Is Wellbutrin (bupropion) safe for anxiety in a patient with multiple premature ventricular contractions (PVCs)?

Wellbutrin (Bupropion) Is Not Recommended for Anxiety in Patients with Multiple PVCs

Wellbutrin (bupropion) should be avoided in patients with anxiety who have multiple premature ventricular contractions (PVCs) due to potential cardiovascular risks and the possibility of exacerbating both anxiety symptoms and arrhythmias.

Understanding PVCs and Their Clinical Significance

PVCs are common arrhythmias that can range from benign to clinically significant:

• Multiple PVCs (≥2) are found in <1% of athletes' ECGs and may indicate underlying heart disease 1
• PVCs with a burden >15% of total heartbeats can produce reversible left ventricular dysfunction 1
• PVCs that increase with exercise require further cardiac evaluation 2

When evaluating a patient with multiple PVCs:

• An ambulatory Holter monitor, echocardiogram, and exercise stress test should be performed to assess PVC burden and exclude underlying structural heart disease 1, 2
• PVCs >2,000/24 hours have a higher association (30%) with structural heart disease 2
• PVC-induced cardiomyopathy risk increases with PVC burden >10% of total heartbeats 2

Bupropion's Cardiovascular Effects and Anxiety

While bupropion has been studied in patients with heart disease, several factors make it unsuitable for patients with anxiety and multiple PVCs:

1. Cardiovascular effects:

   • Bupropion can cause a rise in supine blood pressure 3
   • Treatment was discontinued in 14% of cardiac patients due to adverse effects, including exacerbation of baseline hypertension 3
   • Bupropion therapeutic errors have been associated with tachycardia/palpitations in 12% of cases 4

2. Anxiety-related concerns:

   • Anxiety is already common in PVC patients (33.3% in one study), with PVC count/24 hours being an independent risk factor 5
   • Bupropion overdose can cause "jittery"/anxious/agitated symptoms, which were present in 83% of patients who developed seizures or out-of-hospital adverse events 4

Treatment Recommendations for Patients with PVCs and Anxiety

For patients with anxiety and multiple PVCs, the following approach is recommended:

1. First-line pharmacological options:

   • Beta-blockers or non-dihydropyridine calcium channel blockers are reasonable first-line treatments for symptomatic PVCs in patients with normal ventricular function 6
   • These medications can simultaneously address both PVCs and anxiety symptoms

2. For high-burden PVCs:

   • If PVC burden is >15% and predominantly of one morphology, catheter ablation is useful when medications are ineffective or not tolerated 1
   • Beta-blockers or amiodarone are reasonable to reduce arrhythmias and improve symptoms and LV function in PVC-induced cardiomyopathy 1

3. For anxiety treatment:

   • SSRIs would be preferable over bupropion for anxiety in patients with cardiac concerns
   • While a recent study showed no difference in anxiety outcomes between SSRIs and bupropion in propensity-matched groups 7, this study did not specifically examine patients with PVCs

Monitoring and Follow-up

• Regular echocardiographic follow-up is recommended in patients with high PVC burden to monitor for PVC-induced cardiomyopathy 2
• For patients with exercise-induced PVCs, further evaluation with echocardiogram, 24-hour Holter monitoring, and exercise stress testing is necessary 2

Clinical Pitfalls to Avoid

1. Don't underestimate the significance of multiple PVCs - they require thorough evaluation to exclude underlying structural heart disease
2. Avoid medications that can increase sympathetic tone or heart rate in patients with multiple PVCs
3. Remember that anxiety itself is common in PVC patients and can exacerbate symptoms
4. Don't assume all PVCs are benign - high-burden PVCs can lead to cardiomyopathy if untreated

In conclusion, given the potential cardiovascular effects of bupropion and the existing cardiac concerns in patients with multiple PVCs, alternative treatments for anxiety should be prioritized in this patient population.