Antidepressant Use by Class: Association with Major Adverse Cardiac Events in Patients with Coronary Artery Disease

Abstract

Background: To assess use of antidepressants by class in relation to cardiology practice recommendations, and the association of antidepressant use with the occurrence of major adverse cardiovascular events (MACE) including death. Methods: This is a historical cohort study of all patients who completed cardiac rehabilitation (CR) between 2002 and 2012 in a major CR center. Participants completed the Patient Health Questionnaire (PHQ-9) at the start and end of the program. A linkage system enabled ascertainment of antidepressant use and MACE through 2014. Results: There were 1,694 CR participants, 1,266 (74.7%) of whom completed the PHQ-9 after the program. Depressive symptoms decreased significantly from pre- (4.98 ± 5.20) to postprogram (3.57 ± 4.43) (p < 0.001). Overall, 433 (34.2%) participants were on antidepressants, most often selective serotonin reuptake inhibitors (SSRI; n = 299; 23.6%). The proportion of days covered was approximately 70% for all 4 major antidepressant classes; discontinuation rates ranged from 37.3% for tricyclics to 53.2% for serotonin-norepinephrine reuptake inhibitors (SNRI). Antidepressant use was significantly associated with lower depressive symptoms after CR (before, 7.33 ± 5.94 vs. after, 4.69 ± 4.87; p < 0.001). After a median follow-up of 4.7 years, 264 (20.9%) participants had a MACE. After propensity matching based on pre-CR depressive symptoms among other variables, participants taking tricyclics had significantly more MACE than those not taking tricyclics (HR = 2.46; 95% CI 1.37–4.42), as well as those taking atypicals versus not (HR = 1.59; 95% CI 1.05–2.41) and those on SSRI (HR = 1.45; 95% CI 1.07–1.97). There was no increased risk with use of SNRI (HR = 0.89; 95% CI 0.43–1.82). Conclusion: The use of antidepressants was associated with lower depression, but the use of all antidepressants except SNRI was associated with more adverse events.

Sequential Combination of Cognitive-Behavioral Treatment and Well-Being Therapy in Depressed Patients with Acute Coronary Syndromes: A Randomized Controlled Trial (TREATED-ACS Study)

“…However, facilitating progression toward restoration of the positive ("there is life after ACS") and appreciation of healthy lifestyle is another target that requires specific interventions (WBT). The results of this investigation confirm previous studies on the role of psychotherapeutic strategies in the setting of ACS [6] and provide a valid alternative/integration to pharmacological strategies, which carry the disadvantages of side effects of antidepressant drugs [36-37], with particular reference to cardiovascular safety [38]. The sequential psychotherapeutic strategy that was used may also be applied after pharmacological treatment of depression, if appropriate, and may have potential in extending therapeutic benefits beyond the time of medication administration, as it has been found to be the case in psychiatric settings [39].…”

Iatrogenic Factors in Psychopathology

“…In psychiatry, iatrogenesis has traditionally been concerned with medical complications of psychotropic drug treatment [3], such as tardive dyskinesia [4] and insulin resistance [5] with antipsychotic drugs, and cardiac and metabolic disturbances with antidepressant medications [6-8]. The complications may occur due to direct toxicity, drug-drug interactions, intoxication, or withdrawal from psychotropic medications [3].…”

Is depression a real risk factor for acute myocardial infarction mortality? A retrospective cohort study

“…Regarding the association between antidepressant use and the risk of CHD among subjects with no history of CHD, the results of a meta-analysis provide no evidence of any association between SSRI or NSMRI use and CHD risk [34]. Although the use of antidepressants in patients with CHD helps to control their depression, their use in this group is controversial.…”