Antipsychotics cardiotoxicity: What's known and what's next

Physical illness in schizophrenia and the role of tolerability in antipsychotic selection: an expert consensus with a focus on cariprazine

BACKGROUND

Schizophrenia is a highly heterogeneous disease, and a high percentage of patients are at high risk of developing somatic comorbidities, which must be taken into account in disease management and treatment selection.

MAIN BODY

Antipsychotics are often associated with side effects that worsen the somatic comorbidities. Among the different options, cariprazine is generally safe and usually well tolerated in both acute and long-term treatment and is often a good choice when balancing clinical benefits and side effects. Given the lack of consensus on the priority of symptoms to treat and the reasons for switching therapy based on the balance between side effects and symptom resolution, twelve psychiatrists met for an expert meeting to discuss the most common and worrisome antipsychotic side effects leading to switching, the most important somatic comorbidities, and the best way to address specific symptoms in both the acute and maintenance phases of treatment in schizophrenia. Special attention was given to metabolic comorbidities, sexual dysfunction, and cardiovascular disease. This paper aims to examine the relationship between schizophrenia and specific somatic comorbidities, to discuss how the balance between efficacy and tolerability influences treatment choice in the acute and maintenance treatment of schizophrenia, and how these two variables may have different priorities at different stages of treatment.

CONCLUSION

The choice of treatment is based primarily on efficacy and tolerability. Cariprazine is beneficial in patients with positive and negative symptoms, and it has a side-effect profile with low rates of metabolic side effects, sedation, and sexual dysfunction.

Breaking Barriers Transforming Primary Care to Serve the Physical Health Needs of Individuals With SMI in the NHS

This critical review paper examines the health inequalities faced by individuals with Severe Mental Illness (SMI) in the United Kingdom; highlighting the disproportionate burden of physical health conditions such as respiratory disorders, cardiac illnesses, diabetes and stroke amongst this population. These conditions contribute to a significantly higher rate of premature mortality in individuals with SMI, with two-thirds of these deaths deemed preventable. Despite the National Health Service (NHS) acknowledging the need to address these health inequalities, the mortality gap between those with and without SMI continues to widen. Additionally, there is limited engagement from service users in annual physical health checks, a concern that this paper addresses by identifying several barriers and providing recommendations to improve access and engagement in physical health checks. This review emphasises the focus on primary care systems as a critical point for addressing health disparities in individuals with SMI. Also, it highlights the need for primary care services to be more adaptive and integrated, playing a key role in managing the physical health of patients with SMI through regular health checks, flexible service delivery, and enhanced coordination with secondary care. Effectively supporting individuals with SMI requires tailored, integrated primary care interventions that address both psychological and physical health challenges, considering diverse demographic needs across the UK.

Echocardiography with Strain Assessment in Psychiatric Diseases: A Narrative Review

Mental disorders (MDs) are among the major causes of morbidity and mortality worldwide. Individuals with severe MDs have a shorter life expectancy, primarily due to cardiovascular diseases. Echocardiography facilitates the evaluation of alterations in cardiac morphology and function, resulting from various cardiac pathologies. The aim of this review was to explore the current evidence base behind the myocardial deformation observed in echocardiography in patients with MDs. We primarily focused on the data regarding speckle tracking echocardiography. PubMed, using medical subject headings, was searched to identify studies on this topic. The collected data demonstrated changes in myocardial function in schizophrenia, bipolar disorder, depression, anxiety disorder, stressor-related disorder, post-traumatic stress disorder, eating disorders, sleep-wake disorders, substance-related and addictive disorders, neurocognitive disorders, and borderline personality disorder. The recurrent findings included impaired Left Ventricular Ejection Fraction and Left Ventricular Hypertrophy. Global Longitudinal Strain was significantly altered in patients with anorexia nervosa, bipolar disorder, and substance-related disorders. All reported studies support the consideration of cardiology consultations and a multidisciplinary approach in the care of patients with MDs with suspected cardiac dysfunction. Further investigation is warranted to determine the significance and prognostic value of myocardial deformation and strain measurements among individuals with MDs, focusing on the value of early detection, especially in asymptomatic cases.

