Introduction

After a heart attack, or an attack of acute persistent coronary pain, known as unstable angina, as many as one in five patients will experience a period of severe depression. And this depression is associated with a 3-fold increase in cardiac problems. Although a third of these depressions get better on their own, there is still need for effective treatment for the others.

The usual antidepressant drugs cannot be used, because they are sometimes toxic to the heart. Tricyclic drugs, so-called because of their chemical structure, are effective antidepressants, but they may cause heart rhythm disturbances. The other main class of antidepressants, monoamine oxidase inhibitors (MAOIs), can produce severe high blood pressure changes. And while cognitive behavioral therapy can be effective, it is not readily available in all settings.

Now a study has shown that successful treatment of depression after a heart attack is possible, using a type of antidepressant called a selective serotonin reuptake inhibitor, or SSRI.

What the study showed

The study was done in 40 cardiology and psychiatric clinics in North America, Europe, and Australia. Depressed patients who had been hospitalized for MI or unstable angina were assigned randomly to take 24 weeks of sertraline (a SSRI) or placebo. Measures of heart function and the level of depression were made before, during, and after the study.

A total of 369 patients, average age 57, were given sertraline (the SSRI), or placebo, for 24 weeks. Heart safety, as determined by tests of heart muscle strength, rhythm, and efficiency of electrical conduction, was the same in the sertraline and placebo groups of patients. There were severe cardiovascular events (e.g. angina, palpitations, heart failure, heart attack) in 15% of the sertraline patients, compared with 22% placebo patients.

Significant improvement in depression-scale scores were seen in the patients given sertraline, compared with the placebo patients, at different times during the study.

Consequences

This study shows that that sertraline, an SSRI drug, can be given safely to patients who develop depression after an MI or an unstable angina episode. This represents a big step forward in managing the 'post-MI blues'. It's particularly important because depression at this time has been associated with an overall poor outcome, compared with non-depressed patients.

As some patients recover from depression on their own, we should try to find out what characteristics can identify such individuals, to save unnecessary medication. However, the availability of an apparently safe, effective antidepressant certainly makes the management of the post-MI stage easier.