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.