Cardiovascular risk management in patients using antipsychotics: it is time to take action
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COMMENTARY
Open Access
Cardiovascular risk management in patients using antipsychotics: it is time to take action Erik W. M. A. Bischoff* , Kirsti M. Jakobs and Willem J. J. Assendelft
Keywords: Cardiovascular risk management, Antipsychotic drugs, Primary care
Background The study from Lai and colleagues, recently published in BMC Medicine, provides interesting new insights on sex-related associations between antipsychotic use and acute ischemic heart disease [1]. The authors demonstrated that antipsychotic use was associated with a 32% increased hazard rate of acute ischemic heart disease (IHD) among women (95% CI 1.05–1.67), but not among men. In their Hong Kong primary care population, almost 2% were prescribed antipsychotic drugs. The use of antipsychotic medications is increasing worldwide. Antipsychotics are indicated for the treatment of severe mental illness (SMI), including psychotic and bipolar disorder. Remarkably, a large proportion of patients on antipsychotics do not have a diagnosis of SMI. This off-label use can add up to 60% of antipsychotic prescriptions, particularly for atypical antipsychotic drugs such as olanzapine [2]. Reasons for offlabel prescriptions are anxiety, depression, dementia, sleep, and personality disorders [2]. As a result of such increased use, long-term side effects of antipsychotic drugs may increase the burden on patients and healthcare services globally. Long-term use may affect metabolic pathways, thereby causing weight gain, glucose intolerance, dyslipidemia, and cardiac toxicity, resulting in an increased risk of diabetes, cardiovascular disease, This comment refers to the article available at https://doi.org/10.1186/ s12916-020-01765-w. * Correspondence: [email protected] Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
and mortality [3]. Current guidelines on cardiovascular risk management, such as those from the National Institute for Health and Care Excellence (NICE) [4], are particularly relevant for cardiometabolic risk in patients on antipsychotic drugs, specifically atypical antipsychotics. However, risk management in patients on antipsychotics is often performed poorly [5]. A recent study showed screening rates in less than 10% of Dutch primary care patients using antipsychotics [6]. What do the study results of Lai and colleagues add to current clinical guidelines? And do their results support further improvement of cardiovascular risk management implementation?
Variations in side effects and the influence of patient factors Lai and colleagues performed a retrospective study using primary care data of over one million patients. A retrospective design, however, is unsuitable to prove causality. Important known intermediate variables, like cholesterol and blood glucose level, and an unhealthy lifestyle, were not taken into account. Therefore, confounding by indication cannot be ruled out. The same problem occurs with dosage, duration of the use, and the underlying diagnos
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