Can sertraline (selective serotonin reuptake inhibitor) cause bradycardia in a general adult population?

Can Sertraline Cause Bradycardia?

Yes, sertraline can cause bradycardia, though this is an uncommon adverse effect that occurs primarily in overdose situations or when combined with other rate-lowering medications. 1

Evidence from FDA Drug Labeling

The FDA-approved prescribing information explicitly lists bradycardia as an important adverse event reported with sertraline overdose, alongside other cardiac complications including bundle branch block, QT-interval prolongation, and Torsade de Pointes 1. This establishes bradycardia as a recognized, though rare, cardiovascular effect of sertraline.

Clinical Context and Risk Factors

The risk of sertraline-induced bradycardia increases substantially when combined with beta-blockers like carvedilol, creating a dangerous additive effect on heart rate. 2 This interaction is particularly concerning in:

• Patients aged 75 years or older, who face higher cardiovascular adverse effect risks 2
• Patients with pre-existing sinus node or AV node dysfunction, where severe bradycardia becomes more likely 2
• Patients on multiple rate-lowering agents (beta-blockers plus calcium channel blockers like diltiazem or verapamil) 2

Documented Case Evidence

A recent 2025 case report documented persistent bradycardia (heart rate 46 bpm) in a 63-year-old male after dose escalation from 25 mg to 50 mg daily, accompanied by headache and dizziness 3. Notably, the bradycardia persisted despite switching to escitalopram and only resolved after transitioning to bupropion 3. This contrasts with the typical rapid resolution seen in elderly patients after SSRI discontinuation 3.

Additional case reports document sertraline-provoked asystole during head-up tilt testing in patients with vasovagal syncope, demonstrating sertraline's potential to facilitate severe bradyarrhythmias in susceptible individuals 4.

Cardiovascular Safety Profile at Therapeutic Doses

At standard therapeutic doses (50-200 mg/day), sertraline is considered safe for cardiovascular patients and is recommended by the American Heart Association and American College of Cardiology as a first-line antidepressant for acute coronary syndrome patients. 2 This recommendation stems from sertraline's lower risk of QTc prolongation compared to other SSRIs like citalopram 2.

The drug demonstrates favorable cardiovascular effects in specific populations, such as dialysis patients with intradialytic hypotension, where it may actually improve hemodynamic parameters 2.

Monitoring Recommendations

When prescribing sertraline, particularly at 50 mg/day or higher, obtain a baseline ECG in patients with:

• Concurrent beta-blocker therapy (especially carvedilol) 2
• Age ≥75 years 2
• Known conduction system disease 2
• Concurrent use of other QT-prolonging or rate-lowering medications 2

Implement regular ECG and blood pressure monitoring in the first weeks of therapy when sertraline is combined with carvedilol or other beta-blockers 2. Avoid adding calcium channel blockers (diltiazem, verapamil) to this combination due to compounding bradycardic effects 2.

Clinical Decision-Making Algorithm

1. Screen for high-risk features before prescribing:

   • Current beta-blocker or calcium channel blocker use
   • Age ≥75 years
   • History of syncope or conduction abnormalities
   • Baseline heart rate <60 bpm

2. If high-risk features present:

   • Obtain baseline ECG to assess QTc interval and conduction 5
   • Consider alternative antidepressants (bupropion has no bradycardic effects) 3
   • If sertraline necessary, start at 25 mg daily with close monitoring 3

3. If bradycardia develops (HR <50 bpm with symptoms):

   • Discontinue sertraline immediately 3
   • Switch to bupropion or other non-serotonergic antidepressant 3
   • Evaluate for drug-drug interactions with rate-lowering medications 2

Important Caveats

While sertraline-induced bradycardia is uncommon at therapeutic doses in monotherapy, the combination with beta-blockers creates a clinically significant risk that requires proactive monitoring 2. The literature shows conflicting evidence regarding sertraline's direct bradycardic effects, with limited data specifically linking sertraline to bradycardia compared to other SSRIs like citalopram, escitalopram, and fluoxetine 3. However, the FDA labeling and case reports establish this as a real, albeit rare, adverse effect 1, 3.

The key clinical pitfall is failing to recognize the additive risk when sertraline is prescribed alongside beta-blockers or in elderly patients with underlying conduction disease. 2 In these scenarios, the theoretical risk becomes clinically relevant and warrants heightened vigilance.