Antidepressant may reduce mental stress-induced myocardial ischemia (REMIT Trial)

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1. Rates of mental stress-induced myocardial ischemia (MSIMI) were significantly lower in patients taking escitalopram (Lexapro) vs. placebo at the end of 6 weeks.

2. Rates of exercise-induced myocardial ischemia (ESIMI) were not significantly reduced in patients taking escitalopram vs. placebo at the end of 6 weeks.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Mental stress-induced myocardial ischemia (MSIMI) in patients with pre-existing coronary heart disease (CHD) has been replicated frequently, and it is regarded to be just as, if not more, prognostic as exercise induced myocardial ischemia (ESIMI). However, no clearly beneficial therapeutic options have been demonstrated to deal with it. This study demonstrates that patients with stable CHD prone to MSIMI are 2.62 times less likely to experience MSIMI after 6 weeks when receiving escitalopram instead of placebo. The altered serotonin physiology, the greater improvement in hemodynamic responses and psychological functioning in the escitalopram group over the placebo group demonstrates an intertwining of cardiovascular reaction and psychological response. Nonetheless, there does not appear to be a singular, known  pathophysiologic mechanism to explain this. Additional clinical trials offering longer treatment period beyond 6 weeks, as well as a more detailed analysis of metabolic risk factors before and after treatment with an increased sample size may increase the generalizability of this study and elucidate the relationship between serotonergic function and cardiovascular health.

Click to read the study, published today in JAMA

Relevant Reading: Psychological Stress and Cardiovascular Disease

In-Depth [randomized, double-blind placebo-controlled trial]: This study randomized a total of 127 participants with clinically stable CHD (Coronary Heart Disease) who demonstrated MSIMI during baseline mental and exercise stress testing, to receive either increasing doses of escitalopram or placebo for 6 weeks. Endpoint mental and exercise stress testing were repeated at the end of 6 weeks for detection of MSIMI and ESIMI. Higher rate of patients taking escitalopram did not experience MSIMI vs. placebo (34.2% vs. 17.5%) and this rate was statistically significant (OR, 2.62 [95% CI, 1.06 to 6.44]; p=0.04). There was no statistically significant difference in ESIMI between the two groups (OR, 1.24[95% CI, 0.60 to 2.58]; p=0.56). Significantly higher rates of participants in the escitalopram group reported adverse effects vs. placebo (71.9% vs 44.4%, p=0.002).

By Elizabeth Park and Rif Rahman

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