Antipsychotic agents and sudden cardiac death--how should we manage the risk?

New England Journal of Medicine (Impact Factor: 54.42). 02/2009; 360(3):294-6. DOI: 10.1056/NEJMe0809417
Source: PubMed
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    ABSTRACT: The aims of this study are to analyse, in community-dwelling people aged 65+ living in Italy's Lombardy Region, electrocardiographic (ECG) monitoring for new users of the atypical antipsychotic quetiapine co-prescribed with acetylcholinesterase inhibitors (AChEIs) or memantine and to find independent predictors of ECG monitoring before and after the starting of this prescription.
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    ABSTRACT: Although randomised controlled trials are regarded as the gold standard for treatments efficacy, evidence from observational studies remains relevant. To address the problem of possible confounding in these studies, investigators must employ analysis methods that adjust for confounders and lead to an unbiased estimation of the treatment effect. In this paper, the authors describe two relevant statistical methods. The first method represents the classical approach consisting of a multiple regression model including the effects of treatment and covariates. This approach considers the relation between prognostic factors and the outcome variable as a relevant criterion for adjustment. The second method is based on the propensity score, and focuses on the relation between prognostic factors and treatment assignment. These approaches were applied to a cohort of 183 French schizophrenic patients who were followed for a 2-year period (from 1998 to 2000). The probability of relapse according to antipsychotic treatment exposure was modelled using Cox regression models with the two statistical methods. Goodness-of-fit criteria were used to compare the modelling approaches. This study demonstrates that the propensity score, a predicted probability, has an important balancing property that underscores its value in strengthening the results of nonrandomised observational studies.
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    ABSTRACT: Cardiovascular disease (CVD) is one of the leading causes of death in the general population. An overwhelming body of evidence suggests that patients with serious mental illness (SMI) are at significantly higher risk for cardiovascular morbidity and mortality than those in the general population. The etiology of this excess CVD is multifactorial and includes the excessive accumulation of risk factors such as smoking, obesity, physical inactivity, and dyslipidemia in SMI patients, but other mechanisms due to the mental illness itself, as well as the effects of psychotropic drugs, may also be influential in increasing risk in this group. Psychotropic medications are prescription drugs that are used to treat or manage psychiatric symptoms or challenging behaviors; these include antipsychotics, antidepressants, and anxiolytics, as well as mood stabilizers. Such drugs act both directly and indirectly on the cardiovascular system producing adverse effects that range from orthostatic hypotension to sudden cardiac death. This chapter focuses predominantly on the effects of the available antipsychotic and antidepressant medications reported to be used among clinical populations.
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