Depression has been associated with poorer outcomes for patients who have acute coronary syndrome (ACS), including myocardial infarction. Now, new research indicates that treating depression may improve long-term cardiac outcomes for patients with ACS.
Depression has been associated with poorer outcomes for patients who have acute coronary syndrome (ACS), including myocardial infarction (MI). While clinical trials of antidepressants in patients who experience depression following ACS have demonstrated symptom improvements, typically, the impact of these drugs on cardiac outcomes have not been found within the clinical trial periods or their extensions. Now, new, longer-term research published in JAMA indicates that treating depression may improve long-term cardiac outcomes for patients with ACS.
The study involved an extended follow-up of the 24-week randomized, placebo-controlled clinical trial of escitalopram (Lexapro), an orally administered selective serotonin reuptake inhibitor, for treating depression in patients following ACS. The Escitalopram for Depression in Acute Coronary Syndrome (EsDEPACS) study used The Republic of Korea’s nationwide MI registry to track clinical outcomes among patients with MI in the real-world setting, and data from 300 patients in a single center—one which used a more intensive surveillance approach for its patients—allowed for more detailed follow-up of the patients who were involved in the clinical trial. The first patient enrolled in the study in 2007, and the final patient completed the 24-week follow-up period in 2013.
In the clinical trial, patients who randomized to the study drug (n = 149) received a 10-mg daily dose, though the dose could be adjusted up or down based on patients’ response and the drug’s tolerability. Another 151 patients were randomized to receive a placebo for the 24 weeks. Patients’ mean doses of the study drug at their final visit were 7.6 mg (standard deviation, 3.7). Patients were tapered from their treatment at the study’s end. The EsDEPACS study’s primary outcome was remission of depressive symptoms, and the drug proved to be superior to the placebo.
After the trial’s conclusion, researchers in the current study contacted the patients to facilitate longer-term follow-up (5 to 11 years) of all of the trial’s patients up to June 2017 or death. The current study’s primary endpoint was all major adverse cardiac events (MACE), inclusive of all-cause mortality, MI, and percutaneous coronary intervention (PCI). Secondary endpoints included all-cause mortality, cardiac death, MI, and PCI.
The researchers found a significant difference in the incidence of MACE between the groups; in the escitalopram arm, MACE incidence was 40.9%, versus 53.6% in the placebo arm (hazard ratio [HR], 0.69; 95% CI, 0.49-0.96; P =.03). There was also a significant difference in the incidence of MI, with 8.7% of the escitalopram group and 15.2% of the placebo group experiencing MI (HR, 0.54; 95% CI, 0.27-0.96; P =.04). There were no significant differences in the incidences of the other secondary endpoints, however.
The researchers concluded that, for patients with depression following ACS, a 24-week treatment period with the study drug resulted in a lower risk of MACE after a median of 8.1 years of follow-up. While further research will be needed to assess whether these findings are generalizable, and while the results should be considered in the context of prior studies that did not show a difference between antidepressant treatment and control groups in terms of MACE, the study data suggest that treatment with escitalopram may help to improve long-term cardiac outcomes for this patient population.
Kim JM, Stewart R, Lee YS, et al. Effect of escitalopram vs placebo treatment for depression on long-term cardiac outcomes in patients with acute coronary syndrome: a randomized clinical trial. JAMA. 2018;320(4):350-358. doi:10.1001/jama.2018.9422.