Cardiovascular Effects of Non-Cardiovascular Drugs

NSAIDs & Psychotropics - Ache & Anxious Alerts

• NSAIDs:

  • COX inhibition → ↓ protective prostaglandins (renal, vascular).
  • CV Risks:
    • ↑ BP (Na+/H₂O retention), edema.
    • ↑ Thrombotic events (MI, stroke) - esp. COX-2 selective, diclofenac.
    • Worsen HF; blunt diuretic/ACEi effects.
  • ⚠️ Avoid in high CV risk/HF. Naproxen: relatively safer.

• Psychotropics:

  • TCAs (Tricyclic Antidepressants):
    • Orthostasis (α1-block), tachycardia (anticholinergic).
    • Cardiotoxicity: Na+-channel block → ↑QRS/QT, arrhythmias. 📌 Tri-C's: Cardiotox, Convulsions, Coma.
  • Antipsychotics:
    • Typicals (e.g., Thioridazine): QT prolongation.
    • Atypicals: QT prolongation (Ziprasidone); Myocarditis (Clozapine ⚠️); Metabolic syndrome (Olanzapine, Clozapine) → ↑CV risk.
  • SSRIs (Selective Serotonin Reuptake Inhibitors):
    • QT prolongation: Citalopram (max 40mg), Escitalopram (max 20mg).
  • Lithium:
    • ECG: T-wave changes (benign); bradycardia, SA node dysfunction.

⭐ Clozapine: mandatory baseline & regular ECG for myocarditis/cardiomyopathy risk.

Oncology & Antimicrobials - Chemo's Cardiac Cost

• Oncology Agents:
  • Anthracyclines (Doxorubicin): Dose-dependent dilated cardiomyopathy (DCM). Max cumulative dose <450-550 mg/m². Prevent: Dexrazoxane.
  • Trastuzumab: ↓LVEF, often reversible. Synergistic toxicity with anthracyclines.
  • Tyrosine Kinase Inhibitors (TKIs): QT prolongation, LV dysfunction (e.g., Sunitinib).
  • Immune Checkpoint Inhibitors (ICIs): Myocarditis (rare, severe).
  • 5-FU/Capecitabine: Coronary vasospasm, angina.
• Antimicrobials:
  • Macrolides (Erythromycin, Azithromycin): QT prolongation, Torsades de Pointes (TdP).
  • Fluoroquinolones (Moxifloxacin): QT prolongation, TdP. Aortic aneurysm risk.
  • Azole Antifungals (Voriconazole): QT prolongation. Itraconazole: negative inotropy.

⭐ Doxorubicin's cardiotoxicity is cumulative and dose-limiting; monitor ejection fraction. Max lifetime dose is critical.

Endocrine & Inhaled Agents - Gland & Gasp Griefs

• Glucocorticoids (e.g., Prednisolone):
  • CV: Hypertension (HTN), fluid retention, dyslipidemia, ↑atherosclerosis.
  • High doses: Arrhythmias.
• Thyroid Hormones (Levothyroxine excess):
  • Tachycardia, palpitations, angina, Atrial Fibrillation (AFib).
• Oral Hypoglycemics:
  • Thiazolidinediones (TZDs: Pioglitazone): Fluid retention, can precipitate/worsen Heart Failure (HF). ⚠️
  • DPP-4 inhibitors (e.g., Saxagliptin): Potential ↑risk of HF hospitalization.
• Hormone Therapy (OCPs, HRT):
  • ↑Risk: Venous Thromboembolism (VTE), Myocardial Infarction (MI), stroke, HTN.
• Inhaled Beta-2 Agonists (e.g., Salbutamol):
  • CV: Tachycardia, palpitations, arrhythmias (esp. high dose).
  • Metabolic: Hypokalemia (arrhythmia risk). 📌 Beta-agonists Bin K+ (Potassium).
• Inhaled Anticholinergics (e.g., Ipratropium):
  • Generally fewer CV effects; rare tachycardia.

⭐ Thiazolidinediones (e.g., Pioglitazone) are contraindicated in symptomatic heart failure (NYHA Class II-IV) due to risk of fluid retention and HF exacerbation.

Other Agents & Vigilance - Sundry Drug Dangers

• Sympathomimetics (e.g., pseudoephedrine): Tachycardia, ↑BP, arrhythmias, ischemia.
• Recreational Drugs (cocaine, amphetamines): Severe HTN, MI, stroke, vasospasm, arrhythmias.
• Ergot Alkaloids (ergotamine): Potent vasoconstriction, coronary/peripheral vasospasm; ⚠️CI: CAD, PVD.
• Triptans (sumatriptan): Coronary spasm; ⚠️CI: IHD, uncontrolled HTN, stroke/TIA.
• Atypical Antipsychotics (e.g., clozapine, ziprasidone): QT prolongation, myocarditis (clozapine), orthostatic hypotension.
• PDE5 Inhibitors (sildenafil): Severe hypotension with organic nitrates.
• Drug Vigilance Framework: Essential for preventing iatrogenic CV events.

⭐ Cocaine is notorious for causing acute myocardial infarction, even in young individuals with no prior cardiac history, often due to coronary artery vasospasm and accelerated atherosclerosis.

High‑Yield Points - ⚡ Biggest Takeaways

• NSAIDs (not low-dose aspirin) ↑ BP, worsen HF; Coxibs ↑ thrombotic risk.
• TCAs induce orthostatic hypotension, tachycardia, and quinidine-like arrhythmogenic effects.
• Atypical antipsychotics (e.g., clozapine) risk myocarditis, cardiomyopathy, metabolic syndrome, QT prolongation.
• Beta-2 agonists (e.g., salbutamol) cause tachycardia, palpitations, hypokalemia (arrhythmia risk).
• Corticosteroids lead to hypertension, fluid retention, dyslipidemia, increasing CV risk.
• Anthracyclines (e.g., doxorubicin) cause cumulative dose-dependent cardiotoxicity; Macrolides/Fluoroquinolones cause QT prolongation (risk of TdP).