The antiarrhythmic effect of nortriptyline in cardiac patients with ventricular premature depolarizations

Tricyclic Antidepressants in the Intensive Care Unit

Tricyclic antidepressants (TCAs) are one of the most commonly prescribed classes of antidepressant medica tions, and they may account for more than 25% of all serious drug overdoses for persons admitted to adult intensive care units (ICUs). TCA overdose is the most common life-threatening drug ingestion in the United States, with an in-hospital mortality ranging from 0.6 to 15%. Manifestations of a significant overdose include anticholinergic effects (fever, mydriasis, tachycardia, and urinary retention), central nervous system toxicity (confusion, agitation, coma, hallucinations, and grand mal seizures), respiratory depression, and cardiovascu lar toxicity (ventricular tachycardia or fibrillation, hypotension, and conduction defects). The principal cardiovascular findings associated with therapeutic doses of TCAs are discussed and grouped into three categories: (1) electrocardiographic changes—sinus tachycardia, repolarization abnormalities, conduction disturbances, and ventricular arrhythmias; (2) mild depression of myocardial contractility; and (3) sudden cardiac death. The therapeutic feasibility and selection of a TCA for patients with preexisting cardiovascular disease is discussed, and current recommendations on the diagnosis and management of TCA overdoses are reviewed.

Cardiologic side effects of psychotropic drugs

Psychotropic drugs can produce cardiovascular side effects associated with a degree of cardiotoxicity. The coexistence of a heart disease complicates the management of mental illness, can contribute to a reduced quality of life and a worse illness course. The co-occurrence of psychiatric disorders in cardiac patients might affect the clinical outcome and morbidity. Moreover, the complex underlying mechanism that links these two conditions remains unclear. This paper discusses the known cardiovascular complications of psychotropic drugs and analyzes the important implications of antidepressive treatment in patients with previous cardiac history.

Depression in vascular pathologies: the neurologist's point of view

The coexistence of depression and cardiovascular disease (CVD) is regularly discussed, and much debated. There is strong evidence that there are pathophysiological mechanisms, particularly endothelial dysfunction, altered platelet aggregation, and hyperactivation of the thrombosis cascade, which coexist with hypothalamic-pituitary-adrenocortical axis dysfunction, and link depression to CVD. Therefore, depression should not be automatically considered to be a consequence of life impairment due to myocardial infarction or major stroke. Probably, it should be considered as one of the many other stressful events, or “genetic reactions to life”, which are risk factors for CVD development. This review will examine the significance of depression in clinical daily practice, its pathophysiology as a determinant in vascular events, and its real importance in, before, and after many CVD events.

Depression and related psychological factors in heart disease

In this article we review the role of depression and other related psychological factors in heart disease. The prevalence of heart disease in patients with depression is high, and epidemiological links between depression and heart disease are evident in studies of community samples, psychiatric patients, and heart disease patients. We also describe the links between heart disease and related psychological factors-including vital exhaustion, Type A behavior pattern, anger and hostility, and Type D personality-and summarize proposed mechanisms that may link negative affects with heart disease. Finally, we review treatment of depression in heart disease, including evidence from several large clinical trials.

Safety of antidepressant drugs in the patient with cardiac disease: a review of the literature

Patients with cardiac disease, specifically ischemic heart disease and heart failure, have a higher frequency of major depressive disorder than patients without cardiac disease. The pathophysiologic reason for this is not completely understood. Previous depression, other debilitating illnesses, and type A personality are risk factors for the development of depression in cardiac patients. Depression has been shown to lower the threshold for ventricular arrhythmias. Therefore, treatment of depression potentially may prolong life in these patients. Antidepressant options that have been evaluated include several of the tricyclic antidepressants, trazodone, bupropion, and several of the selective serotonin reuptake inhibitors. Individual antidepressant drugs vary in their pharmacologic activity and side-effect profiles. Although clinical data are limited, it is important to individualize therapy in order to minimize cardiac adverse effects. Clinicians are encouraged to evaluate patients with cardiac disease for major depressive disorder and to consider antidepressant drug therapy for these patients when appropriate.

Considerations for the use of antidepressants in patients with cardiovascular disease

There is convincing evidence that depression can significantly and adversely affect cardiovascular health and increase mortality rates in patients with documented ischemic heart disease. It is unknown whether treatment of depression can reduce the risk of IHD or if treatment can decrease mortality rates after myocardial infarction. Nonetheless, the available evidence strongly suggests that depression in patients with cardiovascular disease should be treated. Tricyclic antidepressants had been considered acceptable for use in patients with ischemic heart disease until data from the Cardiac Arrhythmia Suppression Trial (CAST) demonstrated a significantly increased mortality rate after myocardial infarction in patients treated with type I antiarrhythmics. Because tricyclic antidepressants are type IA antiarrhythmics, they presumably carry a risk similar to that of moricizine in patients with ischemic disease. The limited but growing data available on the use of selective serotonin reuptake inhibitors and bupropion in patients with cardiac disorders suggest that these agents are safer antidepressant treatment alternatives. Larger, long-term, randomized, controlled studies are needed to confirm that selective serotonin reuptake inhibitors are indeed safe in depressed patients with cardiovascular disease.

