Is Bupropion (Wellbutrin) contraindicated in patients with a history of cardiac disease?

From the Guidelines

Wellbutrin (bupropion) is not absolutely contraindicated for patients with cardiac history, but it should be used with caution and under close medical supervision. According to the study published in the Journal of the National Comprehensive Cancer Network 1, bupropion can be used for smoking cessation, but providers should monitor for potential side effects, including those related to cardiac health. The study does not specifically address cardiac history as a contraindication, but it does mention that bupropion can cause blood pressure elevation and heart rate increases, which may be problematic for patients with pre-existing cardiovascular conditions.

Some key considerations for using Wellbutrin in patients with cardiac history include:

• Starting with a lower dose (150 mg daily) and gradual titration if needed
• Using sustained-release or extended-release formulations to minimize cardiovascular effects
• Conducting a thorough cardiac evaluation before starting treatment
• Regular monitoring of blood pressure and heart rate during therapy
• Individualizing the decision to use Wellbutrin based on the specific cardiac condition, its severity, and the potential benefits versus risks of treatment, as suggested by the guidelines for smoking cessation 1.

It is essential to weigh the potential benefits of Wellbutrin against the risks, particularly in patients with unstable heart disease or certain arrhythmias, and to use it only under close medical supervision.

From the FDA Drug Label

The risk of hypertension is increased if bupropion hydrochloride extended-release tablets (XL) are used concomitantly with MAOIs or other drugs that increase dopaminergic or noradrenergic activity [see Contraindications (4)] There are no controlled studies assessing the safety of bupropion in patients with a recent history of myocardial infarction or unstable cardiac disease. In a clinical trial of bupropion immediate-release in MDD subjects with stable congestive heart failure (CHF) (N=36), bupropion was associated with an exacerbation of pre-existing hypertension in 2 subjects, leading to discontinuation of bupropion treatment

Key Points:

• Bupropion may increase the risk of hypertension
• There are no controlled studies on the safety of bupropion in patients with a recent history of myocardial infarction or unstable cardiac disease
• Bupropion may exacerbate pre-existing hypertension in patients with stable congestive heart failure

Bupropion is not explicitly contraindicated with cardiac history, but caution is advised due to the potential increased risk of hypertension and lack of controlled studies in patients with recent myocardial infarction or unstable cardiac disease 2.

From the Research

Wellbutrin and Cardiac History

• Wellbutrin, also known as bupropion, has been studied in patients with preexisting cardiac disease to determine its safety and efficacy 3.
• A study published in 1991 found that bupropion did not cause significant conduction complications, did not exacerbate ventricular arrhythmias, and had a low rate of orthostatic hypotension in patients with left ventricular impairment, ventricular arrhythmias, and/or conduction disease 3.
• However, bupropion treatment was discontinued for 14% of the patients due to adverse effects, including exacerbation of baseline hypertension in two patients 3.
• Another study published in 2017 found that bupropion was not associated with an increased risk of adverse cardiovascular events in smokers with chronic obstructive pulmonary disease (COPD) compared to nicotine replacement therapy (NRT) 4.
• A review of newer antidepressants, including bupropion, found that it was not associated with a higher cardiovascular risk, unlike some other antidepressants such as serotonin-norepinephrine reuptake inhibitors (SNRIs) and reboxetine 5.

Comparison with Other Antidepressants

• Selective serotonin reuptake inhibitors (SSRIs) have been found to be associated with a lower risk of cardiovascular events in patients with coronary artery disease and depression 6.
• A systematic review and meta-analysis published in 2021 found that SSRIs were associated with a significantly lower risk of myocardial infarction in patients with coronary artery disease and depression, but did not find a significant difference in all-cause mortality or cardiovascular mortality 6.
• Varenicline, another smoking cessation treatment, was found to be associated with a reduced risk of heart failure and depression in smokers with COPD, similar to bupropion 4.

Cardiovascular Risks

• The cardiovascular profile of bupropion may make it a useful agent in the treatment of depressed patients with preexisting cardiovascular disease, but further studies are needed to confirm these findings 3.
• Patients with a history of cardiac disease should be monitored closely when taking bupropion, as it may exacerbate underlying conditions such as hypertension 3.
• The use of bupropion in patients with cardiac history should be weighed against the potential benefits of treatment, and alternative treatments such as SSRIs may be considered in some cases 6, 5.