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Depression and coronary heart disease: 2018 ESC Guideline

Depression and coronary heart disease: 2018 ESC Guideline

The European Society of Cardiology (ESC) has released its 2018 Practice Guidelines on Depression and coronary heart disease. Major depression is a highly prevalent condition, affecting approximately 10% of the population. It has been consistently associated with increased risk of coronary heart disease (CHD). The guidelines have appeared in European Heart Journal.

Evidence from both experimental and epidemiological studies indicates that there is a bidirectional association between depression and CHD. Depression is very common in patients with CHD and is an independent risk factor for poorer CHD outcomes.

There are several treatments options for the CHD patient with depression, from medications to various forms of psychotherapy, to exercise and stress management approaches. Although treatment of depression has not been shown to improve cardiovascular outcomes in CHD patients, depression should still be addressed if severe enough, in order to promote patient wellness and QoL.

Key Recommendations are –

  • Clinicians should be aware of the high prevalence of depression in CHD patients. Screening for depression is recommended if patients have access to adequate care support systems
  • Patients with positive screening results should be referred to a qualified health care provider in the management of depression
  • Non-pharmacologic interventions such as exercise and psychotherapy should be considered as additional treatment options for CHD patients
  • Harmonization of care between healthcare providers is essential in patients with combined CHD and depression
  • Tricyclics should be avoided in this patient population.

Pharmacological management of depression in patients with coronary heart disease

Drug classification/ generic name Indication Cardiovascular adverse effects Other adverse effects
Selective serotonin reuptake inhibitors
Fluoxetine Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram
  • Agents of choice in CHD
  • Sertraline: agent of choice in post-MI patients
  • Citalopram: should be used with caution in patients at high risk of QTc prolongation or Torsades de Pointes such as those with congestive heart failure, recent MI, bradyarrhythmias hypokalaemia or hypomagnesaemia, congenital long QT syndrome.
  • Fewer to no anticholinergic and cardiac effects
  • Concomitant use with aspirin and other antiplatelet/anticoagulation treatment may increase risk bleeding especially in the elderly
  • Citalopram is associated with dose-related QTc interval prolongation
Nausea, diarrhoea, headache, insomnia, agitation, loss of libido, delayed ejaculation, and erectile dysfunction
Tricyclic antidepressants
Imipramine Doxepine Amoxapine Nortriptyline Amitriptyline
  • Avoid in CHD, conduction defects, congestive heart failure, and elderly
  • Contraindicated in post-MI patients
  • Increase heart rate
  • Prolongation of the PR interval, QRS duration and QTc interval, and a flattening of the T wave on the electrocardiogram
  • Orthostatic hypotension
  • Abrupt withdraw may associated with increased risk of arrythmias
Anticholinergic effects: dry mouth, constipation, memory problems, confusion, blurred vision, sexual dysfunction, and decreased urination, and memory impairment especially in the elderly
Serotonin-norepinephrine reuptake inhibitors
Desvenlafaxine Duloxetine Levomilnacipran Milnacipran Venlafaxine
  • Venlafaxine: avoid in patients at high risk of malignant ventricular arrhythmias or with uncontrolled hypertension
  • Fewer to no cardiac effects
  • Have been associated with a dose dependent increase in blood pressure and heart rate
  • Regular blood pressure monitoring
  • Venlafaxine: Minor degree of QTc prolongation
Dizziness, constipation, dry mouth, headache, changes in sleep, or more rarely a serotonin syndrome, with restlessness, shivering, and sweating
Antidepressants with novel mechanisms of action
  • Smoking cessation in CHD patients
  • Possible increases in blood pressure
  • Minor degree of QTc prolongation
Weight loss, restlessness, high doses can rarely cause seizures
  • Use with caution in CHD and post-MI patients
  • Mild orthostatic hypotension
  • Minor degree of QTc prolongation
Sweating and shivering, tiredness, strange dreams, dyslipidemia, weight gain, anxiety, and agitation
  • Use with caution in CHD, patients with atrioventricular conductions blocks or other conduction disorders and post-MI patients
  • Orthostatic hypotension
  • Minor to low degree of QTc prolongation
Rarely, it can cause priapism

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