Is an electrocardiogram (ECG) required prior to initiating selective serotonin reuptake inhibitor (SSRI) therapy?

From the Guidelines

In most cases, an electrocardiogram (ECG) is not routinely required before starting a selective serotonin reuptake inhibitor (SSRI) for the average patient. SSRIs such as fluoxetine, sertraline, escitalopram, citalopram, and paroxetine are generally considered to have a favorable cardiac safety profile compared to older antidepressants. However, an ECG should be considered before starting an SSRI in patients with pre-existing cardiovascular disease, those at high risk for QT interval prolongation, elderly patients, or when prescribing citalopram at higher doses (which has a dose-dependent risk of QT prolongation) 1. This recommendation exists because SSRIs, particularly citalopram, can potentially cause QT interval prolongation in susceptible individuals, which could lead to dangerous heart rhythm disturbances. Other risk factors that might warrant an ECG include electrolyte abnormalities, concomitant use of other QT-prolonging medications, or a personal or family history of certain cardiac conditions.

The provided evidence from the British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease 1 supports the consideration of an ECG before initiating therapy in patients with certain risk factors, although this guideline is not directly related to SSRI use, it highlights the importance of assessing QT interval prolongation risk. In contrast, the European LeukemiaNet recommendations for the management and avoidance of adverse events of treatment in chronic myeloid leukemia 1 focus on the use of tyrosine kinase inhibitors (TKIs) and their potential to affect the QT interval, which is not directly applicable to SSRI therapy.

Key points to consider when deciding whether to obtain an ECG before starting an SSRI include:

• Pre-existing cardiovascular disease
• High risk for QT interval prolongation
• Elderly patients
• Use of citalopram at higher doses
• Electrolyte abnormalities
• Concomitant use of other QT-prolonging medications
• Personal or family history of certain cardiac conditions Your healthcare provider will determine if an ECG is necessary based on your individual risk factors and medical history.

From the FDA Drug Label

Electrolyte and/or ECG monitoring is recommended in certain circumstances Patients being considered for citalopram treatment who are at risk for significant electrolyte disturbances should have baseline serum potassium and magnesium measurements with periodic monitoring. ECG monitoring is recommended in patients for whom citalopram use is not recommended (see above), but, nevertheless, considered essential. These include those patients with the cardiac conditions noted above, and those taking other drugs that may prolong the QTc interval.

ECG monitoring is recommended in certain circumstances, such as patients at risk for significant electrolyte disturbances or those with cardiac conditions. However, it is not explicitly stated that an ECG is required prior to starting SSRI treatment for all patients.

• The decision to perform an ECG should be based on individual patient risk factors, such as cardiac conditions or the use of other drugs that may prolong the QTc interval.
• Patients with certain conditions, such as congenital long QT syndrome or recent acute myocardial infarction, should not be given citalopram without careful consideration and monitoring 2.

From the Research

ECG Prior to Starting SSRI

• There is no explicit requirement for an ECG prior to starting an SSRI, but certain factors should be considered:
  • Patient's individual risk factors for arrhythmias and other patient-specific factors 3
  • Presence of comorbidities, such as previous stroke or myocardial infarction, which may increase the risk of adverse events 4
  • Choice of SSRI, as some may have a lower risk of QT prolongation than others 3, 5
• Routine ECG monitoring is not recommended for all patients starting SSRIs, but it may be useful in certain situations:
  • When administering SSRIs to patients with co-existing risk factors for QT prolongation 6
  • When prescribing SSRIs with an established increased risk of torsade de pointes (TdP) and sudden death 6
• The risk of serious arrhythmia associated with SSRIs, such as citalopram and escitalopram, has been investigated in several studies:
  • A population-based cohort study found no increased risk of serious arrhythmia with citalopram or escitalopram compared to other SSRIs 7
  • However, the study did find lower point estimates of risk after safety warnings were issued for these medications 7