Clozapine-related myocarditis and cardiomyopathy in an Australian metropolitan psychiatric service.
OBJECTIVE
Myocarditis and cardiomyopathy are rarely reported complications of clozapine treatment. The incidence of clozapine-related myocarditis has been variably reported at between 0.03% and 0.19% of initiations and cardiomyopathy has been reported even less commonly. In our Brisbane-based service, nine of 94 patients initiated on clozapine over the previous 3 years appeared to have experienced myocarditis or cardiomyopathy. The unique co-location of our service with a major cardiothoracic hospital facilitated a review of identified cases to inform decisions regarding clozapine treatment and rechallenge in this service.


METHODS
Cases were identified by survey of psychiatric and cardiac medical staff at The Prince Charles Hospital and subjected to re-evaluation by a multidiscipline consensus panel. The panel compared cases to international reports and identified the clinical features that supported a diagnosis of clozapine-related myocarditis or cardiomyopathy.


RESULTS
This process resulted in the stratification of the nine cases into the following categories of diagnostic likelihood: three highly probable, three probable, and two possible cases of clozapine-related myocarditis, and one possible case of clozapine-related cardiomyopathy. Successful clozapine rechallenge/continuation was undertaken in two patients and the panel agreed that this was a viable future option for several other patients.


CONCLUSIONS
Findings of the panel review supported the initial clinical diagnoses. This confirmed that there was an apparent high incidence of clozapine-related myocarditis within this service, for which there was no clear reason. Mechanisms underlying clozapine-related myocarditis and cardiomyopathy, as well as successful clozapine continuation and rechallenge were considered, but definitive explanations remain unknown. This review highlighted the clinician's role in post-marketing drug surveillance to guide rational management of suspected adverse drug effects.
Reinders
Jonathan
J
Department of Psychiatry, The Prince Charles Hospital Health Service District, Queensland, Australia. Johnathan_Reinders@health.qld.gov.au
Parsonage
William
W
Lange
Diana
D
Potter
Julia M
JM
Plever
Sally
S
D000328:Adult; D014150:Antipsychotic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001315:Australia / Q000453:epidemiology; D009202:Cardiomyopathies / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000453:epidemiology; D003024:Clozapine / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration*; D008875:Middle Aged; D009205:Myocarditis / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000453:epidemiology; D011567:Psychiatric Department, Hospital / Q000706:statistics & numerical data; D011618:Psychotic Disorders / Q000188:drug therapy*; D013902:Radiography, Thoracic
D014150:Antipsychotic Agents; D003024:Clozapine