Can Lexapro Influence Blood Pressure?
Lexapro (escitalopram) does not increase blood pressure and may actually lower it in certain populations, particularly those with concomitant hypertension and depression. 1
Evidence from Guidelines
The most authoritative guidance comes from the International Society of Hypertension, which explicitly states that SSRIs, including escitalopram, cause no increases in blood pressure. 1 This is reinforced by major hypertension guidelines from the American Heart Association and European societies, which do not list SSRIs among medications that raise blood pressure—instead identifying SNRIs (which increase BP by 2/1 mmHg) and tricyclic antidepressants (odds ratio 3.19 for hypertension) as the problematic antidepressant classes. 1
When managing hypertension in patients with depression, guidelines recommend that blood pressure should be lowered preferentially with RAS-inhibitors and diuretics, which have lower rates of pharmacological interactions with antidepressants. 2 Calcium channel blockers and alpha-1 blockers should be used cautiously in patients on serotonin reuptake inhibitors due to orthostatic hypotension risk. 2
FDA-Approved Labeling Data
The FDA label for escitalopram provides reassuring cardiovascular safety data. Vital sign analyses showed that escitalopram treatment is not associated with clinically important changes in blood pressure, and comparison of supine and standing measurements confirmed no orthostatic changes. 3 In controlled trials, escitalopram and placebo groups showed no differences in mean changes in systolic or diastolic blood pressure. 3
Clinical Research Findings
Multiple studies support the blood pressure-neutral or beneficial profile of escitalopram:
A large pooled analysis of 3,298 patients found no clinically or statistically significant difference in systolic or diastolic blood pressure between escitalopram and placebo. 4 There was only a small 2 beats per minute decrease in heart rate with escitalopram. 4
In hypertensive patients with depression, escitalopram (10-20 mg) decreased heart rate but did not significantly affect systolic or diastolic blood pressure compared to placebo. 5
Two randomized trials in hypertensive patients with depression showed potential blood pressure-lowering effects: One study found more pronounced reductions in 24-hour systolic blood pressure time indexes with citalopram plus antihypertensives compared to antihypertensives alone. 6 Another demonstrated significantly lower systolic (124.5 vs 133.8 mmHg) and diastolic (73.7 vs 80.7 mmHg) blood pressure at 2 months with citalopram added to standard treatment. 7
Important Clinical Considerations
The primary cardiovascular concern with escitalopram is bradycardia, not hypertension. 8 One case report documented symptomatic bradycardia (39 bpm) and mild hypotension with therapeutic doses, which resolved within 48 hours of discontinuation. 8 Therefore, monitor heart rate and blood pressure during the first week of therapy and when modifying doses, particularly in elderly patients or those with pre-existing heart disease. 8
Escitalopram represents a safer cardiovascular choice compared to other antidepressant classes for patients requiring treatment of both hypertension and depression. 1 The risk of pharmacologic interactions and ECG abnormalities must still be considered in the overall management approach. 2