Antidepressant Selection for Patients with History of Myocardial Infarction on Mirtazapine
For patients with a history of heart attack who are already on mirtazapine 45mg for anxiety, sertraline is the most suitable antidepressant to add for depression due to its established cardiovascular safety profile. 1
Cardiovascular Considerations in Antidepressant Selection
When selecting an antidepressant for patients with cardiovascular disease, particularly those with a history of myocardial infarction, medication safety is paramount:
Avoid Tricyclic Antidepressants (TCAs): TCAs can provoke orthostatic hypotension, worsen heart failure, and trigger arrhythmias, making them contraindicated in patients with cardiac history 1
SSRIs are Preferred: Selective serotonin reuptake inhibitors (SSRIs) are considered the safest class of antidepressants for patients with cardiovascular disease 1
Current Mirtazapine Therapy: The patient is already on mirtazapine 45mg for anxiety. While mirtazapine is generally considered safe in cardiovascular disease, it's important to note that:
Recommended Antidepressant: Sertraline
Sertraline is the optimal choice for several reasons:
Cardiovascular Safety: The European Association for Palliative Care specifically recommends SSRIs, particularly sertraline, for patients with heart disease 1
Evidence in Post-MI Patients: Sertraline has been specifically studied in post-MI patients with depression and has shown safety and efficacy 1
Complementary Mechanism: Sertraline works primarily on serotonin pathways, which complements mirtazapine's action on noradrenergic and specific serotonergic pathways 2, 5
Dosing Recommendation:
- Start at a lower dose of 25mg daily 6
- Titrate slowly while monitoring for side effects
- Target dose of 50-200mg daily based on response and tolerability
Other Potential Options
While sertraline is the first choice, other options with considerations include:
Escitalopram: Another SSRI with good cardiovascular safety profile, but like sertraline, can cause QT prolongation 1, 6
Bupropion: Has minimal cardiovascular effects and no sexual side effects, but may increase blood pressure and has seizure risk at higher doses 2
Venlafaxine: Effective but may increase blood pressure, requiring careful monitoring 1
Important Monitoring Considerations
When initiating sertraline in this patient:
Monitor for QT prolongation, especially since both mirtazapine and sertraline can affect cardiac conduction 1
Follow up within 1-2 weeks of medication changes 6
Evaluate for treatment effectiveness every 2-4 weeks during medication adjustments 6
Watch for serotonin syndrome symptoms (agitation, tremor, hyperthermia) due to combination therapy
Continue treatment for at least 9-12 months after symptom remission 6
Common Pitfalls to Avoid
Avoid assuming mirtazapine alone can treat both anxiety and depression at its current dose; its antidepressant effects may be insufficient for major depression
Don't overlook drug interactions: While minimal, there are potential interactions between mirtazapine and sertraline that should be monitored
Don't discontinue mirtazapine abruptly: If considering transitioning medications, taper gradually to prevent discontinuation syndrome
Avoid excessive polypharmacy: While adding sertraline is justified, regularly reassess the need for both medications long-term
By selecting sertraline, you're choosing an antidepressant with established safety in cardiac patients that complements the patient's existing mirtazapine therapy for anxiety.