Is Strattera (atomoxetine) safe to use in patients with recent stent placement after open heart surgery?

Atomoxetine (Strattera) Safety in Patients with Recent Coronary Stents

Atomoxetine should be used with caution in patients with recent coronary stent placement after open heart surgery due to its cardiovascular effects, and antiplatelet therapy must be maintained without interruption to prevent potentially fatal stent thrombosis. 1

Cardiovascular Considerations with Atomoxetine

Atomoxetine carries specific cardiovascular risks that require careful consideration in patients with coronary stents:

• Atomoxetine is contraindicated in patients with severe cardiovascular disorders whose condition would be expected to deteriorate if they experience increases in blood pressure or heart rate (15-20 mmHg in blood pressure or 20 beats per minute in heart rate) 1
• The medication can cause statistically significant increases in both heart rate and blood pressure in patients 2
• Patients with recent stent placement are already at elevated cardiovascular risk, making these hemodynamic effects potentially more concerning

Stent Thrombosis Risk and Antiplatelet Management

The primary concern in patients with coronary stents is maintaining appropriate antiplatelet therapy:

• Premature discontinuation of antiplatelet therapy markedly increases the risk of catastrophic stent thrombosis and death/MI 3
• For drug-eluting stents, dual antiplatelet therapy is recommended for at least 12 months after placement 3, 4
• For bare-metal stents, dual antiplatelet therapy is recommended for at least 4-6 weeks after placement 3

Critical Antiplatelet Management Points:

• Aspirin should be continued indefinitely in patients with coronary stents 4
• Patients at highest risk for stent thrombosis include those with:
  • Drug-eluting stents placed within 6-12 months
  • History of stent thrombosis
  • Multiple stents or long stents
  • Stents placed at bifurcations
  • Incomplete revascularization
  • Diabetes
  • Low ejection fraction 3, 4

Recommendations for Atomoxetine Use in Stent Patients

1. Initial Assessment:

   • Determine stent type (bare-metal vs. drug-eluting) and time since placement
   • Evaluate current antiplatelet regimen and compliance
   • Assess baseline cardiovascular parameters (BP, HR)

2. Decision Algorithm:

   • If stent placement was recent (<12 months for drug-eluting; <4-6 weeks for bare-metal):

     • Consider alternative ADHD treatments if possible
     • If atomoxetine is necessary, start at lowest possible dose (40mg/day in adults) 1
     • Monitor BP and HR closely during initiation and dose adjustments

   • If stent placement was >12 months ago (drug-eluting) or >6 weeks ago (bare-metal):

     • Atomoxetine may be used with careful monitoring
     • Start at lower doses and titrate slowly
     • Regular cardiovascular monitoring is essential

3. Monitoring Requirements:

   • Check BP and HR before starting treatment, after each dose increase, and periodically during treatment
   • Be vigilant for signs of cardiovascular compromise
   • Consider more frequent cardiology follow-up during atomoxetine initiation

Important Precautions and Contraindications

• Atomoxetine is absolutely contraindicated in patients with:

  • Severe cardiovascular disorders 1
  • Pheochromocytoma (due to risk of hypertensive crisis) 1

• Use with extreme caution in patients with:

  • Hypertension
  • Tachyarrhythmias
  • Recent cardiovascular procedures

Multidisciplinary Approach

A multidisciplinary team meeting involving the cardiologist, psychiatrist, and primary care physician should occur before initiating atomoxetine in patients with coronary stents 3. This team should:

• Evaluate individual thrombotic risk
• Assess the necessity of atomoxetine versus alternative treatments
• Determine optimal monitoring parameters
• Document the consensus plan in the medical record

Conclusion

While atomoxetine is not absolutely contraindicated in patients with coronary stents, its cardiovascular effects warrant careful consideration. The most critical aspect of management is ensuring uninterrupted antiplatelet therapy according to guidelines based on stent type and placement timing. When atomoxetine is deemed necessary, start with lower doses, monitor cardiovascular parameters closely, and maintain regular follow-up with both psychiatric and cardiac care providers.