10681706 DOI: 10.7759/cureus.47883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
When evaluating a patient with ST-segment elevation on ECG and acute chest pain, providers often rapidly arrive at the diagnosis of ST-elevation myocardial infarction (STEMI). As myocardial infarction is deadly and time is of the essence in establishing reperfusion, it is reasonable to place it at the top of the differential. However, doing so should not come at the expense of conducting a thorough clinical evaluation, considering all causes of ST-segment elevation, and creating a comprehensive differential. Myocarditis, in particular, can present similarly to myocardial infarction and misdiagnosis can lead to unnecessary and sometimes harmful interventions such as thrombolytic therapy, vasodilator therapy, or coronary angiography. We present a case of myocarditis mimicking STEMI and discuss diagnosis and treatment of myocarditis.
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Affiliation(s)
- Fahad Hussain
- Internal Medicine, Northwell Health, Manhasset, USA
- Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Carmel Moazez
- Cardiology, University of California, Los Angeles, Los Angeles, USA
| | - Kathleen Allen
- Cardiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Pamela Hsu
- Cardiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Kathryn Welch
- Radiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Jennifer Febbo
- Radiology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Mueez Rehman
- Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Mark Garcia
- Cardiology, University of New Mexico School of Medicine, Albuquerque, USA
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Clapham E, Reutfors J, Linder M, Brandt L, Sundström J, Bodén R. The association between exposure to clozapine, olanzapine, and quetiapine and the outcomes perimyocarditis and heart failure: A population-based cohort study. Psychiatry Res 2023; 326:115336. [PMID: 37451082 DOI: 10.1016/j.psychres.2023.115336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
The risk of cardiac adverse events following clozapine use is debated and is unknown for the chemically related and widely used antipsychotics olanzapine and quetiapine. National Swedish registers were used to identify all patients 16-75 years old with antipsychotic dispensations between 2005 and 2018. The short-term outcome was a diagnosis of perimyocarditis (pericarditis and/or myocarditis) within two months of first dispensation, and the long-term outcome was heart failure (including cardiomyopathy) within three years. Cox regressions with time varying exposure were used to estimate hazard rates (HR) and their 95% confidence intervals (CI). A total of 201,045 individuals were included in the cohort. The risk of developing perimyocarditis during clozapine treatment tripled compared to no antipsychotic treatment (HR 3.4, CI 1.6-7.3), although the absolute rate remained comparably low. The long-term risk of heart failure during clozapine treatment was also elevated (HR 1.3, CI 1.1-1.7). Treatment with either or both olanzapine or quetiapine was not associated with an increased relative risk of perimyocarditis, or heart failure compared to no antipsychotic treatment. Clozapine use is therefore associated with a substantially elevated short-term risk of perimyocarditis and an increased risk of heart failure within three years.
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Affiliation(s)
- Eric Clapham
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden; Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden.
| | - Johan Reutfors
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Marie Linder
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden
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3
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De las Cuevas C, Sanz EJ, Rohde C, de Leon J. Association between myocarditis and antipsychotics other than clozapine: a systematic literature review and a pharmacovigilance study using VigiBase. Expert Rev Clin Pharmacol 2022; 15:65-78. [DOI: 10.1080/17512433.2022.2032659] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain
- Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
| | - Emilio J. Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain
- Hospital Universitario de Canarias, Tenerife, Spain
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, US
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Atypical antipsychotics and oxidative cardiotoxicity: review of literature and future perspectives to prevent sudden cardiac death. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2021; 18:663-685. [PMID: 34527032 PMCID: PMC8390928 DOI: 10.11909/j.issn.1671-5411.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Oxidative stress is considered the principal mediator of myocardial injury under pathological conditions. It is well known that reactive oxygen (ROS) or nitrogen species (RNS) are involved in myocardial injury and repair at the same time and that cellular damage is generally due to an unbalance between generation and elimination of the free radicals due to an inadequate mechanism of antioxidant defense or to an increase in ROS and RNS. Major adverse cardiovascular events are often associated with drugs with associated findings such as fibrosis or inflammation of the myocardium. Despite efforts in the preclinical phase of the development of drugs, cardiotoxicity still remains a great concern. Cardiac toxicity due to second-generation antipsychotics (clozapine, olanzapine, quetiapine) has been observed in preclinical studies and described in patients affected with mental disorders. A role of oxidative stress has been hypothesized but more evidence is needed to confirm a causal relationship. A better knowledge of cardiotoxicity mechanisms should address in the future to establish the right dose and length of treatment without impacting the physical health of the patients.
