Antidepressants cut risk of future CV events after acute coronary syndrome : JAMA

The use of escitalopram, a selective serotonin reuptake inhibitor, might lower the risk for adverse cardiovascular events in patients experiencing depression after acute coronary syndrome (ACS), suggests a new JAMA study.

Jae-Min Kim, Department of Psychiatry, Chonnam National University Medical School, Republic of Korea, and colleagues conducted the study to investigate the effect on long-term major adverse cardiac events (MACE) of escitalopram treatment of depression in patients with recent ACS.

For the study, three hundred patients in South Korea who screened positive for depression within 2 weeks after undergoing treatment for ACS were randomized to receive escitalopram or placebo for 24 weeks.

Among 300 randomized patients (mean age, 60 years; 119 women [39.3%]), 100% completed a median of 8.1 (interquartile range, 7.5-9.0) years of follow-up.

Key Findings:

• MACE occurred in 61 patients (40.9%) receiving escitalopram and in 81 (53.6%) receiving placebo (hazard ratio [HR], 0.69; 95% CI, 0.49-0.96).


• Comparing individual MACE outcomes between the escitalopram and placebo groups, respectively, incidences for all-cause mortality were 20.8% vs 24.5%, for cardiac death, 10.7% vs 13.2% for MI, 8.7% vs 15.2%, and for percutaneous coronary intervention (PCI), 12.8% vs 19.9%.

"This paper makes an important contribution to the literature, although one that should be interpreted with caution," commented Kenneth Freedland, Washington University School of Medicine in St. Louis, who was not involved in the trial.

While the long-term analysis was preplanned, it wasn't designed to be powered for that, as "the study was originally planned with remission of depression at 24 weeks as the primary outcome," he told MedPage Today.

"The cardiovascular benefit of escitalopram is surprising, given the results of previous RCTs [randomized clinical trials]," he noted.

In MI patients, MIND-IT showed no difference in cardiac outcomes after 8 weeks of antidepressant, SADHART showed no long-term mortality impact of 6 months of antidepressant, and ENRICHD showed no cardiac advantage over 29-month follow-up after 9 months of cognitive behavioral therapy with or without 12 months of antidepressants.

Kim's Escitalopram for Depression in Acute Coronary Syndrome (EsDEPACS) study included 300 participants (mean age 60 years and 39.3% women) with acute coronary syndrome and depression. The mean depression severity score of 15.9 on the HAM-D scale was less severe than in some prior antidepressant trials in ACS, which have had mixed findings on outcomes.

A trend for better composite MACE in the subgroup with impaired left ventricular ejection fraction didn't reach significance.

While the sample size was "sufficient" to address depression, Freedland suggested a larger sample size would have been desirable for looking at cardiac outcomes.

The authors acknowledged limitations including the single-site design and a small number of patients suffering from MACE, which limited the generalizability of the data. Also, there were no assessments of depression incidence or antidepressant use beyond the 1-year follow-up.

All in all, the investigators, concluded that "further research is needed to assess the generalizability of these findings."

For more information log on to 10.1001/jama.2018.9422