Can Sertraline Cause Bradycardia?
Sertraline can cause bradycardia, but this is a rare adverse effect that occurs primarily in overdose situations rather than at therapeutic doses. The FDA drug label explicitly lists bradycardia among the important adverse events reported with sertraline overdose 1.
Evidence from Overdose Data
The most compelling evidence comes from the FDA-approved prescribing information, which documents bradycardia as one of the "other important adverse events reported with sertraline hydrochloride overdose" 1. This places bradycardia in the context of toxic exposures rather than routine therapeutic use.
Cardiovascular Safety at Therapeutic Doses
At standard therapeutic doses, sertraline demonstrates a favorable cardiovascular safety profile:
In patients with acute MI or unstable angina, sertraline (50-200 mg/day) showed no significant effect on cardiac conduction parameters, with no difference in QTc interval prolongation >450 milliseconds compared to placebo (12% vs 13%, P≥0.05) 2.
Long-term safety data from worldwide clinical trials showed sertraline was "without effect on vital signs or electrocardiogram" at therapeutic doses 3.
The drug has not been associated with cardiovascular toxicity in standard clinical use, distinguishing it from tricyclic antidepressants 4.
Context: Medications That Actually Cause Bradycardia
The 2018 ACC/AHA/HRS Bradycardia Guidelines identify the true culprits of drug-induced bradycardia as negative chronotropic drugs: beta blockers, calcium channel blockers, digoxin, and sodium/potassium-channel blocking antiarrhythmics 5. Sertraline is notably absent from this list.
The 2010 AHA ACLS Guidelines similarly identify specific antiarrhythmic medications (amiodarone, sotalol) as bradycardia-inducing agents 5, but do not mention SSRIs or sertraline.
Risk Assessment in Clinical Practice
For adults with no significant medical history on therapeutic doses of sertraline, bradycardia is not a clinically relevant concern. The primary cardiac consideration with sertraline is:
QT prolongation risk is minimal compared to other SSRIs like citalopram 5, 6.
Arrhythmia risk in post-MI patients is not increased; sertraline actually showed a trend toward fewer severe cardiovascular adverse events (14.5%) compared to placebo (22.4%) 2.
When to Consider Sertraline as a Cause
Bradycardia should only be attributed to sertraline in these specific scenarios:
- Overdose situations where ingestion exceeds therapeutic doses 1
- Polypharmacy with other bradycardia-inducing agents (beta blockers, calcium channel blockers) where sertraline might have additive effects 5
- Drug interactions affecting sertraline metabolism, though sertraline has minimal cytochrome P450 interactions 7
Clinical Bottom Line
If a patient on therapeutic-dose sertraline develops bradycardia, first evaluate for the established causes: beta blockers, calcium channel blockers, digoxin, hypothyroidism, electrolyte abnormalities, or intrinsic cardiac conduction disease 5. Sertraline should be considered only after excluding these more common etiologies, or in the context of overdose 1.