A Practical Approach to Avoiding Cardiovascular Adverse Effects of Psychoactive Medications

Drugs that act on mental state, generally termed "psychoactive agents," are among the most widely used medications in medicine. Psychoactive agents can affect the cardiovascular system and must be used carefully to avoid negative cardiovascular consequences. In the present article we review the potential adverse cardiovascular consequences of psychoactive medications and provide suggestions for practical approaches to avoiding them. We consider adverse reactions in terms of: (1) arrhythmias (particularly acquired long QT syndrome); (2) blood pressure; (3) ventricular function; (4) effect on risk factors; (5) teratogenicity; and (6) drug interactions. Minimizing QT liability requires a consideration of patient-specific risk factors and the risk profile of drugs available to treat the psychiatric condition. Drugs with QT-prolonging properties can be used safely, provided that appropriate precautions are taken. Fear of QT-prolongation should not deprive patients of needed psychiatric therapy. For example, one large study reported substantially increased all-cause mortality/hospitalization, death/depression-hospitalization, and death/arrhythmia-hospitalization in patients for whom citalopram dosage was reduced over QT-concerns after the Food and Drug Administration Black Box Warning. In general, attention to drug-specific cardiac adverse effect risks is needed, along with appropriate patient-related drug selection and follow-up, to detect adverse reactions early and adjust accordingly. Treatment should begin with low doses, followed by careful dose titration and adjustment of drug regimen according to clinical responses. Particular care is needed to minimize negative consequences on cardiovascular/metabolic risk profile, which might have very detrimental long-term effects on cardiovascular health. It is crucial that fear of cardiovascular adverse effects not deprive patients of appropriate psychoactive drug-therapy.