Pediatric Patients Should Undergo Electrocardiogram Assessment Before Antipsychotic Treatment

Patients should undergo a baseline electrocardiogram (ECG) assessment before starting antipsychotic medication treatment, a study published in Journal of Clinical Psychopharmacology stated, with a specific focus on patients with concomitant use of attention-deficit/hyperactivity disorder drugs and a family/personal history of heart disease.¹

Researchers from the Child and Adolescent Psychiatric Unit of the Psychiatry Department at Puerta de Hierro-Majadahonda University hospital in Madrid, Spain, sought to describe the prevalence of corrected QT interval disorders and possible predisposing factors in children and adolescents treated with antipsychotic medications with a long-term follow-up. Part of the impetus behind this study was the relative scarcity of clinical trials as well as real clinical practice studies focusing explicitly on ECG changes in children and adolescents undergoing antipsychotic treatment.

“The effect of individual APs on the QTc in young patients is still uncertain, and clinicians may be concerned about it when prescribing [antipsychotics],” Immaculada Palanca-Maresca, MD, lead researcher of the study, and coauthors wrote.

For this study, the researchers obtained data from the Safety of Neuroleptics in Infancy and Adolescence (SENTIA) registry, which includes patients younger than 18 years who are currently taking or initiating treatment with antipsychotic modifications. At the time of the study, 101 patients had been enrolled since January 1, 2011. The mean age was 11.5 years, and 75% of the patients were boys.

Antipsychotic-naive patients were monitored before starting treatment and after 1, 3, and 6 months, and then on a 6-month basis; patients already taking antipsychotics for longer than 1 month were assessed on a 6-month basis.

All ECGs “were obtained at the same time in the morning. All observed abnormalities were confirmed with a second ECG within the following 0.5 hour and confirmed by a pediatric cardiologist,” the authors write.

“The QT duration was corrected for heart rate according to the Bazett formula and averaged for all assessed leads using the software integrated into the ECG device,” they note. The researchers calculated QTc dispersion as the difference between the longest and shortest individual-lead QTc.

Risperidone (52.2%) and aripiprazole (45.5%) were the antipsychotics prescribed most often. “No patient had a QTc interval lasting more than 500 milliseconds,” and “[s]even patients had abnormal changes in QTc (6.9%),” the authors wrote.

“A statistically significant difference (P = 0.04) in the occurrence of QT abnormalities was found for ECG performed in patients receiving concomitant treatment with [attention-deficit/hyperactivity disorder] medicines.”

The findings of this study contradict earlier research suggesting that “[antipsychotic] treatment, with or without methylphenidate, in very young children is not commonly associated with significant alterations in the QT interval and dispersion. Our findings suggest the opposite and point to a possible risk,” the authors warned.

The researchers also determined that “CV family history in first- and second-generation relatives should be carefully assessed when prescribing antipsychotics because it is a potential risk factor for [ECG] abnormalities.” These abnormalities “do not show a temporal pattern,” and sometimes were only detected after 12 months of chronic treatment.

“It is recommended that physicians consider cardiovascular risk factors and status (including QTc interval) when choosing APs for youth and, depending on patient and treatment-related risk factors, monitor the QTc intervals as well,” the authors wrote.

“[A]lthough QTc changes secondary to [antipsychotic] treatment in pediatric populations seem to be mild and not clinically relevant, additional efforts are necessary to improve monitoring of adverse effects,” the authors wrote. “[T]his recommendation is also valid for medications that do not lead to QTc prolongation in the basal state, but which may do so if a preexisting risk factor is present.”

References

1. Palanca-Maresca I, Ruiz-Antorán B, Centeno-Soto GA, Forti-Buratti MA, et al. Prevalence and risk factors of prolonged corrected qt interval among children and adolescents treated with antipsychotic medications: a long-term follow-up in a real-world population. J Clin Psychopharmacol. 2017;37:78-83. doi: 10.1097/JCP.0000000000000639.
2. Nahshoni E, Spitzer S, Berant M, Shoval G, et al. QT interval and dispersion in very young children treated with antipsychotic drugs: a retrospective chart review. J Child Adolesc Psychopharmacol. 2007;17:187-194. doi: 10.1089/cap.2007.0061