Address depression in patients after a heart attack
How to treat depression after a heart attack? this is important questions. Depression occurs in nearly half of heart attack patients and it's associated with a higher risk of CV events and death. Plus adherence to lifestyle changes and cardiovascular medications, antiplatelets, statins, etc may be even harder for patients with depression. But don't recommend an antidepressant for all heart attack patients. If patients are depressed, emphasize nondrug steps, cardiac rehabilitation, exercise, psychotherapy, etc. Suggest adding an antidepressant if needed.
Selective serotonin reuptake inhibitors (SSRIs) are first-line. Think of sertraline (Lustral) as the go-to. It has the most evidence and seems less risky than other SSRIs in these patients. Advise avoiding citalopram (Cipram) after a heart attack and limiting escitalopram (Cipralex) to 10 mg/day due to risk of QT prolongation and torsades. Explain that taking an SSRI with antiplatelets may increase bleeding risk. But don't jump to a proton pump inhibitor (PPI) to prevent gastrointestinal (GI) bleeding unless the patient has other risks like prior ulcer, taking anticoagulants, etc.
Some weak evidence suggests SSRIs MIGHT improve cardiovascular (CV) outcomes after a heart attack, possibly due to antiplatelet or anti-inflammatory effects. But don't rely on SSRIs or any other antidepressant for CV benefit. Mirtazapine or bupropion may be tried if SSRIs can't be used. These seem safe in CV patients and bupropion can help with smoking cessation.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another option. They may raise blood pressure (BP), but effects are variable. For example, BP increases are rare with duloxetine (Cymbalta), but more common with venlafaxine (Efexor) doses over 225 mg/day compared to lower doses. Trazodone (Trittico) may lead to orthostatic hypotension, especially at higher doses. Suggest limiting to low doses, such as 25 mg for insomnia. Tricyclics antidepressants should be avoided due to heart block and arrhythmia risk. Recommend early and frequent follow-up when patients start an antidepressant and suggest tapering over at least 4 weeks when stopping.
References
- Kim, J.-M., Stewart, R., and others. (2018). Effect of Escitalopram vs Placebo Treatment for Depression on Long-term Cardiac Outcomes in Patients with Acute Coronary Syndrome. JAMA, 320(4), p.350.
- Labos C, Dasgupta K, Nedjar H, Turecki G, Rahme E. Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction. CMAJ. 2011;183(16):1835-1843.
- Geriatric depression: The use of antidepressants in the elderly. British Columbia Medical Journal. [online] Available at: https://bcmj.org/articles/geriatric-depression-use-antidepressants-elderly
