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For patients with depression after acute coronary syndrome, taking the antidepressant escitalopram (Lexapro) for 6 months improved long-term cardiac outcomes, follow-up of a randomized, placebo-controlled clinical trial showed.

Major adverse cardiac events (MACE) occurred in 40.9% of those initially treated with escitalopram and 53.6% of those who got placebo during a median follow-up of 8.1 years (P=0.03), reported Jae-Min Kim, MD, PhD, of Chonnam National University Medical School in Gwangju, South Korea, and colleagues in .

The effect on the composite of all-cause mortality, myocardial infarction (MI), and percutaneous coronary intervention (PCI) was seen even after excluding patients still taking antidepressants at 1 year, with incidence of 40.3% versus 53.4% in the placebo arm (P=0.03).

"This paper makes an important contribution to the literature, although one that should be interpreted with caution," commented Kenneth Freedland, PhD, of Washington University School of Medicine in St. Louis, who was not involved in the trial.

While the long-term analysis was preplanned, it wasn't designed to be powered for that, as "the study was originally planned with remission of depression at 24 weeks as the primary outcome," he told 番茄社区app.

"The cardiovascular benefit of escitalopram is surprising, given the results of previous RCTs [randomized clinical trials]," he noted.

In MI patients, MIND-IT showed no difference in cardiac outcomes after 8 weeks of antidepressant, SADHART showed no long-term mortality impact of 6 months of antidepressant, and ENRICHD showed no cardiac advantage over 29-month follow-up after 9 months of cognitive behavioral therapy with or without 12 months of antidepressants.

Kim's Escitalopram for Depression in Acute Coronary Syndrome (EsDEPACS) study included 300 participants (mean age 60 years and 39.3% women) with acute coronary syndrome and depression. The mean depression severity score of 15.9 on the HAM-D scale was less severe than in some prior antidepressant trials in ACS, which have had mixed findings on outcomes.

The individual outcome incidence for escitalopram versus placebo was as follows:

• All-cause mortality: 20.8% versus 24.5% (P=0.43)
• Cardiac death: 10.7% versus 13.2% (P=0.48)
• MI: 8.7% versus 15.2% (P=0.04)
• PCI: 12.8% versus 19.9% (P=0.07)

A trend for better composite MACE in the subgroup with impaired left ventricular ejection fraction didn't reach significance.

While the sample size was "sufficient" to address depression, Freedland suggested a larger sample size would have been desirable for looking at cardiac outcomes.

The authors acknowledged limitations including the single-site design and small number of patients suffering from MACE, which limited the generalizability of the data. Also, there were no assessments of depression incidence or antidepressant use beyond the 1-year follow-up.

All in all, the investigators, concluded that "further research is needed to assess the generalizability of these findings."

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