The edition · Cardiology
Escitalopram and amitriptyline lengthened QTc most among ten antidepressants, without a rise in early cardiac events
An individual-patient BMJ analysis ranks antidepressants by QTc effect for the cardiac patient who needs one. Also: pace-and-ablate beat pulmonary vein isolation in over-75s with persistent AF, first-line evolocumab at PCI hit targets but not outcomes, and SELECT's benefit is not explained by weight alone.
The edition in brief
An individual participant data network meta-regression of 35 trials (8,679 adults with depression) found escitalopram (+8.7 ms) and amitriptyline (+5.3 ms) lengthened QTc against placebo over eight weeks, while venlafaxine and vortioxetine were least likely to; across 139 trials and 52,398 people there was no excess of early major cardiovascular events. A separate observational meta-analysis associated antidepressant use with ventricular arrhythmia or sudden death (OR 1.34), with very high heterogeneity and confounding by depression itself. In ABLATE versus PACE, 196 patients aged 75 and over with symptomatic persistent AF and normal ejection fraction had fewer primary events at a year with pacemaker and AV-node ablation than with pulmonary vein isolation (24% vs 46%, HR 0.45), though heart failure admissions were more frequent after pace-and-ablate. In AMUNDSEN, evolocumab started before PCI for high-risk MI brought 82% to LDL target against 40%, with no difference in death or cardiovascular admission at a year. A SELECT mediation analysis could not attribute semaglutide's cardiovascular benefit to weight, waist, CRP or other measured risk factors with any certainty.
Over 75 with persistent AF: pace-and-ablate halved the primary event rate compared with PVI
For a patient over 75 with symptomatic persistent AF and normal ejection fraction, offer pace-and-ablate as a first-line option alongside PVI.
Evolocumab before PCI for high-risk MI reached LDL targets in 82%, but outcomes at a year were unchanged
Treat LDL early and to target after MI, but there is no case for a PCSK9 injection at the time of PCI for acute benefit.
SELECT: semaglutide's cardiovascular benefit could not be pinned on weight, waist or any measured risk factor
Do not stop semaglutide in a SELECT-type patient because weight loss is modest; the cardiovascular benefit was not tied to weight.
Antidepressant users had higher odds of ventricular arrhythmia or sudden death in observational data
Treat depression in cardiac patients, but check the ECG and electrolytes first in those at arrhythmic risk.
Measure QT with Fridericia, not Bazett, when the heart rate is fast
At fast heart rates, recalculate QTc with Fridericia before withholding a QT-prolonging drug.
Choosing an antidepressant for a cardiac patient: escitalopram and amitriptyline lengthened QTc most
When a cardiac patient at QT risk needs an antidepressant, steer away from escitalopram and amitriptyline and check the ECG after starting.
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