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2. Managing Tachycardia Jonathan Meyer, MD
Clinical Professor of Psychiatry
University of California, San Diego

3. Clozapine-induced tachycardia
Rule out orthostasis
(reflex tachycardia)
Clozapine-induced tachycardia
Risk of dilated
cardiomyopathy
Meyer JM, et al. Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses 2007; 1(2):
Lally J, et al. Pharmacological interventions for clozapine‐induced sinus tachycardia. Cochrane Database Syst Rev 2016 Jun 9;(6):CD011566
Stryjer, R. et al. (2009). β-Adrenergic antagonists for the treatment of clozapine-induced sinus tachycardia: a retrospective study. Clin Neuropharmacol 2009; 32(5):290-2

4. Clozapine-Induced Tachycardia
α 1 and M1 antagonism
25% incidence
False positive depending on
QTc formula
CLOZAPINE
Meyer JM, et al. Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses 2007; 1(2):
Lally J, et al. Pharmacological interventions for clozapine‐induced sinus tachycardia. Cochrane Database Syst Rev 2016 Jun 9;(6):CD011566
Stryjer, R. et al. (2009). β-Adrenergic antagonists for the treatment of clozapine-induced sinus tachycardia: a retrospective study. Clin Neuropharmacol 2009; 32(5):290-2

5. They should be using these
Bazett
Many machines use this.
Fridericia
Hodges
They should be using these
Meyer, J., Rao, S., & Nielsen, J. (2007). Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses, 1(2),

6. Example: QTc of 400, HR of 60 By HR 90, QTcs greatly diverge.
Start with HR 60, QTc of 400
R-R Interval (sec)
QTcB (Bazett)
(msec)
QTcF (Fridericia)
QTcH (Hodges) 60
1.00
400 72
0.83
438
425
421 80
0.75
462
440
435 90
0.67
490
458
453
100
0.60
516
474
470
By HR 90, QTcs greatly diverge.
Keep HR controlled to avoid false QT alarm.
References: Meyer, J., Rao, S., & Nielsen, J. (2007). Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses, 1(2),
Nielsen J, et. al. (2011). Assessing QT interval prolongation and its associated risks with antipsychotics. CNS Drugs, 25(6),

7. Tachycardia Management
Standard titration, lowest effective dose
Minimize concurrent α1 or M1 antagonists
Manage orthostasis
Meyer JM, et al. Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses 2007; 1(2):
Lally J, et al. Pharmacological interventions for clozapine‐induced sinus tachycardia. Cochrane Database Syst Rev 2016 Jun 9;(6):CD011566

8. Tachycardia Management
Use Beta Blockers (Atenolol)
12.5 mg 9 AM, increase based on tolerance
Goal: resting HR <100 or < 90
Meyer JM, et al. Clozapine and dilated cardiomyopathy. Clinical Schizophrenia & Related Psychoses 2007; 1(2):
Lally J, et al. Pharmacological interventions for clozapine‐induced sinus tachycardia. Cochrane Database Syst Rev 2016 Jun 9;(6):CD011566

9. Key Points
In patients without orthostasis, tachycardia should be managed with low dose atenolol.
One should not base decisions on QTc prolongation if the Bazett formula is used

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