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Sudden cardiac death with clozapine and sertraline combination
J D Hoehns1, M M Fouts, M W Kelly
1College of Pharmacy, The University of Iowa, Iowa City, USA. jhoehns@neimef.org
Insights
Sudden cardiac death occurred in a young man on clozapine and sertraline. Autopsy revealed cardiomyopathy and coronary artery disease, suggesting these medications may have contributed to fatal cardiac arrhythmia.
Area of Science:
- Cardiology
- Psychiatry
- Pharmacology
Background:
- Antipsychotic and antidepressant medications are widely prescribed for various psychiatric conditions.
- Clozapine and sertraline are commonly used, but their cardiac effects warrant careful consideration.
- Sudden cardiac death (SCD) is a significant concern in patients with pre-existing cardiovascular risk factors or those on certain medications.
Observation:
- A 26-year-old male with a history of schizophrenia, OCD, and depression experienced SCD.
- He was on a regimen including clozapine, sertraline, risperidone, atenolol, and lorazepam.
- Autopsy findings included cardiomegaly, coronary artery disease, and normal therapeutic drug levels for clozapine and sertraline.
Findings:
- The patient exhibited cardiomegaly and coronary artery disease, indicative of underlying cardiac pathology.
- Sudden cardiac death was attributed to acute cardiac arrhythmia.
- The combination of clozapine and sertraline, known to have potential cardiac effects, was considered a contributing factor.
Implications:
- This case highlights the potential cardiac risks associated with clozapine and sertraline combination therapy.
- Clinicians should be vigilant for cardiac abnormalities in patients on these medications, especially those with risk factors.
- Further research into the cardiotoxicity of combined antipsychotic-antidepressant therapy is warranted to inform clinical practice and patient safety.
Objective:
To report a case of sudden cardiac death in a patient receiving combination therapy with clozapine and sertraline.
Case Summary:
A 26-year-old white man was discovered dead at his residence. His medical history included chronic paranoid schizophrenia, obsessive-compulsive disorder, major depressive disorder, obstructive sleep apnea, and akathisia. He had no prior history of cardiovascular disease. His medication regimen included clozapine 100 mg twice daily (started 4 y prior to his death), risperidone 3 mg twice daily, sertraline 200 mg once daily, atenolol 50 mg twice daily, and lorazepam 0.5 mg four times daily. Autopsy and toxicology studies revealed cardiomegaly suggestive of idiopathic cardiomyopathy, single-vessel coronary artery disease, sertraline and clozapine blood concentrations in the expected range, undetectable lorazepam and risperidone blood concentrations, obesity, and moderate fatty changes to the liver. The most likely cause of death was sudden cardiac death due to acute cardiac arrhythmia.
Discussion:
Clozapine is structurally similar to the tricyclic antidepressants, which have type 1 A antiarrhythmic properties. Case reports have described electrocardiographic abnomalities, cardiomyopathy, and fatal myocarditis associated with its use. Unexplained death in patients on clozapine therapy has also been reported. Sertraline appears to have less cardiac effect; however, one report has observed clinically significant QT prolongation during sertraline therapy.
Conclusions:
Clozapine-induced cardiomyopathy and cardiac arrhythmia from clozapine and/or sertraline use may have contributed to this man's death.