Most people starting an antidepressant do not need an ECG. The ones who do can be found with three questions: is there a cardiac history (structural heart disease, arrhythmia, unexplained syncope, family history of sudden death)? Is there a metabolic risk (low potassium or magnesium, eating disorder, heavy alcohol use, renal impairment)? And is the person already on another QT-prolonging drug — antipsychotics, methadone, macrolides, fluoroquinolones, ondansetron, domperidone?
If any answer is yes, get a baseline ECG, correct electrolytes, and prefer an agent with a smaller QT effect. For citalopram and escitalopram, stay within the regulator-recommended maximum doses, which are lower in people over 65.
- Ask about cardiac history, syncope and family history of sudden death
- Check potassium and magnesium where there is vomiting, diuretics, eating disorder or alcohol misuse
- Review the medication list for other QT-prolonging drugs
- Get a baseline ECG if any risk factor is present
- Keep citalopram and escitalopram within recommended maximums, lower over 65
Why it matters
It targets ECGs at the minority who need them rather than delaying treatment for everyone.
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