Treating depression in patients with ischaemic heart disease - Which agents are best to use and to avoid?

There are a number of dimensions to the complex relationship between cardio vascular disease and affective disorders including: (i) patients with depre ssion are at an increased risk of dying from sudden cardiovascular death co mpared with the general population; (ii) patients with depression over the course of a lifetime have a higher rate of symptomatic and fatal ischaemic heart disease compared with a control group without depression; and, (iii) patients after either a myocardial or a cerebrovascular infarction who are depressed have a higher mortality rate than their medically comparable nond epressed counterparts. The deleterious impact of depression on the prognosis of cardiac disease an d the suggestion that treatment of depression may reduce cardiac mortality has led clinicians to seek safe and effective treatment for patients with c omorbid depression and ischaemic disease. Though they are robustly effective, the tricyclic antidepressants are type 1A antiarrhythmic agents and presumably carry the same risk in patients wit h ischaemic disease as treatment with other type 1 antiarrhythmics such as moricizine. Short term studies of the safety of other antidepressant agents , specifically amfebutamone (bupropion) and the selective serotonin (5-hydr oxytryptamine; 5-HT) reuptake inhibitors (SSRIs) fluoxetine, paroxetine and sertraline, suggest that these medications have a benign cardiovascular pr ofile in patients with depression and pre-existing cardiac disease. However , given the methodological limitations of study design and the relatively s mall number of patients included, it is premature to conclude that SSRIs ar e a 'safe' treatment in patients with heart disease. Thus, clinicians must still make treatment decisions on a case by case basi s, considering the type and severity of depression and cardiovascular disea se, as well as what is known about the cardiovascular effects and therapeut ic profile of the different classes of antidepressant medications.