Heart disease and depression

Depression is common in people with coronary heart disease (CHD). It is associated with higher risk of death due to cardiovascular causes and so it is important that it is well-managed.

This article does not cover the management of complex depression and assumes the decision to prescribe an antidepressant in someone with CHD has already been made. Refer to NICE Clinical Knowledge Summary for management of depression in general.

Preferred antidepressants

These options are preferred by a range of mental health resources including Bazire’s Psychotropic Drug Directory, Maudsley Prescribing Guidelines in Psychiatry and published papers. Preferred antidepressants have data to demonstrate safe use in people with CHD and have minimal or no effects on the cardiovascular system.
The recommendations on choices assume use of antidepressants at standard doses.

Selective Serotonin Re-uptake Inhibitors (SSRIs) and Mirtazapine

SSRIs are the preferred antidepressants in CHD. Sertraline, fluoxetine, or paroxetine are the SSRIs of choice. Mirtazapine is also a preferred antidepressant in CHD.

Consider gastroprotection

The NICE Guideline on Depression in adults with a chronic physical health problem [CG91] advises that SSRIs increase the risk of gastrointestinal (GI) bleeding, particularly in older people and in those who take aspirin and SSRIs. Consider if gastroprotection is needed in these scenarios.

Less preferred antidepressants

You should always explore first whether preferred antidepressants can be used; however, there may be a good reason why they can’t.

The options below are less preferred by a range of mental health resources including Bazire’s Psychotropic Drug Directory, Maudsley Prescribing Guidelines in Psychiatry, published papers and manufacturer’s recommendations. There are fewer data to demonstrate safe use in people with CHD and/or they have demonstrated effects on the cardiovascular system.

Citalopram and escitalopram

Citalopram and escitalopram are less preferred options and should generally be avoided. In particular do not use citalopram in people with known QT interval prolongation, congenital long QT syndrome or in people taking other medicines that prolong the QT interval.

Safety and monitoring

If citalopram and escitalopram are the only feasible antidepressant options:

• The MHRA advises that both citalopram and escitalopram be subject to additional monitoring in patients with CHD.
• Use citalopram with extreme caution in people with CHD, particularly in those with recent MI, bradyarrhythmias / bradycardia, hypokalaemia or hypomagnesaemia or decompensated heart failure.

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants are less preferred options and should generally be avoided.

Of the TCAs: doxepin, lofepramine and mianserin may be considered lower risk, but should still be used with caution.

If TCAs are the only feasible option consider ECG monitoring (at baseline and a week after dose increases), particularly in those who may be vulnerable to arrhythmias.

Monoamine oxidase inhibitors (MAOIs)

MAOIs should almost always be avoided.

Where they are used, they will usually be initiated by mental health specialists after careful consideration. There will be a reason why preferred antidepressants cannot be used.

It is important to seek advice from the specialist who knows the person before considering any changes to an MAOI regimen.

Of the MAOIs:

• Moclobemide is considered a lower risk option.
• If MAOIs are used in people with a risk of arrhythmias, discuss the risks with the mental health specialist and consider if ECG monitoring would be beneficial.

Other antidepressants

Antidepressants other than SSRIs, TCAs, or MAOIs may vary with respect to their risks and monitoring requirements.

Agomelatine and vortioxetine

These may be considered third line options

Duloxetine, reboxetine, and venlafaxine

These should be avoided if possible

Patient characteristics and considerations

When making an initial choice to prescribe, or deciding how to manage people who are currently on an antidepressant, you should consider the persons individual needs as well as their CHD.

Making a choice when starting an antidepressant

Individualise choice using the options above. Consider:

• Persons circumstances, history, preferences and past experience with antidepressants and indication for use
• Extent and severity of CHD (including any complications) and other medical history

Initiate with a low dose first and titrate up

Initiate the chosen antidepressant at a low dose and increase gradually until a standard therapeutic dose is achieved. Review regularly thereafter as recommended by NICE Clinical Knowledge Summary for management of depression.

Managing patients currently on a less preferred antidepressant

Managing patients with a new diagnosis of CHD currently on an antidepressant requires care. You should:

• Seek advice from a mental health specialist (ideally one who knows the person) before switching.
• Take into account the extent and severity of CHD and other medical history
• Consider the person’s preferences and past experience with antidepressant use if any
• Check cautions, contraindications relating to the cardiovascular system and any drug interactions (e.g. in electronic medicines compendium).

Refer to NICE Clinical Knowledge Summary for management of depression in general.

Switching from less to more preferred options

Switching patients with CHD from their current antidepressant to another antidepressant may sometimes be necessary. Our advice on antidepressant switching may be helpful.

• Switching strategies for antidepressants
• MAOI to other antidepressants: switching in adults
• Moclobemide to other antidepressants: switching in adults
• Trazodone to other antidepressants: switching in adults
• Vortioxetine to other antidepressants: switching in adults
• SNRIs to other antidepressants: switching in adults
• Agomelatine to other antidepressants: switching in adults
• Mirtazapine to other antidepressants: switching in adults
• Considerations when choosing an alternative antidepressant
• Establishing if a person needs to switch their antidepressant

Acknowledgements

With thanks to Makhan Chohan, Deputy Chief Pharmacist at the Essex Partnership University NHS Foundation Trust for his contribution.

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