A recent clinical trial published in JAMA investigated the effects of depression treatment on cardiac outcomes of patients with a recent acute coronary syndrome.
The worldwide depression rate is a growing concern. Oftentimes patients have depression along with other medical conditions such as diabetes or cardiovascular disease.
Acute coronary syndrome is a condition where a major artery is blocked. This can lead to many cardiac complications such as heart attack or angina. Since depression rates are a global concern, it is common to find both acute coronary syndrome and depression in patients. Depression itself is a risk factor for cardiac events since it is associated with poor outcomes in death and non-fatal cardiac episodes.
Can depression treatment improve cardiac outcomes?
Researchers have attempted to determine if depression treatment can decrease the load on the cardiovascular system and therefore improve cardiac outcomes and death. The results of previous studies have been inconclusive. Most studies concluded that depression treatment had no difference in cardiac outcomes. One study concluded a worsening effect on cardiovascular health and one study found an improvement. These trials included a small sample of patients and did not include a long follow-up period. In addition, previous studies used a limited cardiovascular health evaluation.
Researchers at the Department of Psychiatry at the Chonnam National University Medical School in South Korea designed a study to help answer the question if depression treatment can improve cardiovascular health. They used a more complete cardiovascular evaluation including the risk of major adverse cardiac events, heart attack, and percutaneous coronary interventions. They published their results in JAMA.
For the study, the researchers chose one antidepressant and randomized eligible patients to receive escitalopram or placebo. Patients were asked to continue the traditional antidepressant therapy for 24 weeks. The follow-up period lasted between five and 11 years, until death or until the end of the study period. Previous studies included follow-up of fewer than two years and the study participants were not all assigned the same antidepressant medication.
More than half of the patients receiving the placebo experienced a major cardiac event
Depending on the response to treatment, patients either received 5mg, 10mg, 15mg or 20mg. These patients were compared with participants receiving placebo. Interestingly, during the 24-week trial period, 40.9% of the patients receiving escitalopram and 53.6% of patients receiving the placebo experienced a major adverse cardiac event. Also, heart attack rates were significantly higher in the placebo group compared with the treatment group. All other cardiac outcomes were similar across both treatment groups.
Several limitations are obvious in this trial. Firstly, the study participants were all South Koreans, therefore, it is necessary to repeat this study in other ethnic groups. Secondly, the severity of depression and acute coronary syndrome in this South Korean study population was lower than in previous trials. Lower antidepressant doses were required in this study. In order to generalize these results to the population, further studies are required.
Trial should be repeated with more diverse participants
After 24 weeks of antidepressant treatment, patients with depression and acute coronary syndrome have demonstrated better cardiac outcomes when taking escitalopram. This placebo-controlled trial must be repeated with a more diverse population of ethnicities as well as disease severities before any generalized conclusion can be made.
Written by Jessica Caporuscio, PharmD
References:
- Kim JM, Stewart R, Lee YS, et al. Effect of Escitalopram vsPlacebo Treatment for Depression on Long-term Cardiac Outcomes in Patients WithAcute Coronary Syndrome: ARandomized Clinical Trial. JAMA. 2018
- Warnica JW. Overview of Acute Coronary Syndrome. Merck Manual Professional Version. 2016. https://www.merckmanuals.com/en-ca/professional/cardiovascular-disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs
