Depression in coronary heart disease

People who are diagnosed with heart disease have an increased risk of developing depression. Depression also increases the risk of cardiovascular disease and sudden cardiac death.

General safety concerns

Many antidepressants have unwanted cardiovascular effects, so choosing between them may not be straightforward in people with coronary heart disease (CHD).

Potential unwanted side effects include increased heart rate, arrhythmia, conduction problems, hypertension and postural hypotension.

Some cardiovascular side effects may be dose related and require additional monitoring. For example, a baseline ECG should be considered in people with cardiac disease before starting them on citalopram or escitalopram.

There is also the risk of interactions between antidepressants and medicine used for CHD. Always take a full medication history and ask about over the counter medicine and complementary medicine use. You may find our article on Drug interactions: resources to support answering questions useful.

Preferred antidepressants

Preferred antidepressants have data to demonstrate safer use in people with CHD and have minimal or no effects on the cardiovascular system.
The recommendations assume antidepressants are used at standard doses.

Selective Serotonin Re-uptake Inhibitors (SSRIs)

The first line choice is sertraline. It has few known cardiac side effects and no interactions with cardiac medicines. Other options include fluoxetine and paroxetine.

Safety concerns

SSRIs increase the risk of gastrointestinal (GI) bleeding, particularly in older people and in those who take aspirin, clopidogrel, direct oral anticoagulants (DOAC) or warfarin.

Consider if gastroprotection with a proton pump inhibitor (PPI) is needed in these scenarios.

Mirtazapine

Mirtazapine has shown data that suggests it is suitable for people with CHD.

Less preferred antidepressants

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

There is less data to demonstrate safe use in people with CHD or they have demonstrated effects on the cardiovascular system.

Citalopram and escitalopram

Citalopram and escitalopram are less preferred options and should generally be avoided.

If citalopram and escitalopram are the only feasible antidepressant options, then additional monitoring will be required and maximum daily dosing schedules advised.

Safety concerns

Citalopram and escitalopram have dose dependant effects on the QT interval. The maximum dose of both medicines has been restricted in people over 65 years due to this risk being increased with age.

Co administration of citalopram and escitalopram with medicines that prolong the QT interval is contraindicated. See our article on Identifying risk factors for developing a long QT interval for additional information.

SSRIs increase the risk of gastrointestinal (GI) bleeding, particularly in older people and in those who take aspirin, clopidogrel, DOACs or warfarin. 

Consider if gastroprotection with a proton pump inhibitor (PPI) is needed in these scenarios.

Omeprazole can increase the plasma level of citalopram and escitalopram. Consider reducing the dose of citalopram and escitalopram or changing the interacting medicine.

The MHRA monitoring recommendations include an ECG review before treatment with citalopram or escitalopram.

Tricyclic antidepressants (TCAs)

TCAs are less preferred options and should generally be avoided.

TCAs increase heart rate and rhythm, prolong the PR and the QT intervals and can cause postural hypotension. They are highly cardiotoxic in overdose.

Some interactions can increase the risk of TCA cardiotoxicity such as electrolyte disturbances caused by diuretics.

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

Dosulepin should not be prescribed.

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 in CHD.

They can cause hypotension and have serious drug-drug and drug-food interactions.

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.

Moclobemide is considered a lower risk option.

MAOIs can cause arrhythmia as a side effect. If MAOIs are used in people with a risk of arrhythmias, discuss the risks with the mental health specialist and the person. 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.

Agomelatine and vortioxetine have not been linked to QT prolongation or other cardiac side effects but as newer agents, less is known about them.

Duloxetine, reboxetine, and venlafaxine

These should be avoided if possible.

• Duloxetine and venlafaxine can cause dose related increases in blood pressure, postural hypotension and arrhythmias.
• Reboxetine can cause tachycardia, palpitations and dose-related postural hypotension. Blood pressure monitoring is recommended with its use.

Patient characteristics and considerations

Consider individual needs and their CHD when prescribing or managing people currently on antidepressants.

Initial antidepressant choice in CHD

Individualise choice using the options discussed. Consider the:

• 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
• use of concomitant medicines and potential drug interactions

Dose titration

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:

• consider if you require advice from a mental health or pain specialist (ideally one who knows the person) before switching
• consider if the person requires Deprescribing of antidepressants for depression and anxiety
• 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
• consider any concomitant medicines and potential drug interactions
• check manufacturers cautions and contraindications relating to the cardiovascular system

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
• Monitoring a person during and after antidepressant switching

Guidelines

NICE guidelines are available for managing depression in adults with a chronic physical health problem such as CHD. These advise that antidepressants should not routinely be used to treat less severe depression (subthreshold depressive symptoms or mild depression) in people with a chronic physical condition.

NICE guidelines on the general management of adults with depression are also available.

These guidelines help in the recognition and assessment of people with depression. They include the treatment of complex and more severe depression which is outside the scope of this article.

Update history