Gli effetti sul cuore degli inibitori della colinesterasi

Acetylcholinesterase inhibitors (AchEI), like donepezil, galantamine and rivastigmine are the only drugs – together with memantine (glutamate receptor antagonist) – which obtained the indication for the symptomatic treatment of Alzheimer disease, but are also used for the treatment of other types of dementia.3,4In Italy, the estimated average consumption of acetylcholinesterase inhibitors from 2008 to 2010 amounts to 0.974 DDDs (defined daily dose)/1,000 population/day for donezepil; 0.448 DDDs/1,000 population/day for rivastigmine; 0.112 DDDs/1,000 population/day for galantamine and 0.211 DDDs/1,000 population/day for memantine. Most reported adverse effects are: diarrhea, nausea, vomit and more rarely cardiovascular effects.2.5 Their cardiotoxicity is often disregarded to such a point that in the 50% of patients hospitalized for bradycardia the therapy is prescribed again.5 If these drugs are not identified as the causes for symptomatic bradycardia, the patient could incur in serious consequences, besides undergoing expensive investigations.6 A recent study did not reveal any correlation between the use of acetylcholinesterase inhibitors and the increment of chronotropic negative effects, hypotensive effects or arrhythmia in elderly patients with Alzheimer disease;7 on the other side, another study underlined a modest risk for bradycardia, but a high doses.4However, the percentage of brachycardia or syncope caused by acetylcholinesterase inhibitors in the daily clinical practice is not clear yet.According to some authors, the use of acetylcholinesterase inhibitors in elderly patients with dementia, in addition to bradycardia, would be associated to an increased incidence of syncope, pacemaker implant and femur fracture.6 It is opportune to highlight that patients with dementia who suffer a femur fracture have an elevate risk of ulterior functional decline, institutionalization and death.11