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van der Horst MZ, van Houwelingen F, Luykx JJ. Isolated nausea and vomiting as the cardinal presenting symptoms of clozapine-induced myocarditis: a case report. BMC Psychiatry 2020; 20:568. [PMID: 33246443 PMCID: PMC7694895 DOI: 10.1186/s12888-020-02955-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Clozapine is an atypical antipsychotic proven to be superior in the treatment of treatment-resistant schizophrenia. Myocarditis is a rare, but well-known complication of treatment with clozapine. Only few cases have been reported in which nausea and vomiting were prominent symptoms. This is the first described report in which nausea and vomiting were the only presenting symptoms of clozapine-induced myocarditis. CASE PRESENTATION We report a case of a 58-year-old woman, suffering from schizoaffective disorder, who is being treated with clozapine. Two weeks after initiation of clozapine, she developed nausea and vomiting, in absence of any other clinical symptoms. Laboratory examination and magnetic resonance imaging confirmed the diagnosis of clozapine-induced myocarditis. Clozapine was discontinued and the patient recovered fully. CONCLUSIONS This case emphasizes the importance of recognizing myocarditis as a cause of isolated nausea and vomiting in patients treated with clozapine. Early recognition improves clinical outcome and reduces mortality.
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Affiliation(s)
- M. Z. van der Horst
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, The Netherlands
| | - F. van Houwelingen
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J. J. Luykx
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, The Netherlands
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Sweeney M, Whiskey E, Patel RK, Tracy DK, Shergill SS, Plymen CM. Understanding and managing cardiac side-effects of second-generation antipsychotics in the treatment of schizophrenia. BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
SUMMARYSecond-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.LEARNING OBJECTIVESAfter reading this article you will be able to:
•understand the relative incidence of cardiotoxic side-effects of the various SGAs•perform preliminary investigations to diagnose the common cardiotoxic side-effects of SGAs•understand the treatments for these cardiac side-effects and the role of cardiologists involved the care of these patients.
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Li X, Peng Z, Zhou Y, Wang J, Lin X, Dong X, Liu X, Jiang J, Jiang Y, Li L. Quetiapine induces myocardial necroptotic cell death through bidirectional regulation of cannabinoid receptors. Toxicol Lett 2019; 313:77-90. [PMID: 31220554 DOI: 10.1016/j.toxlet.2019.06.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/18/2022]
Abstract
Quetiapine is a common atypical antipsychotic used to treat mental disorders such as schizophrenia, bipolar disorder, and major depressive disorder. There has been increasing number of reports describing its cardiotoxicity. However, the molecular mechanisms underlying quetiapine-induced myocardial injury remain largely unknown. Herein, we reported a novel cell death type, quetiapine-induced necroptosis, which accounted for quetiapine cardiotoxicity in mice and proposed novel therapeutic strategies. Quetiapine-treated hearts showed inflammatory infiltration and evident fibrosis after 21-day continuous injection. The specific increases of protein levels of RIP3, MLKL and the phosphorylation of MLKL showed that quetiapine induced necroptotic cell death both in vivo and in vitro. Pharmacologic blockade of necroptosis using its specific inhibitor Necrostatin-1 attenuated quetiapine-induced myocardial injury in mice. In addition, quetiapine imbalanced the endocannabinoid system and caused opposing effects on two cannabinoid receptors (CB1R and CB2R). Specific antagonists of CB1R (AM 281, Rimonabant), but not its agonist ACEA significantly ameliorated the heart histopathology induced by chronic quetiapine exposure. By contrast, specific agonists of CB2R (JWH-133, AM 1241), but not its antagonist AM 630 exerted beneficial roles against quetiapine cardiotoxicity. The protective agents (AM 281, Rimonabant, AM 1241, and JWH-133) consistently inactivated the quetiapine-induced necroptosis signaling. Quetiapine bidirectionally regulates cannabinoid receptors and induces myocardial necroptosis, leading to cardiac toxic effects. Therefore, pharmacologic inhibition of CB1R or activation of CB2R represents promising therapeutic strategies against quetiapine-induced cardiotoxicity.
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Affiliation(s)
- Xiaoqing Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Zhao Peng
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Yiling Zhou
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Jing Wang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Xinyi Lin
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Xiaoru Dong
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Xiaochen Liu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Jieqing Jiang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Yan Jiang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China.
| | - Liliang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China; Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Public Security Bureau, Shanghai 200083, China.
