May 29, 2013
Common SSRI Reduces Mental Stress–Induced
Myocardial Ischemia

Durham, North Carolina—Treatment with the antidepressant escitalopram, marketed as Lexapro, significantly reduced mental stress–induced myocardial ischemia (MSIMI) in patients with stable coronary disease.

That’s according to Duke Medicine research finding that the selective serotonin re-uptake inhibitor (SSRI) commonly used for depression and anxiety also reduced by more than two-and-a-half times the likelihood of the heart condition brought on by mental stress. The preliminary communication was published recently in the Journal of the American Medical Association.

“Mental stress-induced myocardial ischemia is a serious condition, as patients with the condition tend to have worse heart problems compared to patients without it,” said lead author Wei Jiang, MD, associate professor of psychiatry and behavioral sciences and internal medicine at Duke. “This study showed for the first time that it is treatable with an emotion-modulating medication.”

Changes in the heart, including new wall motion abnormality, a reduction in how much blood is pumped out of the heart's left ventricle, ischemic changes with electrocardiography, or a combination of these symptoms can lead to a diagnosis of MSIMI. While the condition is known to be serious, little research had been done on effective treatment.

“In order to advance our understanding of improving cardiovascular health, we believe that continued research between the intersection of mental health and cardiovascular disease should be a priority,” said senior author Christopher O'Connor, MD, director of the Duke Heart Center and chief of the Division of Cardiology.

To that end, Duke researchers led the Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment (REMIT) study, a randomized, double-blind, placebo-controlled clinical trial.

For the study, participants with existing but stable coronary heart disease were subjected to a treadmill exercise stress test and three mental stress tests: a difficult mental math task, tracing a diagram of a star while looking at hand movement reflected in a mirror, and telling a story about a situation that evoked anger or sadness.

Heart function was assessed during the stress tests using echocardiography and electrocardiography testing, as well as blood pressure and heart rate measurements.

Of 310 participants who were tested, 127 developed MSIMI and were randomized to either receive escitalopram or placebo. Most—112 participants—completed the full study and final assessments.

At the end of the 6-week study, the same stress tests were used and participants’ cardiovascular function again was measured. Compared to effects before administration of medication or placebo, those who took escitalopram were 2.62 times less likely to experience MSIMI during the three mental stress tasks compared with those taking placebo.

Researchers found that at the end of 6 weeks, more patients taking escitalopram (34.2%) had absence of MSIMI during the three mental stressors compared with patients taking placebo (17.5%).

In fact, according to researchers, participants in the escitalopram group felt significantly more in control and calmer than those in the placebo group during the final mental stress tasks. Escitalopram use also was associated with several positive changes in cardiovascular markers, including reducing the number of platelet serotonin receptor transporters.

“Our findings support the hypothesis that short-term use of SSRIs improves levels of biomarkers associated with adverse cardiovascular outcomes,” Jiang said.

Commentary in the study raised the issue of whether SSRIs or similar treatments should play a role in managing coronary heart disease.

“All physicians treating patients with coronary artery disease need to be aware of how emotional stressors may negatively impact their disease management,” said study author Eric Velazquez, MD, associate professor of cardiology at Duke. “We should be having conversations with our patients about their lifestyles to gauge their levels of mental stress and whether the coping mechanisms they use are adequate or if more mental health-focused help is needed.”

Researchers said that more data needs to be gathered about the mechanisms behind MSIMI and whether escitalopram use could reduce occurrence or recurrence of heart attack or angina, stroke, heart failure, or death. Further studies also need to determine how long escitalopram should be used and whether maximum benefit already had been achieved at 6 weeks.

U.S. Pharmacist Social Connect