People who use drugs with anticholinergic properties, such as certain antidepressants, urinary incontinence drugs, and common antihistamines, are at increased risk of developing cardiovascular disease. This is shown in a new study published by Karolinska Institutet. BMC Medicine.
Anticholinergic drugs reduce the effects of the neurotransmitter acetylcholine and are commonly prescribed to middle-aged and elderly people. This large group of drugs includes antihistamines used for allergy symptoms, anxiety or insomnia, urinary incontinence medications, and certain antidepressants. Tricyclic antidepressants have strong anticholinergic effects, whereas SSRIs have weaker effects. High cumulative use of these drugs, called anticholinergic burden (see fact box), has previously been associated with impaired cognitive performance.
May affect heart regulation
New research suggests that these drugs may also affect the parasympathetic nervous system, thereby affecting the regulation of the cardiovascular system. This result indicates that monitoring total drug load may be important in daily clinical practice.
The study included more than 500,000 people living in Stockholm, Sweden, aged 45 and over and without a history of cardiovascular disease other than high blood pressure at the start of the study. Researchers followed participants for up to 14 years and analyzed how anticholinergic drug use was associated with the development of cardiovascular disease.
Many of these drugs are used by older adults and people with multiple medical conditions. We wanted to investigate whether total exposure has any implications for the risk of developing cardiovascular disease over time. ”
Nanbo Zhu, Postdoctoral Researcher, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet
71% higher heart risk
This study showed that the risk of cardiovascular disease increased depending on the amount of anticholinergic drugs participants used each year. Those with the highest exposure had a 71 percent higher risk of cardiovascular events than those who never used anticholinergic drugs. This association was seen in all types of cardiovascular disease, but especially in heart failure and various forms of arrhythmia.
“Our results show that the accumulation of drug load can affect cardiac regulation not only in the short term but also in the long term. This does not mean that drugs should always be avoided, but it does mean that drug exposure should be carefully monitored,” says Hong Xu, assistant professor in the Department of Neurobiology, Care Sciences and Sociology.
The researchers note that the study is observational and cannot prove cause and effect. Other factors, such as underlying medical conditions, may also influence the association.
The study was carried out within the Stockholm CREAtinine Measurements project, in collaboration with Karolinska Institutet and several research groups in the Stockholm region. This research was funded by the Swedish Research Council, the Foundation Center for Innovative Medicine, and other foundations. Some researchers have reported assignments to the pharmaceutical industry, which have been published in scientific publications.
facts about drugs
Anticholinergic drugs in this study were identified based on the Anticholinergic Cognitive Load (ACB) scale, a tool used in research and clinical practice. This scale covers a variety of drugs, which are scored between 1 and 3, depending on how well the drug blocks the neurotransmitter acetylcholine. Add up the intake of these drugs to estimate the patient’s anticholinergic burden.
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Reference magazines:
Zhu N. Others. (2026). Anticholinergic drug burden and incidence of cardiovascular events: a population-based study. BMC Medicine. DOI: 10.1186/s12916-026-04751-w. https://link.springer.com/article/10.1186/s12916-026-04751-w