An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction (the SADHAT Trial). Sertraline Anti-Depressant Heart Attack Trial

BACKGROUND

Depression occurs frequently in patients with acute myocardial infarction and is associated with increased mortality rates. It is not known whether serotonin reuptake inhibitors would be safe and effective for patients with depression after myocardial infarction and whether such treatment would reduce mortality rates.

METHODS AND RESULTS

We conducted a multicenter, open-label, pilot study of sertraline treatment in patients with major depressive disorder identified 5 to 30 days after admission for acute myocardial infarction. Outcome measures included cardiovascular and hemostatic function, adverse events, and mood ratings. Twenty-six patients were enrolled in the study. During treatment there were no significant changes in heart rate, blood pressure, cardiac conduction, or left ventricular ejection fraction, and there was a trend toward reduced ventricular ectopic activity. There were no changes in coagulation measures. Bleeding time increased in 12 patients, decreased in 4 patients, and was unchanged in 2 patients. Three (12%) patients withdrew from treatment prematurely because of adverse events. Significant improvements in mood ratings occurred over the course of treatment.

CONCLUSIONS

Sertraline treatment was associated with clinical improvement and was well tolerated in >85% of the patients in this open-label treatment trial for patients with major depression after myocardial infarction. These results encourage further controlled trials to establish the effects of treatment for this high-risk population.

Psychiatric aspects of cardiovascular disease

The co-occurrence of psychiatric and cardiac disease in many patients exemplifies the complexity of psychosomatic medicine, with both psychosomatic and somatopsychic effects. Psychological factors including depression, anxiety, and hostility influence the development, clinical expression, and prognosis of coronary heart disease. Depression and anxiety are especially common problems complicating cardiac disease. The physician must approach the patient with an appreciation of the confounding aspects of diagnosis and a readiness to think flexibly about the nature of the problems encountered. SSRIs play an increasingly prominent role in psychopharmacotherapy of this population. Innovative treatments in cardiology, such as heart transplantation, defibrillators and mechanical ventricular assist devices are associated with characteristic psychiatric problems for which psychiatrists must devise treatment strategies.

Issues in the perioperative care of the patient with psychiatric illness

Several topics have been reviewed pertaining to psychiatric patients requiring either surgery or ECT. Most of the morbidity unique to this group of patients in the perioperative period results from drug side effects or interactions. Complications can be minimized by familiarity with the side effects of psychotropic medication and by the discontinuation of these medications when indicated.

Drug treatment of depression in medically ill patients

Depressive symptoms are common in medically ill patients although depressive disorders are considerably underdiagnosed and undertreated. Drug treatments for depression are reviewed in terms of a risk/benefit analysis. The main benefit is approximately to double the chance of recovery (from about 30 to 65%), with possible associated improvements in physical condition. The risks of treatment are considerable and include overdose, unwanted effects at therapeutic dose and interaction with other drugs. Among the risks associated with specific medical conditions are orthostatic hypotension, cardiotoxicity, deterioration of seizure control in epileptic patients and increased side effects in patients with renal and hepatic impairment. The available data suggest that there is relatively little to choose between antidepressants in terms of efficacy (although the quantity and quality of these data vary). It is therefore primarily the risks which should determine the choice of antidepressant, and these must be separately evaluated for each patient.

Use of antidepressants in medically ill older patients

Major depression is common in older medical patients, and it can exert a deleterious effect on the treatment, course, and outcome of physical illnesses. Tricyclic or tetracyclic antidepressants (TCAs) and psychosocial interventions often play a role in the treatment of depressed medically ill patients, but well-founded doubts about the efficacy and the safety of TCAs in older, frail medical patients have developed. Based on a review of current knowledge about antidepressant use in these patients, the authors recommend the cautious use of TCAs in medically ill older patients until more data are available.

Antiarrhythmic efficacy of desipramine

The effect of desipramine on chronic ventricular ectopic depolarizations (VEDs) was studied in 10 patients with at least 30 VEDs per hour. A single-blind, placebo-controlled, dose-ranging protocol was followed. Efficacy was defined as a decrease in VED frequency of at least 75%, base on three 24 hour ambulatory ECGs obtained on each dose. Among seven patients with analyzable data, one responded to 75 mg daily, and three others responded to 150 mg daily. Six of the seven patients demonstrated decreases in VED frequency with increases in desipramine serum concentration. Among five patients with episodes of nonsustained ventricular tachycardia, desipramine completely abolished the episodes in two, and reduced the frequency of episodes by at least 90% in two others. Adverse reactions were common, and necessitated drug discontinuation or dose reduction in five patients. Desipramine has an antiarrhythmic effect in patients with chronic ventricular ectopy, but its clinical utility is limited by adverse effects.

Use of cyclic antidepressants in patients with cardiac conduction disturbances

Cyclic antidepressants can produce cardiac complications in patients with certain types of cardiac conduction abnormalities. Most cyclic antidepressants have a quinidinelike effect on the heart, which, in combination with Type I antiarrhythmic agents such as quinidine, disopyramide and procainamide, may induce heart block and potentially lethal arrhythmias in susceptible individuals. Patients with known cardiovascular disease warrant careful evaluation before tricyclic therapy is initiated. Guidelines are presented for identifying high-risk patients and for using cyclic antidepressants in patients with cardiac conduction abnormalities.