Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
CNS Drugs. 2017 Sep;31(9):777-795. doi: 10.1007/s40263-017-0461-9.
Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.
心肌炎在接受氯氮平治疗的患者中约占 3%，但监测可降低严重后果的风险。心肌炎后或长期心动过速可能导致心肌病。使用超声心动图监测被认为不具有成本效益。心动过速、体位性低血压和心率变异性降低是一组与自主神经功能障碍相关的氯氮平相关不良影响，长期来看可能会产生严重后果。升高的心率和较差的心率变异性可以用β受体阻滞剂或非二氢吡啶类钙通道阻滞剂治疗，而体位性低血压可以通过增加液体摄入和腹部包扎来缓解，但可能需要药物干预。适当纠正心率可能表明氯氮平不会延长 QT 间期。其他心血管效应、肺栓塞、代谢综合征、心源性猝死，特别是心血管疾病事件导致的死亡率过高，可能与精神疾病、生活方式因素以及心血管疾病及其危险因素的治疗不佳的关联比与氯氮平治疗的关联更为密切。鉴于氯氮平的疗效和与其他抗精神病药物相比死亡率降低的证据，当指征明确时应开氯氮平处方，应将患者纳入生活方式方案以增加运动和改善饮食，并转介进行心血管疾病及其危险因素的诊断和治疗。
