From the Journals

Early escitalopram for post-ACS depression improves MACE, 8 years on



Even years after their cardiac events, acute coronary syndrome patients whose depression was treated with 6 months of an antidepressant had fewer cardiovascular events, according to a randomized, controlled trial.

Compared with patients who were given placebo for depression after experiencing acute coronary syndrome (ACS), patients who received escitalopram experienced a lower incidence of a composite outcome of major adverse cardiovascular events (MACE), in this extension study of a 6-month trial reported previously (J Clin Psychiatry. 2015 Jan;76[1]:62-8).

After a median of 8.1 years, MACE, the study’s primary outcome, was experienced by 40.9% of patients taking escitalopram, compared with 53.6% of those taking placebo (hazard ratio 0.69, 95% confidence interval 0.49-0.96, P = .03). The investigators also tracked the individual MACE components (all-cause mortality, myocardial infarction, and percutaneous coronary intervention), finding that MI was also significantly less common in the escitalopram group compared with those who took placebo (8.7% vs. 15.2%, HR 0.54, 95% CI, 0.27-0.96, P = .04).

The other MACE components were seen less frequently in the escitalopram group, but the differences from those taking placebo were not statistically significant. The study did not show a mortality benefit for those who took escitalopram, noted first author Jae-Min Kim, MD, of the department of psychiatry at Chonnam University Medical School, Gwangju, South Korea, and his coauthors.

The randomized, double-blind, placebo-controlled trial comprised 300 patients who recently had ACS and also met DSM-IV criteria for major or minor depression.

Over a 5-year period at a single site, patients were randomized to receive escitalopram at an initial dose of 10 mg daily (149 patients), or placebo (151), for 24 weeks after their ACS event. Escitalopram doses could be adjusted according to clinician judgment from 5 to 20 mg daily.

Patients who consented to participate were enrolled and screened for depression within 2 weeks of their ACS event, and any who scored higher than 10 on the Beck Depression Inventory at the initial screen or at follow-up appointments up to 12 weeks post enrollment went on for further screening.

Demographic data were collected with an eye toward identifying factors that could affect cardiac outcomes, said Dr. Kim and his colleagues. So in addition to age, sex, and educational level, the investigators tracked participants’ living situations and marital and employment status.

Patients were a mean of 60 years old, and about 60% were male. The median Beck Depression Inventory score was 16-17.

The study differed from others, said the investigators, because it followed patients for a longer period of time. In previous studies, “[E]ffects on cardiac outcomes have not generally been found within the treatment period,” they wrote.

Though the study’s generalizability might be limited by the fact that it was conducted at a single site and all participants were Asian, the single-site design and South Korea’s comprehensive patient data registries also allowed for complete data collection over a very long follow-up period, noted Dr. Kim and his colleagues.

Adherence was high, at 93% for those taking escitalopram and 95% for those taking placebo. Other work published from the study has shown that those taking 24 weeks of escitalopram had less depression than did those taking placebo, they added.

One coauthor reported receiving financial support from Janssen and Roche. The study was supported by the National Research Foundation of Korea.

SOURCE: Kim J-M et al. JAMA. 2018;320(4):350-8.

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