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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by Phillipa on December 1, 2010, at 13:35:13
Another article on TCA's and increased CVA risk. Phillipa
From Medscape Medical News > Psychiatry
Tricyclic Antidepressants Linked to Increased Cardiovascular Risk
Megan Brooks
November 30, 2010 Findings from a prospective cohort study released today suggest tricyclic antidepressants (TCAs) are associated with a 35% increased risk for cardiovascular disease (CVD), which is not explained by existing psychiatric illness.However, researchers found no increased cardiac risk associated with selective serotonin reuptake inhibitors (SSRIs).
"This suggests that there may be some characteristic of tricyclics that is raising the risk," Mark Hamer, PhD, of University College London, United Kingdom, said in a release. "Tricyclics are known to have a number of side effects; they are linked to increased blood pressure, weight gain, and diabetes, and these are all risk factor for CVD," he adds.
Dr. Hamer told Medscape Medical News that clinicians need to "be cautious about prescribing TCAs, especially in people with other risk factors."
In the study, published online December 1 in the European Heart Journal, Dr. Hamer and colleagues assessed the association between antidepressant medication use and future risk for CVD in 14,784 Scottish adults with no known history of CVD.
All were participants in the Scottish Health Survey, which collects information from the general population every 3 to 5 years. Data from separate surveys in 1995, 1998, and 2003 were combined and linked with records on hospital admissions and deaths, with follow-up until 2007. Individuals with a history of clinically confirmed CVD were excluded.
According to the investigators, 729 (4.9%) of the 14,784 study subjects reported using antidepressant medication: 2.2% reported TCA use, 2% reported SSRI use, and 0.7% reported taking other antidepressants.
Findings Support Previous Research
During an average of 8 years of follow-up, there were 1434 CVD events, of which 26.2% were fatal. After adjusting for various confounding factors, including indicators of mental illness, there was a 35% increased risk for CVD associated with TCA use (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 1.77).
There was also a nonsignificant association between TCA use and coronary heart disease events (969 events; multivariate HR, 1.24; 95% CI, 0.87 1.75).
In contrast, SSRI use was not associated with increased CVD risk (HR, 1.11; 95% CI, 0.77 1.60) and neither class of drug was associated with all-cause mortality.
"Our study is the first to contain a representative sample of the whole community, including elderly and unemployed participants, men and women, [and] our data are largely consistent with the few previous studies in healthy people," Dr. Hamer said.
In 1 such study, use of TCAs was associated with about a 2-fold increased relative risk for myocardial infarction during 4.5 years of follow-up, compared with subjects who did not use antidepressants. There was no increased risk with SSRIs in this study (Cohen et al. Am J Med. 2000).
The absence of information on medication compliance and dosage is a limitation of the current study, Dr. Hamer and colleagues note. However, because this was an observational study, it is not possible to infer causation, they add, and it is "plausible that the results could be explained by residual confounding due to unmeasured or unknown risk factors."
Consider CVD in Depressed Patients
Reached for outside comment, Andrew H. Kemp, PhD, MAPS, of the University of Sydney, Australia, who was not involved in the study, called the findings "interesting and important," and he said the findings are "consistent with the well-known, increased anticholinergic effects of TCAs."
"These effects," Dr. Kemp explained, "are likely to be due to the effects on the heart and involve blockade of the muscarinic acetylcholine receptors at the sinoatrial node of the heart, the generator of the sinus rhythm. Blockade of these receptors leads to inhibition of parasympathetic activity and tachycardia.
"While TCAs are associated with greater affinity to muscarinic receptors, SSRIs are more benign, with the exception of paroxetine, which has considerable antimuscarinic potency," Dr. Kemp continued. "Decreased parasympathetic activity leads to increased heart rate and a decrease in heart rate variability, the latter of which may predict sudden cardiac death, even in relatively healthy individuals without a prior history of CVD."
In a study published in Biological Psychiatry in October 2010, Dr. Kemp and colleagues showed that major depressive disorder without CVD is associated with reductions in heart rate variability and that antidepressants do not reverse the observed reductions. This, they say, highlights the need to consider the cardiovascular system in patients presenting with and being treated for depression (Kemp et al. Biol Psychiatry. 2010).
Dr. Hamer and colleagues and Dr. Kemp have disclosed no relevant financial relationships.
Eur Heart J. Published online December 1, 2010.
Posted by bleauberry on December 1, 2010, at 18:59:11
In reply to TCA's Linked To Cardiovascular risk, posted by Phillipa on December 1, 2010, at 13:35:13
I don't understand scientists trying to point a finger at TCAs for heart risk when American food choices at the grocery store pose a much higher risk IMO.
The #1 killer is obesity. #2 is alcohol. #3 is cigarettes. TCAs aren't even on a top 100 list.
TCAs at least present a benefit of improving and extending lives that would otherwise die earlier due to complications of depression.