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8
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The use of quetiapine in the treatment of major depressive disorder: Evidence from clinical and experimental studies. Neurosci Biobehav Rev 2018; 86:36-50. [DOI: 10.1016/j.neubiorev.2017.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/24/2017] [Accepted: 12/24/2017] [Indexed: 12/19/2022]
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Abstract
The use of antipsychotic medications has now expanded to multiple mental health conditions beyond schizophrenia. This has increased the overall population exposure to these medications, which have been associated with both metabolic changes and adverse cardiovascular effects. QTc prolongation, torsades de pointes, sudden cardiac death, myocarditis, and cardiomyopathy are all very real concerns that clinicians face on a regular basis. One must take these risks into consideration when selecting antipsychotic therapy and also when determining whether therapeutic changes and adjustments are necessary. This review examines a number of cardiac-associated concerns, the role that antipsychotics may play in contributing to these adverse events, and suggested management interventions.
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Affiliation(s)
- Steven C Stoner
- Chair and Clinical Professor, Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri,
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11
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Solmi M, Murru A, Pacchiarotti I, Undurraga J, Veronese N, Fornaro M, Stubbs B, Monaco F, Vieta E, Seeman MV, Correll CU, Carvalho AF. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag 2017; 13:757-777. [PMID: 28721057 PMCID: PMC5499790 DOI: 10.2147/tcrm.s117321] [Citation(s) in RCA: 248] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.
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Affiliation(s)
- Marco Solmi
- Neuroscience Department, University of Padua
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Juan Undurraga
- Department of Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo
- Early Intervention Program, J. Horwitz Psychiatric Institute, Santiago, Chile
| | - Nicola Veronese
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- National Research Council, Ageing Section, Padua
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, School of Medicine, University “Federico II”, Naples, Italy
- New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Brendon Stubbs
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Francesco Monaco
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Eduard Vieta
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Christoph U Correll
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks
- Department of Psychiatry and Molecular Medicine Hempstead, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - André F Carvalho
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Translational Psychiatry Research Group and Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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Vang T, Rosenzweig M, Bruhn CH, Polcwiartek C, Kanters JK, Nielsen J. Eosinophilic myocarditis during treatment with olanzapine - report of two possible cases. BMC Psychiatry 2016; 16:70. [PMID: 26988850 PMCID: PMC4794841 DOI: 10.1186/s12888-016-0776-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 03/09/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Drug-induced eosinophilic myocarditis is a life-threatening and frequently overlooked condition. The prevalence of myocarditis in clozapine-treated patients may be as high as 3 %. An association between olanzapine and myocarditis has not previously been described, but given the chemical similarity between olanzapine and clozapine, we hypothesized the existence of such an association. We searched the spontaneous adverse drug reports database of the Danish Health and Medicines Authority for olanzapine and myocarditis in the period from October 21, 1996 to - June 03, 2015. We identified two fatal cases of eosinophilic myocarditis associated with the use of olanzapine. CASE PRESENTATION Case 1 was a 39-year-old Caucasian man with known substance abuse and schizophrenia. He was found dead in his home. Olanzapine was prescribed at day -54, and dose at time of death was 40 mg/day. Post-mortem toxicological examination demonstrated presence of olanzapine, morphine, venlafaxine and oxazepam. Syringes indicating substance abuse were found in his home. Case 2 was a 36-year-old Caucasian man diagnosed with schizophrenia was found dead unexpectedly. There was no history of substance abuse. Current treatment was olanzapine 20 mg/day +5 mg as PRN (prescribed for almost 4 years), aripiprazole 30 mg/day (prescribed for 6 months) and mirtazapine 30 mg/day (prescribed for 6 months). Both cases of eosinophilic myocarditis were confirmed by autopsy findings and both patients received olanzapine in doses exceeding the recommendations. CONCLUSION Olanzapine may have contributed to and/or worsened the two reported fatal cases of myocarditis. Additional studies are required to establish a causal link between olanzapine and eosinophilic myocarditis.
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Affiliation(s)
- Torkel Vang
- Aalborg University Hospital, Psychiatry, Brandevej 5, 9220 Aalborg, Demmark
| | | | | | - Christoffer Polcwiartek
- Aalborg University Hospital, Psychiatry, Brandevej 5, 9220 Aalborg, Demmark ,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jørgen Kim Kanters
- Laboratory of Experimental Cardiology, University of Copenhagen, Copenhagen, Denmark ,Department of Cardiology, Herlev University Hospital, Copenhagen, Denmark
| | - Jimmi Nielsen
- Aalborg University Hospital, Psychiatry, Brandevej 5, 9220, Aalborg, Demmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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