The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry

David M. Taylor, Fiona Gaughran, Toby Pillinger

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119554240
• Edition: 1
• Topic: Medicina
• Subtopic: Psichiatria e salute mentale

Learn to improve your assessment, investigation, and management of physical health conditions in people with severe mental illness

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry offers psychiatric and general practitioners an evidence-based and practical guide for the appropriate assessment, investigation, and management of common physical health conditions seen in people with severe mental illness. Written by a renowned team of respected experts in medicine, surgery, pharmacy, dietetics, physiotherapy, and psychiatry, the book bridges the gap between psychiatric and physical health services for the severely mentally ill.

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry also provides practitioners with expert guidance on making effective referrals to other medical and surgical subspecialties, telling readers what information subspecialties would expect to receive. Its use will improve the quality of clinical care received by mentally ill patients and, by promoting a holistic approach to treatment that considers both body and mind, will enhance the therapeutic relationship between patient and practitioner.

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry covers the following:

• Guidance on assessment and management of well over a hundred different medical and surgical presentations commonly seen in people with serious mental illness
• Management of physical health emergencies in a psychiatric setting
• Evidence-based approaches to management of physical side effects of psychiatric medications
• Advice on approaches to promote a healthy lifestyle in people with serious mental illness, such as smoking cessation and changes to diet and physical activity

Perfect for both psychiatrists and general practitioners who wish to improve the quality of care they provide to people with serious mental illness, The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry will be of use to anyone setting out to navigate the divide between the treatment of psychiatric and physical health conditions.

Part 1
Cardiology

Chapter 1
Tachycardia

Guy Hindley, Eromona Whiskey, Nicholas Gall

In adults, tachycardia is defined as a heart rate faster than 100 beats per minute (bpm). This may represent a normal physiological response, a sign of systemic illness, or primary cardiac pathology [1]. There are several possible cardiac rhythms associated with tachycardia. Identifying the underlying rhythm is central to the diagnostic process and directs management. Classifying these rhythms according to the width of the QRS complex and the regularity of the rhythm (as seen on an ECG) helps to simplify this process (Table 1.1) [2].

SINUS TACHYCARDIA

Sinus tachycardia is the most commonly encountered rhythm disturbance. In the majority of cases, this is an appropriate physiological response mediated by the sympathetic nervous system to an identifiable cause, which may be benign or pathological (Box 1.1) [3]. In the context of mental health, sinus tachycardia may be experienced during episodes of agitation, anxiety or panic. Sympathomimetic and anticholinergic drugs are also important causes to consider, including clozapine which causes a transient sinus tachycardia in 25% of patients, usually limited to the first six weeks of treatment [4]. Among pathological causes, people with serious mental illness (SMI) are at higher risk of sepsis [5] and pulmonary embolism [5,6], while sinus tachycardia is also associated with clozapine‐induced myocarditis [7], neuroleptic malignant syndrome, and serotonin syndrome [8]. Hyperthyroidism and, more rarely, phaeochromocytoma may present with both psychiatric symptoms and sinus tachycardia [9,10]. The reader is directed to other chapters for detailed information on sepsis (Chapter 72), venous thromboembolism (Chapter 18), myocarditis (Chapter 8), neuroleptic malignant syndrome (Chapter 85), serotonin syndrome (Chapter 86), and hyperthyroidism (Chapter 79).

Table 1.1 Differential diagnosis of tachycardia according to the length of the QRS complex and regularity of rhythm [2].

	Narrow QRS (≤120 ms)	Broad QRS (>120 ms)
Regular	Sinus tachycardia Supraventricular tachycardia Atrioventricular re‐entrant tachycardia (AVRT) Atrioventricular nodal re‐entrant tachycardia (AVNRT) Atrial flutter (with regular atrioventricular block) Focal atrial tachycardia	Monomorphic ventricular tachycardia (VT) Any regular narrow‐complex tachycardia with aberrant conduction (e.g. bundle branch block/accessory pathway)
Irregular	Atrial fibrillation (AF) Atrial flutter with varying atrioventricular block Multifocal atrial tachycardia	Torsade de pointes Polymorphic VT Ventricular fibrillation AF with aberrant conduction (bundle branch block/accessory pathway)

ATRIAL FIBRILLATION

Atrial fibrillation (AF) is the second most prevalent rhythm disturbance, occurring in 0.4–1% of adults [11]. Risk increases significantly with age [11]. Alcohol and stimulant use, hyperthyroidism, heart failure, hypertension, and chronic lung disease are associated with AF, all of which are more prevalent in patients with SMI (Table 1.2) [12]. AF can cause acute cardiac decompensation presenting as pulmonary oedema or myocardial ischaemia (see Chapters 67 and 68), as well as longer‐term complications such as thromboembolic disease (e.g. stroke; see Chapter 82) [13].

SUPRAVENTRICULAR TACHYCARDIA

Conventionally, supraventricular tachycardia (SVT) refers to any tachycardia other than AF that originates above the level of the ventricles, i.e. involving the atria, the atrioventricular node, or the bundle of His [2]. Atrioventricular nodal re‐entrant tachycardia (AVNRT), atrioventricular re‐entrant tachycardia (AVRT), atrial flutter, and focal atrial tachycardia are the most common forms of SVT and each is associated with its own distinct pathophysiology and management [14]. Among people with SMI, alcohol and stimulant use may precipitate SVT (see Box 1.1) [15]. Ischaemic heart disease is also an important risk factor [16], the incidence of wh...