The Use of IV Cyclizine in Cardiac Chest Pain
Date First Published:
September 15, 2005
Last Updated:
September 16, 2005
Report by:
Gabby May, Clinical Fellow (Manchester Royal Infirmary)
Search checked by:
Ricky Kumar, Manchester Royal Infirmary
Three-Part Question:
[In patients with symptoms compatible with myocardial ischaemia] is [the use of iv cyclizine] associated with [increased myocardial work, morbidity or mortality]?
Clinical Scenario:
A 52 year old man presents to the emergency department with a history suggestive of myocardial ischaemia. He requires intravenous opioids for pain and is feeling nauseous so you decide to give him an intravenous antiemetic. However, your consultant tells you not to use cyclizine as it can increase the heart rate, and thus myocardial oxygen demand, in already ischaemic muscle. You wonder whether this is true, or just more evidence of his eccentricity?
Search Strategy:
Medline 1966- September Week 1 2005 using OVID interface
Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials:
Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials:
Search Details:
[{exp Myocardial Infarction/or MI.mp or myocardial infarction.mp. or exp Myocardial Infarction/or exp Coronary Disease/or heart attack.mp or chest pain.mp. or exp Chest Pain/or angina.mp. or exp Angina Pectoris/or acute coronary syndrome.mp. or exp Angina, Unstable/or exp Myocardial Ischemia/or myocardial ischaemia.mp. or myocardial ischemia.mp. or ACS.mp. or exp Coronary Thrombosis/or exp Coronary Disease/or acute coronary$.mp.} AND {cyclizine.mp. or exp CYCLIZINE/or valoid.mp. or antihistamine.mp. or exp Histamine H1 Antagonists/or antihistamine$.mp.}] Limit to humans and English language
Cochrane:cyclizine
Cochrane:cyclizine
Outcome:
70 articles found of which 1 was relevant to the three part question. Cochrane: 66 citations. No new papers found.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Detrimental Haemodynamic Effects of Cyclizine in Heart Failure Tan LB, Bryant S, Murray RG. 1988 UK | 11 patients (9 male; 2 female) with severe heart failure (New York Heart Association grade 4). Patients had invasive haemodynamic monitoring. All patients were given 50 mg intravenous cyclizine, monitored for 30 min, then given 10 mg intravenous diamorphine. Parameters were measured at baseline, and 10 min and 30 min after administration of cyclizine | Observational study | Heart rate (beats/min) | 99.9 at baseline; 107 at 10 min (p<0.05); 107 at 30 min | Small study in a very specific group of patients |
| Right atrial pressure(mm Hg) | 10.1 at baseline; 12.7 at 10 min (p<0.01); 13.1 at 30 min (p<0.01) | ||||
| Mean pulmonary artery pressure(mm Hg) | 37.9 at baseline; 43.8 at 10 min (p<0.01); 43.1at 30 min (p<0.01) | ||||
| Pulmonary artery wedge pressure(mm Hg) | 21.9 at baseline; 27.7 at 10 min (p<0.01); 27.0 at 30 min (p<0.01) | ||||
| Mean blood pressure (mm Hg) | 82.5 at baseline; 91.5 at 10 min (p<0.01); 90.9 at 30 min (p<0.01) | ||||
| Cardiac output (l/min) | 4.5 at baseline; 4.3 at 10 min; 4.1 at 30 min (p<0.01) | ||||
| Systemic vascular resistance (dyne/cm2) | 1352 at baseline; 1576 at 10 min (p<0.05); 1608 at 30 min | ||||
| Change in parameters after diamorphine | All returned to within 1 SEM 10 min after diamorphine administration (except for persistent elevation of right atrial and mean pulmonary pressures) |
Author Commentary:
Although intravenous cyclizine is used regularly as an antiemetic in patients with cardiac chest pain concerns have been expressed about its potential effects on myocardial work/ischaemia. This well controlled but small study demonstrated significant changes in haemodynamic parameters with cyclizine, which appeared to be independent of the effects of diamorphine. In theory, raised vent filling pressures and an increase in afterload described in this study and confirmed by a reduction in cardiac output could lead to reduction of coronary artery flow and increase in myocardial oxygen consumption.
The major limitation of this study is the patient group studied and whether the results can be translated to the emergency department patient. In addition the effects of other antiemetics have not been studied so no comparative data are available, although cyclizine, as an antihistamine, is in a different group than most other commonly prescribed antiemetics. However, as it is often difficult to predict the clinical course of a patient when first assessed, it may be advisable to avoid cyclizine as a first line antiemetic.
The major limitation of this study is the patient group studied and whether the results can be translated to the emergency department patient. In addition the effects of other antiemetics have not been studied so no comparative data are available, although cyclizine, as an antihistamine, is in a different group than most other commonly prescribed antiemetics. However, as it is often difficult to predict the clinical course of a patient when first assessed, it may be advisable to avoid cyclizine as a first line antiemetic.
Bottom Line:
Cyclizine should be avoided in patients with acute coronary events.
References:
- Tan LB, Bryant S, Murray RG.. Detrimental Haemodynamic Effects of Cyclizine in Heart Failure