Cardiovascular disease is a leading cause of death and morbidity world wide. In spite of tremendous strides in the last few decades in the prevention and management of heart disease, with the changing demographics and the average age of the world population increasing, it continues to be in most places the leading cause of death. Many people suffer a heart attack and need to be treated with agents that help prevent a clot but don’t cause adverse bleeding complications. Likewise, depression, and treatment with selective serotonin reuptake inhibitors (SSRI) is also common. What happens with a person on a SSRI suffers a heart attack?
Recently an article in the Canadian Medical Journal looked at the risk of bleeding after a myocardial infarction in people on aspirin (ASA) therapy along with clopidogrel. A bleeding episode in this study was defined as intestinal bleeding, hemorrhagic stroke or other bleeding.
There were over 25,000 people in the study. About 3%, about 1 in 30 people, were taking an SSRI in addition to antiplatelet therapy. Older patients were more likely than younger patients to be on an SSRI antidepressant. They found that patients on an SSRI were more likely to have a bleeding episode, when added to either ASA therapy alone or when added to combined ASA and clopidogrel therapy.
The hazard ratios found in this study suggest about a 50% increased risk of a bleeding episode in patients who are on SSRI therapy in addition to ASA therapy or combined ASA and clopidogrel therapy. This is an important drug interaction, and quantifying the risk may help guide medical management. The authors also concluded that women seemed to have a decreased risk of bleeding, as did patients who underwent angioplasty during the index admission.
This is a complicated issue, since depression is fairly common, it increases with age, and SSRI therapy is a widely used and generally very safe medical therapy. Since only 3% of the people admitted to the hospital for a heart attack were on SSRI therapy, when looking at all people together the effect of SSRI therapy is very low. Nevertheless, this is something to consider when deciding what therapy to utilize for elderly patients at risk of a heart attack. People who have a heart attack likely will benefit from stopping (or never starting) SSRI medications.
REFERENCE
Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction. Labos C, Dasgupta K, Nedjar H, Turecki G, Rahme E. CMAJ. 2011 Nov 8;183(16):1835-43. Epub 2011 Sep 26.