Coronary artery disease is the leading cause of death in the United States and is one of the main contributors for the global burden of disease. One in four patients with coronary artery disease also suffer from depression, which adds to the risk of recurrent myocardial infarction and death.
Guidelines exist to urge primary care providers and cardiologists who see patients with coronary artery disease to screen for depression and refer for treatment as appropriate. It is therefore worthwhile to review appropriate treatment recommendations, both pharmacological and non-pharmacological, for these cases.
For mild-moderate cases and/or based on patient preference, a referral for psychotherapy can be appropriate as a first line intervention. This removes the concern about problematic side effects that might occur from a medication intervention. Of course, close follow-up is necessary, typically within 2-3 months, to make sure there is improvement in depression symptoms with therapy or if there is a need to consider a medication intervention.
Multiple well-designed studies have shown the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for treating depression in patients with coronary artery disease. The SSRIs sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro) and fluoxetine (Prozac) have been studied in short-term trials and found to be effective. Many of these studies have assessed for cardiovascular safety measures related to the prescribed medication, and most show no difference between the medication arm and placebo arm. The caveat is that most of these studies have looked at safety of short-term use of SSRIs but not long-term use in patients with coronary artery disease. This still needs to be studied.
Other antidepressant classes have either not been studied in patients with coronary artery disease or the use is not recommended. The tricyclic antidepressants are not commonly used in patients with coronary artery disease because of possible side effects, including orthostatic hypotension, effects on cardiac conduction, and anticholinergic effects.
When considering an SSRI, it is important to pay attention to possible drug interactions. Strong 2D6 inhibitors like fluoxetine and paroxetine can increase blood levels of beta-blockers, which are commonly used in patients with coronary artery disease. Increased blood levels of beta-blockers can lead to bradycardia. SSRIs may also interact with antiplatelet agents and anticoagulants to raise the risk of bleeding but this needs to be studied more to determine the exact risk and resulting clinical implications. There have been concerns raised with respect to citalopram about QT interval prolongation at higher doses, but upon further investigation, the concern may be overstated.
The bottom line is that for patients with coronary artery disease who are assessed to also have depression, the first-line recommendation, especially for mild-moderate cases, should be psychotherapy, with consideration of an SSRI for moderate-severe cases or if psychotherapy is not effective on its own. If considering an SSRI, sertraline and escitalopram have been found to be effective with minimal concerns about problematic side effects. As always, primary care providers are welcome to consult with SmartCare PC2 to help determine a best treatment course of action.