Safety of Antidepressant Drugs in the Patient with Cardiac Disease: A Review of the Literature

Abstract

Patients with cardiac disease, specifically ischemic heart disease and heart failure, have a higher frequency of major depressive disorder than patients without cardiac disease. The pathophysiologic reason for this is not completely understood. Previous depression, other debilitating illnesses, and type A personality are risk factors for the development of depression in cardiac patients. Depression has been shown to lower the threshold for ventricular arrhythmias. Therefore, treatment of depression potentially may prolong life in these patients. Antidepressant options that have been evaluated include several of the tricyclic antidepressants, trazodone, bupropion, and several of the selective serotonin reuptake inhibitors. Individual antidepressant drugs vary in their pharmacologic activity and side-effect profiles. Although clinical data are limited, it is important to individualize therapy in order to minimize cardiac adverse effects. Clinicians are encouraged to evaluate patients with cardiac disease for major depressive disorder and to consider antidepressant drug therapy for these patients when appropriate.

Role of depression in heart failure — Choosing the right antidepressive treatment

“…Data support that SSRIs decrease the serotonin-induced activation of platelets [43], but we do not know yet the clinical implication of this effect. Ziegelstein et al [60] demonstrated that patients with ACS, under SSRI treatment on top of conventional antiplatelet therapy, had a lower risk of myocardial ischemia, rise of cardiac enzymes and development of HF during hospitalization compared to those not receiving SSRIs, at the expense however of increased bleeding risk [60].…”

“…TCA overdose may trigger AV block, bundle branch block or ventricular arrhythmias. The Cardiac Arrhythmia Suppression Trial (CAST) [42] suggested that TCAs should be avoided in patients with cardiovascular disease (CVD) due to the risk of lifethreatening arrhythmias especially when co-prescribed with other drugs prolonging QT interval [43]. On the other hand SSRIs have lower risk of adverse anti-cholinergic and anti-histaminergic side effects [43].…”

Effects of paroxetine on cardiovascular response to mental stress in subjects with a history of coronary artery disease and no psychiatric diagnoses

“…Studies assessing SSRI efficacy in the treatment of depression in which resting effects on heart rate or blood pressure were also reported generally show either small or no effects of the SSRI on these cardiovascular parameters (Alvarez and Pickworth 2003;Amsterdam et al 1999;Glassman et al 2002). The reason for the relatively large differences observed in resting blood pressure and heart rates between the two treatment groups is unclear, although this could be potentially explained by the study conditions.…”

Heart Failure and Depression

“…40 For example, SSRIs may decrease thrombotic events by reducing platelet activation. 41 Treatment with tricyclic antidepressants and SNRIs has been associated with decreased pro-inflammatory markers, when compared with treatment with SSRIs, which may slow progression of heart failure. 14 SSRIs are considered to be both efficacious and safe.…”