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Risks of antidepressants in the elderly: tricyclic antidepressants and arrhythmia-revising risks
1Department of Clinical Psychopharmacology, College of Physicians and Surgeons, Columbia University, New York, N.Y. 10032.
Insights
Class I antiarrhythmic drugs, including tricyclic antidepressants (TCAs), may increase mortality in patients with heart conditions like myocardial infarction. Psychiatrists should understand this risk associated with TCAs.
Area of Science:
- Cardiology
- Psychiatry
- Pharmacology
Background:
- Class I antiarrhythmic drugs unexpectedly increased mortality in post-myocardial infarction patients.
- This finding, observed in the mid-1980s, has been consistently confirmed by subsequent studies.
Purpose of the Study:
- To highlight the potential increased risk of death associated with tricyclic antidepressants (TCAs).
- To inform psychiatrists about the proarrhythmic effects of Class I antiarrhythmics under anoxic conditions.
Main Methods:
- Review of existing studies on Class I antiarrhythmic drugs and patient mortality.
- Analysis of the pharmacological properties of TCAs as Class I antiarrhythmics.
Main Results:
- Class I antiarrhythmic drugs can become proarrhythmic under anoxic conditions, such as those present during myocardial infarction.
- A significant risk of increased mortality is suspected with the use of TCAs in patients with ischemic heart disease.
Conclusions:
- TCAs, being Class I antiarrhythmics, may pose a proarrhythmic risk in patients with ischemic heart disease.
- Further discussion is needed on the implications for TCA use and potential effects of selective serotonin reuptake inhibitors.
Abstract:
Unexpected events have occurred in cardiology over the last 4 years. A study by the Heart and Lung Institute of the National Institute of Health in the mid-1980s showed to great surprise that class I antiarrhythmic drugs given to patients with ventricular arrhythmias following myocardial infarction, instead of preventing deaths, actually increased the number of patients dying. Since then, a series of studies has consistently confirmed this original observation. The problem for psychiatry is that the tricyclic antidepressant (TCA) drugs are also class I antiarrhythmics. There is every reason to believe that a similar increased risk of death would exist with the TCAs. It is, therefore, important for psychiatrists to understand the cause and magnitude of this excess in deaths. Evidence to date would suggest that all class I compounds, despite being powerful antiarrhythmics under usual physiological conditions, become proarrhythmic under anoxic conditions. Such conditions would exist in ischaemic heart disease during angina and, particularly, myocardial infarction. How this might alter our use of TCAs and whether this happens with the selective serotonin reuptake inhibitors is discussed.