Heart abnormality associates with a wide spectrum of psychiatric disorders: Evidence from Mendelian randomization analyses

Psychiatric disorders and heart abnormality are closely interconnected. Previous knowledge has been well-established that psychiatric disorders can lead to increased cardiovascular morbidity and even sudden cardiac death. Conversely, whether heart abnormality contributes to psychiatric disorders remains rarely studied. The work by Zhang et al pointed out that chronic heart failure had effects on the anxiety and depression (AD) severity, and indices including left ventricular ejection fraction, N-terminal pro-brain natriuretic peptide and interleukin-6 were independent risk factors for AD severity. In addition to the aforementioned AD, we herein find that heart failure might additionally impact the development of autism spectrum disorder and post-traumatic stress disorder (albeit P > 0.05), and significantly protects against the presence of attention deficit hyperactivity disorder (ADHD), [odds ratio (OR) = 0.61, P = 0.0071] by using a Mendelian randomization analysis. Bradycardia is also a protective factor for ADHD (OR = 0.61, P = 0.0095), whereas hypertrophic cardiomyopathy is a mild risk factor for schizophrenia (OR = 1.02, P = 0.032). These data suggest a wide spectrum of psychiatric disorders secondary to heart abnormality, and we highlight more psychiatric care that should be paid to patients with heart abnormality.

Second Generation Antipsychotics and Cardiovascular Adverse Effects: Developing Evidence-Based Recommendations for Primary Care Medicine

Background

Second-generation antipsychotic medications (SGAs) are often used by primary care physicians (PCPs) to treat multiple psychiatric diagnoses. SGAs have been connected to a number of adverse effects, including cardiovascular disease. Currently, there are no published evidence-based recommendations addressing SGAs and cardiotoxicity that are directed toward PCPs. This project aims to fill this gap.

Methods

Relevant search terms related to SGAs and cardiovascular disease were identified and then used to search databases (PubMed, PubMed Central, and AccessMedicine). Research studies obtained from the searches were narrowed to include systematic reviews and meta-analyses. The Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool was utilized by 2 investigators to evaluate the quality of the research independently. Research rated by both investigators to be of high and moderate quality using the AMSTAR-2 system was employed to develop recommendations for PCPs when using SGAs with their patients.

Results

Seven systematic reviews and meta-analyses were found to be of high or moderate quality by AMSTAR-2 evaluations. The studies identified associations between SGAs and a number of adverse cardiac conditions, including corrected QT interval (QTc) prolongation, arrhythmias, myocardial infarction, tachycardia, and other cardio-metabolic associated morbidities.

Conclusion

Our project indicated that cardiovascular risks can be associated with SGAs and that screening and monitoring for cardiac toxicities are indicated when treating patients with this class of medications. These risks, however, do not appear to override benefits in most patients. Furthermore, it appears that when using SGAs, methods of risk reduction can be applied effectively in the primary care setting.

Aripiprazole, but Not Olanzapine, Alters the Response to Oxidative Stress in Fao Cells by Reducing the Activation of Mitogen-Activated Protein Kinases (MAPKs) and Promoting Cell Survival

Prolonged use of atypical antipsychotics (AAPs) is commonly associated with increased cardiovascular disease risk. While weight gain and related health issues are generally considered the primary contributors to this risk, direct interference with mitochondrial bioenergetics, particularly in the liver where these drugs are metabolized, is emerging as an additional contributing factor. Here, we compared the effects of two AAPs with disparate metabolic profiles on the response of Fao hepatoma cells to oxidative stress: olanzapine (OLA), which is obesogenic, and aripiprazole (ARI), which is not. Results showed that cells treated with ARI exhibited resistance to H2O2-induced oxidative stress, while OLA treatment had the opposite effect. Despite enhanced survival, ARI-treated cells exhibited higher apoptotic rates than OLA-treated cells when exposed to H2O2. Gene expression analysis of pro- and anti-apoptotic factors revealed that ARI-treated cells had a generally blunted response to H2O2, contrasting with a heightened response in OLA-treated cells. This was further supported by the reduced activation of MAPKs and STAT3 in ARI-treated cells in response to H2O2, whereas OLA pre-treatment enhanced their activation. The loss of stress response in ARI-treated cells was consistent with the observed increase in the mitochondrial production of O2•-, a known desensitizing factor. The physiological relevance of O2•- in ARI-treated cells was demonstrated by the increase in mitophagy flux, likely related to mitochondrial damage. Notably, OLA treatment protected proteasome activity in Fao cells exposed to H2O2, possibly due to the better preservation of stress signaling and mitochondrial function. In conclusion, this study highlights the underlying changes in cell physiology and mitochondrial function by AAPs. ARI de-sensitizes Fao cells to stress signaling, while OLA has the opposite effect. These findings contribute to our understanding of the metabolic risks associated with prolonged AAP use and may inform future therapeutic strategies.

