Background: Antipsychotics are frequently used in the hospital setting for managing both acute and chronic neuropsychiatric disorders. However, antipsychotics have been associated with higher rates of adverse events, including mortality, due to their association with QT prolongation, which can lead to fatal cardiac arrhythmias such as torsade de pointes, earning a black box warning for use in dementia related psychosis. Yet, guidelines for ECG monitoring are outdated and unclear. This study aimed to determine ECG monitoring practices for hospitalized adults receiving antipsychotics during admission.
Methods: A retrospective multi-site study of all adults (18+) admitted to one of seven hospitals (3 tertiary and 4 community) in the New York Metropolitan area, who received antipsychotics during their admission and had a length of stay of at least 2 days. Data was extracted from the electronic health records. The primary outcome was receipt of a follow-up ECG (yes/no) after receiving antipsychotics. Demographic and clinical variables were tested for their association with this follow-up ECG.
Results: Of the 26,353 visits, average age was 61.4 years, 50.1% were female, 64.8% were white, and 27.8% were married, with an average comorbidity score of 1.4. Only 60.6% (n=15,977) had an ECG administered at any time during hospitalization and only 41% (n = 10,865) had an ECG following antipsychotic administration; with a median time of 45.6 hours (IQR 12.8-154.2). Demographic variables (age, sex, race, marital status, and comorbidity score) were not associated with follow-up ECG. Patients with longer length of stay (19.5 vs. 11.2 days) were more likely to get an ECG. Follow-up ECGs were more likely amongst patients with history of heart failure (OR 1.19, 95% CI 1.08-1.32, p<0.001), those who received multiple antipsychotics (OR 1.3, 95% CI 1.24-1.36, p<0.001), those on other QT prolonging medications (OR 1.09, 95% CI 1.07-1.1, p<0.001), and those on risperidone (OR 1.12, 95% CI 1.004-1.25, p=0.04), Follow-up ECGs were less likely in those on antipsychotics prior to admission (OR 0.93, 95% CI 0.87-0.997, p<0.001) and those discharged on an antipsychotic.
Conclusions: While it is well known that antipsychotics can lead to adverse cardiac events, there is no standardization with regard to ECG monitoring practices. Updated recommendations to guide ECG practices for hospitalized adult patients receiving antipsychotic medications are urgently needed.