Risks of Antidepressants in the Elderly: Tricyclic Antidepressants and Arrhythmia – Revising Risks

Abstract

Unexpected events have occurred in cardiology over the last 4 years. A study by the Heart and Lung Institute of the National Institute of Health in the mid-1980s showed to great surprise that class I antiarrhythmic drugs given to patients with ventricular arrhythmias following myocardial infarction, instead of preventing deaths, actually increased the number of patients dying. Since then, a series of studies has consistently confirmed this original observation. The problem for psychiatry is that the tricyclic antidepressant (TCA) drugs are also class I antiarrhythmics. There is every reason to believe that a similar increased risk of death would exist with the TCAs. It is, therefore, important for psychiatrists to understand the cause and magnitude of this excess in deaths. Evidence to date would suggest that all class I compounds, despite being powerful antiarrhythmics under usual physiological conditions, become proarrhythmic under anoxic conditions. Such conditions would exist in ischaemic heart disease during angina and, particularly, myocardial infarction. How this might alter our use of TCAs and whether this happens with the selective serotonin reuptake inhibitors is discussed.

Does Panic Disorder Increase the Risk of Coronary Heart Disease? A Cohort Study of a National Managed Care Database

“…Also, immune activation and hypercortisolemia as stress responses to depression (42)(43)(44)(45) may result in decreased insulin resistance and increased steroid production and blood pressure, thereby increasing the risk of cardiac disease (46). Unhealthy lifestyles, have also been found to be more common among depressed than nondepressed people (47,48), and antidepressants, specifically tricyclic antidepressants, may have a cardiotoxic effect (49). However, in a communitybased sample, antidepressants were used only sparingly and dosages were generally low (50).…”

Depression and Cardiac Disease

“…Tricyclic antidepressants (TCAs), which act by increasing brain levels of serotonin, dopamine, and norepinephrine in addition to antagonizing histaminic, muscarinic, and alpha 1 -adrenergic receptors, are among the oldest antidepressant agents. 92 Although these medications are effective for the treatment of depression, they are suboptimal in cardiac patients, given their propensity to cause orthostatic hypotension, 93,94 conduction disturbances, 93,94 and arrhythmias. 94 In fact, TCAs have been linked with significantly more frequent adverse cardiac events in patients with ischemic heart disease as compared with SSRIs.…”

Cardiovascular side effects of psychopharmacologic therapy

“…They could only be given after a careful risk/benefit analysis [37]. Data suggests there is increased risk of death with the TCAs [41]. Phenelzine is an irreversible monoamine oxidase inhibitor (MAOI) [42].…”

“…According to available report the TCA, amitriptyline, is reported to induce ST-segment elevation in the right precordial ECG leads [52]. The problem for psychiatry is that the TCA drugs are also class I antiarrhythmic [41]. SSRI are generally believed to cause fewer pro-arrhythmic SE then TCAs [53].…”