Cardiovascular effects of cholinesterase inhibitors in Alzheimer's disease.

Introduction. In the treatment of mild to moderate Alzheimer's disease, cholinesterase inhibitors (ChEIs) have shown modest clinical benefits. State of the art. Use of donepezil, galantamine and rivastigmine is widespread in clinical practice. Although relatively safe, ChEIs are prescribed for a frail population and may have clinically significant adverse drug effects on the cardiovascular system. Arrhythmia and syncope have been reported. Most of the cardiovascular adverse drug reactions to ChEls might be related to stimulation of the parasympatic nervous system. Perspectives. Early and accurate recognition of past and present arrhythmia or syncope appears to be essential. Monitoring for pharmacokinetic (cytochromes P450 CYP2D6 or CYP3A4) and pharmacodynamic interactions and a more systematic clinical follow-up are mandatory. In patients with relevant risk factors or with cardiovascular adverse drug reactions a multidisciplinary approach with a cardiologist is required. Conclusion. Prevention of cardiac adverse events requires a careful clinical evaluation before the introduction of the ChEls and an early recognition of cardiac disturbances under treatment.