Evaluation of Global Dystonia Rating Scale as a predictor of unfavorable outcomes among acute antipsychotics poisoned patients

Worldwide, acute antipsychotic poisoning results in high morbidities and mortalities. Though extrapyramidal syndromes are commonly associated, the extent of extrapyramidal syndromes in relation to the severity of antipsychotic poisoning has not been addressed yet. Thus, this study aimed to assess the Global Dystonia Rating Scale (GDRS) as an unfavorable outcomes predictive tool in acute antipsychotic poisoning. A cross-sectional study included 506 antipsychotic-poisoned patients admitted to Tanta University Poison Control Center, Egypt, over three years was conducted. The mean GDRS was 9.1 ± 16.7 in typical antipsychotic poisoning, which was significantly higher than that of atypical antipsychotics (4.2 ± 11.5) (p = 0.003). Patients with GDRS> 20 showed significantly higher liability for all adverse outcomes (p < 0.05). However, poisoning with typical antipsychotics was associated with significantly more cardiotoxicity (p = 0.042), particularly prolonged QRS (p = 0.005), and intensive care unit (ICU) admission (p = 0.000). In contrary to the PSS, which failed to predict the studied adverse outcomes, GDRS significantly predicted all adverse outcomes (p < 0.000) for all antipsychotic generations. In atypical antipsychotics, GDRS above three accurately predicted cardiotoxicities, prolonged QTc interval, and respiratory failure with Area under curves (AUC) of 0.937, 0.963, and 0.941, respectively. In typical antipsychotic poisoning, at higher cutoffs (7.5, 27.5, 18, and 7.5), cardiotoxicities, prolonged QTc interval, and respiratory failure were accurately predicted (AUC were 0.974, 0.961, and 0.960, respectively). GDRS is an objective, substantially useful tool that quantifies dystonia and can be used as an early reliable predictor of potential toxicity in acute antipsychotic poisoning.

Olanzapine-induced cardiomyopathy: A mimicker of obesity cardiomyopathy?

Olanzapine, an atypical antipsychotic medication, has gained prominence in the treatment of schizophrenia and related psychotic disorders due to its effectiveness and perceived safety profile. However, emerging evidence suggests a potential link between olanzapine use and adverse cardiovascular effects, including cardiomyopathy. This narrative review explores the mechanisms, clinical implications, and management strategies associated with olanzapine-induced cardiomyopathy. A comprehensive review of the literature was conducted to investigate the relationship between olanzapine and cardiomyopathy. The search included epidemiological studies, clinical case reports, and mechanistic research focusing on the pathophysiology of olanzapine-induced cardiomyopathy. The review also examined treatment strategies for managing this potential complication. Olanzapine-induced cardiomyopathy is hypothesized to be associated with metabolic disturbances and receptor antagonism. The metabolic effects of olanzapine, such as weight gain, insulin resistance, and dyslipidemia, share similarities with obesity-related cardiomyopathy. Additionally, olanzapine's antagonism of certain receptors may contribute to cardiovascular stress. The review highlighted that patients with new-onset heart failure and significant weight gain while on olanzapine should be closely monitored for signs of cardiomyopathy. Early detection and prompt withdrawal of olanzapine, along with initiation of goal-directed medical therapy, are crucial for mitigating this potentially life-threatening condition. The relationship between olanzapine and cardiomyopathy is complex and not yet fully understood. However, the potential for significant cardiovascular risk necessitates vigilance among healthcare providers. Early identification and management of olanzapine-induced cardiomyopathy can improve patient outcomes. Further research is needed to elucidate the precise mechanisms behind this adverse effect and to develop optimized treatment strategies for patients requiring antipsychotic therapy.

Cardiomyopathies and Psychiatric Disorders: An Overview and General Clinical Recommendations

The association between cardiomyopathies (CMPs) and psychiatric disorders is a complex and bidirectional phenomenon that involves multiple mechanisms and factors. CMPs may raise the risk of psychiatric disorders due to the psychological stress, physical limitations, social isolation, or poor prognosis associated with the underlying disease. Psychiatric disorders, on the other hand, can increase the possibility of developing or worsening CMPs due to the behavioral, neuroendocrine, inflammatory, or pharmacological effects of mental illness or its treatment. Moreover, some common genetic or environmental factors may have a relevant influence on both conditions. With this comprehensive review, we sought to provide an overview of the current evidence on the strict and intriguing interconnection between CMPs and psychiatric disorders, focusing on the epidemiology, pathophysiology, clinical implications, and management strategies.

