Is trazodone (an antidepressant medication) safe for patients with cardiac (cardiovascular) disease?

From the Guidelines

Trazodone should be used with caution in cardiac patients, as it can cause QT interval prolongation, orthostatic hypotension, and arrhythmias, and its safety is not as well-established as some other antidepressants, such as SSRIs, particularly sertraline, which has been shown to have a lower risk of QTc prolongation 1. When considering the use of trazodone in cardiac patients, it is essential to weigh the potential benefits against the risks, particularly in patients with pre-existing cardiac conditions, such as conduction disorders, recent heart attacks, or heart failure.

• Key considerations include:
  • Starting with lower doses, typically 25-50mg at bedtime, and gradually increasing as needed
  • Obtaining baseline ECGs before starting treatment and conducting follow-up monitoring
  • Carefully using trazodone alongside other medications that affect heart rhythm or blood pressure
  • Monitoring patients for symptoms like dizziness, fainting, palpitations, or chest pain, and instructing them to report these symptoms immediately to their healthcare provider. According to the American Heart Association, cognitive behavioral therapy for insomnia is recommended as first-line treatment before the initiation of sedating antidepressants like trazodone 1.
• Alternative treatments, such as SSRIs, particularly sertraline, may be safer for cardiac patients, but the decision to use trazodone should be made on a case-by-case basis, taking into account the individual patient's medical history, current medications, and potential risks and benefits.

From the FDA Drug Label

Clinical studies indicate that trazodone hydrochloride may be arrhythmogenic in patients with preexisting cardiac disease. Arrhythmias identified include isolated PVCs, ventricular couplets, tachycardia with syncope, and torsade de pointes Trazodone Hydrochloride Tablets should also be avoided in patients with a history of cardiac arrhythmias, as well as other circumstances that may increase the risk of the occurrence of torsade de pointes and/or sudden death, including symptomatic bradycardia, hypokalemia or hypomagnesemia, and the presence of congenital prolongation of the QT interval Trazodone Hydrochloride Tablets are not recommended for use during the initial recovery phase of myocardial infarction. Caution should be used when administering Trazodone Hydrochloride Tablets to patients with cardiac disease and such patients should be closely monitored, since antidepressant drugs (including Trazodone Hydrochloride Tablets) may cause cardiac arrhythmias

Trazodone is not safe for all cardiac patients. Cardiac patients with preexisting cardiac disease, history of cardiac arrhythmias, or other conditions that may increase the risk of torsade de pointes and/or sudden death should be closely monitored or avoided.

• Key considerations for cardiac patients include:
  • History of cardiac arrhythmias
  • Preexisting cardiac disease
  • Symptomatic bradycardia
  • Hypokalemia or hypomagnesemia
  • Congenital prolongation of the QT interval
  • Initial recovery phase of myocardial infarction 2

From the Research

Safety of Trazodone for Cardiac Patients

• Trazodone is hypothesized to be less cardiotoxic than tri-tetracyclic antidepressants 3
• The drug has little effect on cardiac conduction and does not worsen supraventricular arrhythmias 3
• Trazodone produces less postural hypotension than most other antidepressants and tends to lower heart rate 3
• Lower doses of trazodone (100-300 mg) are better tolerated and more effective in major depressives simultaneously debilitated by significant cardiovascular disease 3

Cardiovascular Risks Associated with Trazodone

• Trazodone has been associated with some adverse effects, including orthostatic hypotension, particularly in elderly patients or those with heart disease 4, 5
• The drug may cause QTc interval prolongation, cardiac arrhythmias, and torsade de pointes, although these events are rare 5, 6
• Fatal arrhythmias can occur in trazodone overdose, and close monitoring and supportive care are crucial for patient survival 6

Comparison with Other Antidepressants

• Trazodone has emerged as the antidepressant drug with the least risk of death in overdose, and as a useful alternative to standard tricyclic antidepressant drugs in patients with preexisting conduction disease 4
• Mianserin and trazodone are comparable for both antidepressant efficacy and paucity of cardiovascular effects, although caution is advised when prescribing either drug to patients with transient cerebral ischaemic attacks or those with coronary artery disease receiving medication 7