Posted by Phillipa on December 1, 2010, at 21:36:22
In reply to Re: TCA's Linked To Cardiovascular risk, posted by bleauberry on December 1, 2010, at 18:59:11
Seriously guess ask the scientists. Who knows? Phillipa
Posted by Conundrum on December 2, 2010, at 11:43:45
In reply to TCA's Linked To Cardiovascular risk, posted by Phillipa on December 1, 2010, at 13:35:13
A nice plug for SSRIs. Muscarinic agonists do exist. Also lumping TCAs together hardly makes any sense. The effects of amitriptyline, aren't going to be the same as clomipramine, or desipramine. SSRIs are more similar as a group.
> Another article on TCA's and increased CVA risk. Phillipa
>
> From Medscape Medical News > Psychiatry
> Tricyclic Antidepressants Linked to Increased Cardiovascular Risk
> Megan Brooks
> November 30, 2010 Findings from a prospective cohort study released today suggest tricyclic antidepressants (TCAs) are associated with a 35% increased risk for cardiovascular disease (CVD), which is not explained by existing psychiatric illness.
>
> However, researchers found no increased cardiac risk associated with selective serotonin reuptake inhibitors (SSRIs).
>
> "This suggests that there may be some characteristic of tricyclics that is raising the risk," Mark Hamer, PhD, of University College London, United Kingdom, said in a release. "Tricyclics are known to have a number of side effects; they are linked to increased blood pressure, weight gain, and diabetes, and these are all risk factor for CVD," he adds.
>
> Dr. Hamer told Medscape Medical News that clinicians need to "be cautious about prescribing TCAs, especially in people with other risk factors."
>
> In the study, published online December 1 in the European Heart Journal, Dr. Hamer and colleagues assessed the association between antidepressant medication use and future risk for CVD in 14,784 Scottish adults with no known history of CVD.
>
> All were participants in the Scottish Health Survey, which collects information from the general population every 3 to 5 years. Data from separate surveys in 1995, 1998, and 2003 were combined and linked with records on hospital admissions and deaths, with follow-up until 2007. Individuals with a history of clinically confirmed CVD were excluded.
>
> According to the investigators, 729 (4.9%) of the 14,784 study subjects reported using antidepressant medication: 2.2% reported TCA use, 2% reported SSRI use, and 0.7% reported taking other antidepressants.
>
> Findings Support Previous Research
>
> During an average of 8 years of follow-up, there were 1434 CVD events, of which 26.2% were fatal. After adjusting for various confounding factors, including indicators of mental illness, there was a 35% increased risk for CVD associated with TCA use (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 1.77).
>
> There was also a nonsignificant association between TCA use and coronary heart disease events (969 events; multivariate HR, 1.24; 95% CI, 0.87 1.75).
>
> In contrast, SSRI use was not associated with increased CVD risk (HR, 1.11; 95% CI, 0.77 1.60) and neither class of drug was associated with all-cause mortality.
>
> "Our study is the first to contain a representative sample of the whole community, including elderly and unemployed participants, men and women, [and] our data are largely consistent with the few previous studies in healthy people," Dr. Hamer said.
>
> In 1 such study, use of TCAs was associated with about a 2-fold increased relative risk for myocardial infarction during 4.5 years of follow-up, compared with subjects who did not use antidepressants. There was no increased risk with SSRIs in this study (Cohen et al. Am J Med. 2000).
>
> The absence of information on medication compliance and dosage is a limitation of the current study, Dr. Hamer and colleagues note. However, because this was an observational study, it is not possible to infer causation, they add, and it is "plausible that the results could be explained by residual confounding due to unmeasured or unknown risk factors."
>
> Consider CVD in Depressed Patients
>
> Reached for outside comment, Andrew H. Kemp, PhD, MAPS, of the University of Sydney, Australia, who was not involved in the study, called the findings "interesting and important," and he said the findings are "consistent with the well-known, increased anticholinergic effects of TCAs."
>
> "These effects," Dr. Kemp explained, "are likely to be due to the effects on the heart and involve blockade of the muscarinic acetylcholine receptors at the sinoatrial node of the heart, the generator of the sinus rhythm. Blockade of these receptors leads to inhibition of parasympathetic activity and tachycardia.
>
> "While TCAs are associated with greater affinity to muscarinic receptors, SSRIs are more benign, with the exception of paroxetine, which has considerable antimuscarinic potency," Dr. Kemp continued. "Decreased parasympathetic activity leads to increased heart rate and a decrease in heart rate variability, the latter of which may predict sudden cardiac death, even in relatively healthy individuals without a prior history of CVD."
>
> In a study published in Biological Psychiatry in October 2010, Dr. Kemp and colleagues showed that major depressive disorder without CVD is associated with reductions in heart rate variability and that antidepressants do not reverse the observed reductions. This, they say, highlights the need to consider the cardiovascular system in patients presenting with and being treated for depression (Kemp et al. Biol Psychiatry. 2010).
>
> Dr. Hamer and colleagues and Dr. Kemp have disclosed no relevant financial relationships.
>
> Eur Heart J. Published online December 1, 2010.