Cardiotoxic effects of common and emerging drugs: role of cannabinoid receptors

Drug-induced cardiotoxicity has become one of the most common and detrimental health concerns, which causes significant loss to public health and drug resources. Cannabinoid receptors (CBRs) have recently achieved great attention for their vital roles in the regulation of heart health and disease, with mounting evidence linking CBRs with the pathogenesis and progression of drug-induced cardiotoxicity. This review aims to summarize fundamental characteristics of two well-documented CBRs (CB1R and CB2R) from aspects of molecular structure, signaling and their functions in cardiovascular physiology and pathophysiology. Moreover, we describe the roles of CB1R and CB2R in the occurrence of cardiotoxicity induced by common drugs such as antipsychotics, anti-cancer drugs, marijuana, and some emerging synthetic cannabinoids. We highlight the 'yin-yang' relationship between CB1R and CB2R in drug-induced cardiotoxicity and propose future perspectives for CBR-based translational medicine toward cardiotoxicity curation and clinical monitoring.

The role of inflammasomes in human diseases and their potential as therapeutic targets

Inflammasomes are large protein complexes that play a major role in sensing inflammatory signals and triggering the innate immune response. Each inflammasome complex has three major components: an upstream sensor molecule that is connected to a downstream effector protein such as caspase-1 through the adapter protein ASC. Inflammasome formation typically occurs in response to infectious agents or cellular damage. The active inflammasome then triggers caspase-1 activation, followed by the secretion of pro-inflammatory cytokines and pyroptotic cell death. Aberrant inflammasome activation and activity contribute to the development of diabetes, cancer, and several cardiovascular and neurodegenerative disorders. As a result, recent research has increasingly focused on investigating the mechanisms that regulate inflammasome assembly and activation, as well as the potential of targeting inflammasomes to treat various diseases. Multiple clinical trials are currently underway to evaluate the therapeutic potential of several distinct inflammasome-targeting therapies. Therefore, understanding how different inflammasomes contribute to disease pathology may have significant implications for developing novel therapeutic strategies. In this article, we provide a summary of the biological and pathological roles of inflammasomes in health and disease. We also highlight key evidence that suggests targeting inflammasomes could be a novel strategy for developing new disease-modifying therapies that may be effective in several conditions.

Advances in the Study of MG53 in Cardiovascular Disease

Cardiovascular diseases represent a global health crisis, and understanding the intricate molecular mechanisms underlying cardiac pathology is crucial for developing effective diagnostic and therapeutic strategies. Mitsugumin-53 (MG53) plays a pivotal role in cell membrane repair, has emerged as a multifaceted player in cardiovascular health. MG53, also known as TRIM72, is primarily expressed in cardiac and skeletal muscle and actively participates in membrane repair processes essential for maintaining cardiomyocyte viability. It promotes k-ion currents, ensuring action potential integrity, and actively engages in repairing myocardial and mitochondrial membranes, preserving cardiac function in the face of oxidative stress. This study discusses the dual impact of MG53 on cardiac health, highlighting its cardioprotective role during ischemia/reperfusion injury, its modulation of cardiac arrhythmias, and its influence on cardiomyopathy. MG53's regulation of metabolic pathways, such as lipid metabolism, underlines its role in diabetic cardiomyopathy, while its potential to mitigate the effects of various cardiac disorders, including those induced by antipsychotic medications and alcohol consumption, warrants further exploration. Furthermore, we examine MG53's diagnostic potential as a biomarker for cardiac injury. Research has shown that MG53 levels correlate with cardiomyocyte damage and may predict major adverse cardiovascular events, highlighting its value as a biomarker. Additionally, exogenous recombinant human MG53 (rhMG53) emerges as a promising therapeutic option, demonstrating its ability to reduce infarct size, inhibit apoptosis, and attenuate fibrotic responses. In summary, MG53's diagnostic and therapeutic potential in cardiovascular diseases presents an exciting avenue for improved patient care and outcomes.

Cardiometabolic Effects of Antipsychotics in Challenging Behavior and Neuropsychiatric Symptoms in Patients With Intellectual Disability

Introduction Despite the well-established association between antipsychotics and metabolic adverse effects in psychiatric disorders, the variable influence of long-term and off-label antipsychotic medication on behavioral disorders has not been investigated in detail. Objective To clarify the impact of antipsychotic use on challenging behavior (CB) and neuropsychiatric symptoms (NPS), we evaluated the clinical findings and cardiometabolic effects in individuals with intellectual disability (ID) hospitalized in our residential facility for profoundly disabled patients. Patients and methods A total of 130 individuals hospitalized in our residential facility were retrospectively investigated and divided into two groups - individuals with and without CB and NPS. Antipsychotics (first- and second-generation antipsychotics) are prescribed to all individuals in the CB and NPS-positive ID group. Conversely, antipsychotics were not prescribed to any individuals in the CB- and NPS-negative ID groups. To investigate the cardiometabolic effects of antipsychotics, the following metabolic parameters were measured: body weight (BW), total calorie intake per day, body mass index (BMI), blood pressure, serum lipid levels (total cholesterol, high-density lipoprotein cholesterol, and triglyceride), and corrected QT interval (QTc) of electrocardiogram (ECG). The etiology of disabilities, level of ID, severity of motor disability, and presence or absence of epilepsy were also examined. Results Two main results were derived: (1) Autism spectrum disorder was the most predominant etiology in individuals with CB and NPS who were prescribed antipsychotics, and (2) the mean values of metabolic parameters were all normal in both medicated and nonmedicated individuals, but the total calorie intake was significantly higher in individuals who were prescribed antipsychotics. Conclusions Our investigation demonstrated that in individuals with an adequate energy intake, most metabolic parameters can be maintained within normal limits. We suggest that body weight control is the primary step in avoiding the cardiometabolic adverse effects of antipsychotics in intellectually disabled individuals with CB and NPS.

MicroRNAs in Myocarditis-Review of the Preclinical In Vivo Trials

Myocarditis is an inflammatory heart disease with viruses as the most common cause. Regardless of multiple studies that have recently been conducted, the diagnostic options still need to be improved. Although endomyocardial biopsy is known as a diagnostic gold standard, it is invasive and, thus, only sometimes performed. Novel techniques of cardiac magnetic resonance are not readily available. Therapy in viral infections is based mainly on symptomatic treatment, while steroids and intravenous immunoglobulins are used in autoimmune myocarditis. The effectiveness of neither of these methods has been explicitly proven to date. Therefore, novel diagnostic and therapeutic strategies are highly needed. MiRNAs are small, non-coding molecules that regulate fundamental cell functions, including differentiation, metabolism, and apoptosis. They present altered levels in different diseases, including myocarditis. Numerous studies investigating the role of miRNAs in myocarditis have already been conducted. In this review, we discussed only the original preclinical in vivo research. We eventually included 30 studies relevant to the discussed area. The altered miRNA levels have been observed, including upregulation and downregulation of different miRNAs in the mice models of myocarditis. Furthermore, the administration of mimics or inhibitors of particular miRNAs was shown to significantly influence inflammation, morphology, and function of the heart and overall survival. Finally, some studies presented prospective advantages in vaccine development.

Adverse effects of tyrosine kinase inhibitors in cancer therapy: pathophysiology, mechanisms and clinical management

Since their invention in the early 2000s, tyrosine kinase inhibitors (TKIs) have gained prominence as the most effective pathway-directed anti-cancer agents. TKIs have shown significant utility in the treatment of multiple hematological malignancies and solid tumors, including chronic myelogenous leukemia, non-small cell lung cancers, gastrointestinal stromal tumors, and HER2-positive breast cancers. Given their widespread applications, an increasing frequency of TKI-induced adverse effects has been reported. Although TKIs are known to affect multiple organs in the body including the lungs, liver, gastrointestinal tract, kidneys, thyroid, blood, and skin, cardiac involvement accounts for some of the most serious complications. The most frequently reported cardiovascular side effects range from hypertension, atrial fibrillation, reduced cardiac function, and heart failure to sudden death. The potential mechanisms of these side effects are unclear, leading to critical knowledge gaps in the development of effective therapy and treatment guidelines. There are limited data to infer the best clinical approaches for the early detection and therapeutic modulation of TKI-induced side effects, and universal consensus regarding various management guidelines is yet to be reached. In this state-of-the-art review, we examine multiple pre-clinical and clinical studies and curate evidence on the pathophysiology, mechanisms, and clinical management of these adverse reactions. We expect that this review will provide researchers and allied healthcare providers with the most up-to-date information on the pathophysiology, natural history, risk stratification, and management of emerging TKI-induced side effects in cancer patients.

Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates

Objective

Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed.

Methodology

An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management.

Results

The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects.

Conclusion

Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.

