Is atomoxetine (Strattera) contraindicated in patients post-coronary artery bypass grafting (CABG)?

Atomoxetine Use Post-CABG

Atomoxetine is not specifically contraindicated after CABG, but should be used with extreme caution due to its cardiovascular effects, particularly its tendency to increase heart rate and blood pressure in a population that requires strict hemodynamic control.

Cardiovascular Effects of Atomoxetine

Atomoxetine, as a selective norepinephrine reuptake inhibitor, has well-documented cardiovascular effects that are particularly relevant in post-CABG patients:

• Atomoxetine causes statistically significant increases in systolic blood pressure (in adults) and diastolic blood pressure (in children/adolescents), along with consistent increases in mean pulse rate across all age groups 1
• These hemodynamic changes occur early in therapy, stabilize over time, and return toward baseline upon discontinuation 1
• Cardiovascular adverse events including palpitations (3.7% vs 0.8% placebo), syncope, orthostatic hypotension, and tachycardia have been reported with atomoxetine use 1, 2
• The noradrenergic activity of atomoxetine directly opposes the hemodynamic goals in post-CABG management 2

Post-CABG Medication Priorities

The 2011 ACC/AHA CABG guidelines establish clear medication priorities that should take precedence:

• Beta blockers are Class I recommendations and should be prescribed to all CABG patients without contraindications at hospital discharge 3
• Beta blockers reduce mortality, prevent atrial fibrillation, and decrease perioperative myocardial ischemia 3
• ACE inhibitors or ARBs are Class I recommendations for post-CABG patients, though their safety when initiated before discharge is not well established 3
• Statins and antiplatelet therapy are also essential components of post-CABG medical management 4, 5

Clinical Decision Framework

If atomoxetine is being considered in a post-CABG patient, the following approach should be followed:

Immediate Post-Operative Period (0-3 months)

• Avoid initiating atomoxetine during this critical recovery phase 4
• Focus on optimizing guideline-directed medical therapy including beta blockers, statins, ACE inhibitors/ARBs, and antiplatelet agents 4, 5
• The hemodynamic instability risk and need for strict blood pressure/heart rate control make atomoxetine particularly problematic during this window 1, 2

Delayed Consideration (3-6 months post-CABG)

• Only consider atomoxetine after complete surgical recovery and cardiovascular stabilization 4
• Ensure the patient is on optimized beta blocker therapy, as this may partially counteract atomoxetine's tachycardic effects 3
• Obtain cardiology consultation before initiation in this high-risk population 4

If Proceeding with Therapy

• Start with the lowest effective dose and titrate slowly 4
• Monitor blood pressure and heart rate closely at each dose adjustment 1
• Watch for signs of cardiovascular decompensation including palpitations, chest pain, or syncope 1, 2
• Consider more frequent cardiology follow-up than standard post-CABG care 4

Key Contraindications and Cautions

Atomoxetine should be avoided entirely in post-CABG patients with:

• Uncontrolled hypertension or tachycardia despite optimal medical therapy 1
• Recent perioperative complications including myocardial infarction or heart failure 3
• Left ventricular ejection fraction <30%, where hemodynamic stability is particularly critical 3
• Inability to tolerate beta blockers, as these provide some protection against atomoxetine's cardiovascular effects 3

Alternative Considerations

Given the cardiovascular risks, strongly consider alternative ADHD treatments in post-CABG patients, particularly non-pharmacologic interventions or medications with more favorable cardiovascular profiles in this specific population 1, 2.