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Am Fam Physician. 2006;73(4):713-716

Cardiovascular disease is the leading cause of death in the United States, with approximately 6 million persons having symptomatic coronary heart disease. About 20 percent of patients who have had a recent myocardial infarction will suffer from major depression, and another 20 percent will experience minor depression. Depression is a risk factor for recurrent nonfatal myocardial infarction and for cardiac mortality in patients who have had a recent myocardial infarction, independent of cardiac disease severity. Although antidepressants have been shown to improve depression, their impact on patients with cardiovascular disease is controversial. Tricyclic antidepressants have been shown to increase the risk of developing cardiovascular disease, but in some studies, selective serotonin reuptake inhibitors (SSRIs) have had a positive impact on patients with regard to cardiovascular disease. Taylor and associates evaluated the effects of antidepressants on morbidity and mortality in patients postinfarction.

The authors conducted an observational secondary analysis of the Enhancing Recovery in Coronary Heart Disease trial. Patients from multiple sites were considered for the study if they met the diagnostic criteria for acute myocardial infarction. Participants were screened for depression and low social support. They were included in the study if they met the criteria for major or minor depression or dysthymia. Patients were randomized to receive usual care or cognitive behavior therapy. Those who received therapy and had a high depression score or a poor response to therapy were treated with sertraline (Zoloft) starting at 50 mg per day and titrating up to response or a maximum of 200 mg per day. Other antidepressants were used if patients were unable to tolerate sertraline or were unresponsive. The primary endpoint was recurrent myocardial infarction or death from any cause. Other endpoints included revascularization procedures and cardiovascular-related hospitalization.

The trial included 1,834 patients from eight academic centers. During the 29-months of follow-up, there were 457 fatal and nonfatal cardiovascular events. Patients who received SSRIs had a significantly lower risk of death or recurrent myocardial infarction when compared with nonusers (hazard ratio 0.57; 95% confidence interval, 0.38 to 0.84). Those who were treated with SSRIs also had a significantly lower risk for all-cause mortality and recurrent myocardial infarction. Patients who were treated with non-SSRIs also had significantly lower rates of recurrent myocardial infarction, cardiovascular deaths, and all-cause mortality.

The authors conclude that the use of SSRIs in patients with depression who experience acute myocardial infarction may reduce later cardiovascular morbidity and mortality. They add that a controlled trial is needed to examine this question further.

editor’s note: Over the past few years, there has been an increased emphasis on the interaction between the physical and psychological aspects of disease. This is particularly true in the management of stroke patients. Recent studies have demonstrated the correlation between depression and stroke recovery. Treating patients who have had a stroke with antidepressants has been shown to reduce morbidity and mortality, even in those with only minor depression.1,2 Depression has been shown to be a risk factor for recurrent cardiac disease regardless of the cardiovascular disease severity. In the study by Taylor and colleagues, the use of antidepressants in patients with depression after an acute myocardial infarction did reduce cardiovascular morbidity and mortality. The concept of treating the whole patient (mind, body, and soul) during acute or chronic illnesses is now being researched in an attempt to provide better care for patients.—k.e.m.

REFERENCESJorgeRERobinsonRGArndtSStarksteinSMortality and poststroke depression: a placebo-controlled trial of antidepressants.Am J Psychiatry2003;160:1823–9.MurrayVvon ArbinMBartfaiABerggrenALLandtblomAMLundmarkJet alDouble-blind comparison of sertraline and placebo in stroke patients with minor depression and less severe major depression.J Clin Psychiatry2005;66:708–16.

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