Psychopathology, Personality and Depression after Acute Coronary Syndrome: A Network Analysis in an Italian Population

Several biopsychosocial factors are associated with the onset of a Major Depressive Episode (MDE) after cardiovascular events. However, little is known of the interaction between trait- and state-like symptoms and characteristics and their role in predisposing cardiac patients to MDEs. Three hundred and four subjects were selected among patients admitted for the first time at a Coronary Intensive Care Unit. Assessment comprised personality features, psychiatric symptoms and general psychological distress; the occurrences of MDEs and Major Adverse Cardiovascular Events (MACE) were recorded during a two-year follow-up period. Network analyses of state-like symptoms and trait-like features were compared between patients with and without MDEs and MACE during follow-up. Individuals with and without MDEs differed in sociodemographic characteristics and baseline depressive symptoms. Network comparison revealed significant differences in personality features, not state-like symptoms: the group with MDEs displayed greater Type D personality traits and alexithymia as well as stronger associations between alexithymia and negative affectivity (edge differences between negative affectivity and difficulty identifying feelings was 0.303, and difficulty describing feelings was 0.439). The vulnerability to depression in cardiac patients is associated with personality features but not with state-like symptoms. Personality evaluation at the first cardiac event may help identify individuals more vulnerable to development of an MDE, and they could be referred to specialist care in order to reduce their risk.

Sudden unexplained death in schizophrenia patients: An autopsy-based comparative study from China

Explainable sudden deaths in schizophrenia patients due to both cardiac (SCD) and non-cardiac causes (SNCD) have been extensively documented. However, sudden unexplained death (SUD) in this cohort remains to be elucidated. This study retrospectively analyzed 18 SUD cases that underwent systematic autopsy at our institutes during the period 2010-2022. The etiological, demographic, and autopsy features of the SUD cases were then compared with 37 year-matched sudden explainable deaths (23 SCD cases and 14 SNCD cases). Our results showed that the average age of the SUD was 39.0 ( ± 8.4) years, with the disease duration of 11.8 ( ± 8.1) years and a male/female ratio of 11:7. Most cases occurred during daytime (72.2%) and outside of hospital (77.8%). A large proportion of the SUD cases (77.8%) had persistent psychiatric episodes before death. Clozapine was found to be the most commonly used antipsychotic (33.3%), followed by Olanzapine (27.8%), Risperidone (27.8%) and Chlorpromazine (27.8%) in the SUD cases. When compared among groups, the SUD cases showed significantly younger ages (p = 0.035), lower heart weight (p = 0.004) and lower proportion of Clozapine use (p = 0.045). The presence of persistent psychiatric episodes was significantly higher in the SUD group than in any explainable deaths (p = 0.018) and was an independent risk factor for SUD (OR = 4.205, p = 0.040). This is the first autopsy-based study of SUD cases from China. We conclude that a stable mental state maintained by antipsychotics (i.e., Clozapine) is vital to schizophrenia patients.

Sudden unexpected death in epilepsy: Investigation of autopsy-based studies

Epilepsy is a common neurological disorder that is associated with increased morbidity and mortality. Sudden unexpected death in epilepsy (SUDEP) is one of the most common causes for epilepsy-related deaths and its characteristics remain largely unknown, particularly from a forensic autopsy perspective. The present study aimed to investigate the neurological, cardiac, and pulmonary findings for a total of 388 SUDEP decedents, encompassing three cases from our forensic center during 2011-2020 and 385 literature-reported autopsy cases. In the cases mentioned in this study, two of them presented with only mild cardiac abnormalities, such as focal myocarditis and mild coronary atherosclerosis of the left anterior coronary artery. The third one was negative of any pathological findings. After pooling together these SUDEP cases, we found that neurological changes (n = 218 cases, 56.2%) were the most common postmortem findings associated with SUDEP, with cerebral edema/congestion (n = 60 cases, 15.5%) and old traumatic brain injury (n = 58 cases, 14.9%) being the major findings. Interstitial fibrosis, myocyte disarray/hypertrophy, and mild coronary artery atherosclerosis were the most common findings related to primary cardiac pathology, documented in 49 (12.6%), 18 (4.6%), and 15 (3.9%) cases, respectively. Non-specific pulmonary edema was the major finding in the lungs. This is an autopsy-based study that reports the scenario of postmortem findings for SUDEP cases. Our study paves the way for understanding the pathogenesis of SUDEP and the interpretation of death.

