From the Guidelines
Selective Serotonin Reuptake Inhibitors (SSRIs), specifically sertraline, are the antidepressants with the least cardiac effects and should be considered as the first-line treatment option. When considering antidepressants for patients with cardiac concerns, it is crucial to prioritize medications that do not significantly impact cardiac function. According to a recent study published in Circulation in 2024 1, SSRIs, particularly sertraline, have been extensively studied and appear to be safe for patients with coronary heart disease and heart failure, with a lower risk of QTc prolongation compared to other SSRIs like citalopram or escitalopram.
Some key points to consider when prescribing antidepressants to patients with cardiac concerns include:
- Starting with low doses and gradually increasing while monitoring for any cardiovascular changes
- Avoiding tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) due to their significant cardiovascular side effects, including hypertension, hypotension, and arrhythmias
- Considering mirtazapine, an atypical antidepressant, as a safe option, although its efficacy in treating depression in patients with cardiovascular disease has not been fully assessed
- Being cautious with citalopram, as higher doses may prolong the QT interval, potentially leading to dangerous heart rhythm disturbances, as noted in the study 1.
In terms of specific medications, the following SSRIs are considered to have minimal cardiac effects:
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
- Escitalopram (Lexapro)
- Paroxetine (Paxil) It is essential to weigh the benefits and risks of each medication and consider the individual patient's medical history and current health status when making a treatment decision, as emphasized in the study 1.
From the Research
Antidepressants with Minimal Cardiac Effects
- Selective serotonin reuptake inhibitors (SSRIs) are generally considered to be safe and have cardio-protective effects on ventricular function, as well as cardiac conductive system 2, 3
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered to have neutral effects on the cardiovascular system, with some exceptions 2, 4
- Agomelatine, mirtazapine, vilazodone, and vortioxetine are identified as having no current evidence of cardiovascular risk 4
Antidepressants with Potential Cardiac Effects
- Levomilnacipran and vilazodone have not received enough study to judge their safety in older patients or in those with, or at high risk for, cardiovascular disease 5
- Citalopram and escitalopram are associated with increased out-of-hospital cardiac arrest (OHCA) rate at high doses 6
- Mirtazapine is associated with increased OHCA rate at high doses, particularly in patients without cardiac disease and cardiovascular risk factors 6
Key Considerations
- Careful administration and attention to potential adverse reactions are necessary when prescribing antidepressants to patients with cardiovascular disease or at high risk for cardiovascular disease 5, 2, 4
- The selection of antidepressants should be based on their cardiovascular effects, with consideration of the patient's individual risk factors and medical history 2, 4