>
Posted by Conundrum on December 2, 2010, at 11:45:46
In reply to Re: TCA's Linked To Cardiovascular risk, posted by bleauberry on December 1, 2010, at 18:59:11
Maybe they will be balanced and put out a report on the increased risk of emotional blunting on SSRIs...
> I don't understand scientists trying to point a finger at TCAs for heart risk when American food choices at the grocery store pose a much higher risk IMO.
>
> The #1 killer is obesity. #2 is alcohol. #3 is cigarettes. TCAs aren't even on a top 100 list.
>
> TCAs at least present a benefit of improving and extending lives that would otherwise die earlier due to complications of depression.
Posted by Abby Cunningham on December 2, 2010, at 13:22:07
In reply to TCA's Linked To Cardiovascular risk, posted by Phillipa on December 1, 2010, at 13:35:13
I for one developed Supra Ventricular Tachycardia while on amitriptyline, and cannot take a TCA because of it. That is my own personal experience. I never had it before taking the TCA, and now I am on calcium channel blocker for the rest of my life to keep my heart rhythm normal. (I ended up in the hospital with a heart rate of 228 while on the Elavil).
Is SVT a disease? Is it CVD? I'm not sure, but don't discount drug-caused "conditions". I'm living proof.
Posted by Phillipa on December 2, 2010, at 19:35:38
In reply to Re: TCA's Linked To Cardiovascular risk » Phillipa, posted by Abby Cunningham on December 2, 2010, at 13:22:07
Abby I didn't know that. Glad I couldn't take them then. Phillipa
Posted by ed_uk2010 on December 3, 2010, at 9:09:17
In reply to Re: TCA's Linked To Cardiovascular risk » Phillipa, posted by Abby Cunningham on December 2, 2010, at 13:22:07
>I for one developed Supra Ventricular Tachycardia while on amitriptyline, and cannot take a TCA because of it. That is my own personal experience. I never had it before taking the TCA, and now I am on calcium channel blocker for the rest of my life to keep my heart rhythm normal. (I ended up in the hospital with a heart rate of 228 while on the Elavil).
>
> Is SVT a disease? Is it CVD? I'm not sure, but don't discount drug-caused "conditions". I'm living proof.TCAs do affect cardiac conduction temporarily, but there is no evidence that they cause permanent changes to cardiac conduction. SVT is a common condition, so it's difficult to come to any conclusions.
If your SVT was induced by amitriptyline, it should not recur now that you have stopped amitriptyline. So why the CCB for the rest of your life? You may be able to come off it.
If you are continuing to suffer arrhythmias in the absence of amitriptyline, that would suggest that amitriptyline was not the cause.
Posted by Conundrum on December 3, 2010, at 11:48:53
In reply to Re: TCA's Linked To Cardiovascular risk » Abby Cunningham, posted by ed_uk2010 on December 3, 2010, at 9:09:17
> If your SVT was induced by amitriptyline, it should not recur now that you have stopped amitriptyline. So why the CCB for the rest of your life? You may be able to come off it.
>
> If you are continuing to suffer arrhythmias in the absence of amitriptyline, that would suggest that amitriptyline was not the cause.
>It sounds, to me, like the arrhythmias did not reoccur after stopping amitrip, but that they never stopped after discontinuing amitriptyline.
I don't doubt the possibility of a drug causing long term problems, even after stopping. I've had it happen with fluoxetine and also with an herbal cleanse that permanently altered gut functioning. Drugs are a risky game.
Its nice to say the patient would have developed the disorder on their own and its not the drug, because it makes us feel safer about taking drugs, if we are a patient, and more confident, if we are a doctor prescribing them. My belief is that almost anything can happen when ingesting a potent drug, plant or chemical and the effects can be long lasting.
Posted by ed_uk2010 on December 3, 2010, at 17:30:17
In reply to Re: TCA's Linked To Cardiovascular risk » ed_uk2010, posted by Conundrum on December 3, 2010, at 11:48:53
>Its nice to say the patient would have developed the disorder on their own...
TCAs can certainly induce arrhythmias. They alter cardiac conduction. TCA-induced arrthymias are especially likely at high doses, in overdose, and probably at normal doses in poor metabolisers. There is also a particular risk in those with underlying structural heart disease. As far as I am aware, the risk of arrhythmias goes away after the drugs have been stopped, and cardiac conduction returns to normal.
Posted by linkadge on December 5, 2010, at 14:47:41
In reply to Re: TCA's Linked To Cardiovascular risk » ed_uk2010, posted by Conundrum on December 3, 2010, at 11:48:53
I remember reading somewhere that amitriptyline induced cardiac inflamation and programmed cell death.
Linkadge
Posted by Brainbeard on December 7, 2010, at 15:33:30
In reply to Re: TCA's Linked To Cardiovascular risk, posted by linkadge on December 5, 2010, at 14:47:41
Yeah, amitriptyline is the TCA most rough on the heart.
I take 225mg of clomipramine with 50mg of fluvoxamine, and these posts make me remember my fear of cardiac failure before starting clomipramine. I hate the cardiovascular risk, but OCD can do a lot of damage to one's life too.
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