Myocardial Cell Preservation from Potential Cardiotoxic Drugs: The Role of Nanotechnologies

Cardiotoxic therapies, whether chemotherapeutic or antibiotic, represent a burden for patients who may need to interrupt life-saving treatment because of serious complications. Cardiotoxicity is a broad term, spanning from forms of heart failure induction, particularly left ventricular systolic dysfunction, to induction of arrhythmias. Nanotechnologies emerged decades ago. They offer the possibility to modify the profiles of potentially toxic drugs and to abolish off-target side effects thanks to more favorable pharmacokinetics and dynamics. This relatively modern science encompasses nanocarriers (e.g., liposomes, niosomes, and dendrimers) and other delivery systems applicable to real-life clinical settings. We here review selected applications of nanotechnology to the fields of pharmacology and cardio-oncology. Heart tissue-sparing co-administration of nanocarriers bound to chemotherapeutics (such as anthracyclines and platinum agents) are discussed based on recent studies. Nanotechnology applications supporting the administration of potentially cardiotoxic oncological target therapies, antibiotics (especially macrolides and fluoroquinolones), or neuroactive agents are also summarized. The future of nanotechnologies includes studies to improve therapeutic safety and to encompass a broader range of pharmacological agents. The field merits investments and research, as testified by its exponential growth.

Use of potassium ion channel and spliceosome proteins as diagnostic biomarkers for sudden unexplained death in schizophrenia

Sudden unexplained death in schizophrenia (SUD-SCZ) is not uncommon and its incidence is approximately three times higher than that in the general population. However, diagnosis of SUD-SCZ remains a great challenge in forensic pathology. This study designed a two-phase study to investigate whether three proteins, namely two potassium ion channel proteins (KCNJ3 and KCNAB1) and one spliceosome protein (SF3B3) that were identified in our previous work, could be applied in the postmortem diagnosis of SUD-SCZ. Immunohistochemical staining of the three biomarkers, followed by a rigorous quantitative analysis, was performed on heart specimens from both SUD-SCZ and control groups. A diagnostic software based on the logistic regression formula derived from the test phase data was then constructed. In the test phase, we found that the staining intensities of KCNJ3, KCNAB1, and SF3B3 were all significantly lower in the SUD-SCZ group (n = 20) as compared with the control group that died from non-natural causes (n = 25), with fold-changes being 14.85 (p < 0.001), 4.13 (p = 0.028) and 2.12 (p = 0.048), respectively. Receiver operating characteristic analysis further illustrated that combination of the three biomarkers achieved the optimal diagnostic specificity (92%) and area under the curve (0.886). In the validation phase, the diagnostic software was confirmed to be a promising tool for predicting the risk of SUD-SCZ in authentic cases. Our study provided a valid strategy towards the practical diagnosis of SUD-SCZ by using KCNJ3, KCNAB1, and SF3B3 proteins as diagnostic biomarkers.

Electrocardiographic Patterns of Depolarization Abnormalities Help to Identify Reduced Left Ventricular Ejection Fraction

The aim of the study was to investigate the relationship between a decrease in the left ventricular ejection fraction (EF) and traditional ECG signs associated with structural changes of the myocardium (pathological Q wave, ventricular arrhythmias) and relatively new and poorly understood (fragmented QRS complex (fQRS), early repolarization pattern (ERP)) and evaluate their significance for identifying patients with mildly reduced EF (mrEF). The study included 148 patients who were treated and examined at the Almazov Medical Research Center. FQRS, ERP, pathological Q wave, and premature ventricular contractions (PVC) were described in the analysis of the ECG, and the results of echocardiography and statistical data were analyzed: Fisher’s test and chi-square, correlation analysis, and ROC analysis. According to the level of EF, patients were divided into three groups: group 1—patients with low EF (lEF) (less than 40%), group 2—patients with mildly reduced EF (mrEF) (40–49%); group 3—patients with preserved EF (pEF) (more than 50%). In the first group (EF), fQRS was registered in 16 (51.6%) patients, in the mrEF in 16 (18.2%). Pathological Q wave was detected in lEF in 20 (65%), in mrEF in 10 (35%), 15 (18%), in pEF in 15 (18%). The fQRS has been found to be more important in identifying patients with mrEF. In lEF in 2 (6.5%) patients, in mrEF in 2 (6.9%), in pEF in 11 (12.5%). There was no relationship between ERP, the amount of PVC, and the presence of ventricular tachycardia with EF. FQRS is significantly more common occurred with a decrease in EF and may be a marker of a mrEF. Thus, fQRS is associated with mrEF and pay close attention in routine clinical practice to identify patients at high risk of developing systolic dysfunction.

Cardiotoxicity of current antipsychotics: Newer antipsychotics or adjunct therapy?

Use of newer antipsychotics for substitution of current antipsychotics might be one way awaiting to be clinically verified to address antipsychotic cardiotoxic effects. Alternatively, the combination of existing antipsychotics with cardioprotective agents is also beneficial for patients with mental disorders for avoiding cardiotoxicity to the maximum.

CB1R-stabilized NLRP3 inflammasome drives antipsychotics cardiotoxicity

Long-term use of antipsychotics is a common cause of myocardial injury and even sudden cardiac deaths that often lead to drug withdrawn or discontinuation. Mechanisms underlying antipsychotics cardiotoxicity remain largely unknown. Herein we performed RNA sequencing and found that NLRP3 inflammasome-mediated pyroptosis contributed predominantly to multiple antipsychotics cardiotoxicity. Pyroptosis-based small-molecule compound screen identified cannabinoid receptor 1 (CB1R) as an upstream regulator of the NLRP3 inflammasome. Mechanistically, antipsychotics competitively bond to the CB1R and led to CB1R translocation to the cytoplasm, where CB1R directly interacted with NLRP3 inflammasome via amino acid residues 177-209, rendering stabilization of the inflammasome. Knockout of Cb1r significantly alleviated antipsychotic-induced cardiomyocyte pyroptosis and cardiotoxicity. Multi-organ-based investigation revealed no additional toxicity of newer CB1R antagonists. In authentic human cases, the expression of CB1R and NLRP3 inflammasome positively correlated with antipsychotics-induced cardiotoxicity. These results suggest that CB1R is a potent regulator of the NLRP3 inflammsome-mediated pyroptosis and small-molecule inhibitors targeting the CB1R/NLRP3 signaling represent attractive approaches to rescue cardiac side effects of antipsychotics.

Sudden Cardiac Death in Schizophrenia During Hospitalization: An Autopsy-Based Study

Schizophrenia is a severe mental disorder that is often comorbid with heart dysfunction and even sudden cardiac death (SCD). Clinical studies of SCD in schizophrenia have been largely reported, while there are limited autopsy studies that directly showed whole-scale information of such events. In this study, we present nine autopsy-based SCD cases in schizophrenia patients who died suddenly during hospitalization. Their medical records before and during hospitalization, and postmortem autopsy findings were summarized. These decedents had an average duration of schizophrenia for 6.83 ± 3.75 years with a male/female ratio of 4:5. They were all on intermittent antipsychotics medication before hospitalization and died within 15 days after hospitalization. Seven of the nine cases (77.8%) died of organic heart diseases such as severe coronary artery atherosclerosis (n = 4), myocarditis (n = 1), cardiomyopathy (n = 1), and pulmonary thromboembolism (n = 1). Two cases remained unexplained after systemic autopsy and toxicological examinations. Postmortem autopsy identified hepatic steatosis (n = 6) and respiratory inflammation (n = 3) as the most common associate extra-cardiac lesions. Our data provided autopsy-based data of SCD cases in schizophrenia and highlighted an intensive care of such patients during hospitalization.

Mapping the Knowledge of Antipsychotics-Induced Sudden Cardiac Death: A Scientometric Analysis in CiteSpace and VOSviewer

The drugs on the market for schizophrenia are first-generation and second-generation antipsychotics. Some of the first-generation drugs have more side effects than the other drugs, so they are gradually no longer being applied clinically. Years of research have shown that the risk of sudden cardiac death in psychotic patients is associated with drug use, and antipsychotic drugs have certain cardiotoxicity and can induce arrhythmias. The mechanism of antipsychotic-induced sudden cardiac death is complicated. Highly cited papers are among the most commonly used indicators for measuring scientific excellence. This article presents a high-level analysis of highly cited papers using Web of Science core collection databases, scientometrics methods, and thematic clusters. Temporal dynamics of focus topics are identified using a collaborative network (author, institution, thematic clusters, and temporal dynamics of focus topics are identified), keyword co-occurrence analysis, co-citation clustering, and keyword evolution. The primary purpose of this study is to discuss the visual results, summarize the research progress, and predict the future research trends by bibliometric methods of CiteSpace and VOSviewer. This study showed that a research hotspot is that the mechanisms of cardiotoxicity, the safety monitoring, and the assessment of the risk-benefit during clinical use of some newer antipsychotics, clozapine and olanzapine. We discussed relevant key articles briefly and provided ideas for future research directions for more researchers to conduct related research.