The risk for a first acute coronary syndrome in patients treated with different types of antidepressants: A population based nested case-control study

Background: Tricyclic antidepressants (TCAs) are still used in 30% of anxiety/depression cases and have been related to increased cardiovascular risk. Newer serotonin/norepinephrine reuptake inhibitors (SSRI_s/SNRI_s) safety remains conflicting. Our aim was to assess the risk of a first acute coronary syndrome (ACS) in patients treated by various types of antidepressants. Methods: Study was a retrospective nested case-control of 40–80 years old northern-Israeli members of Clalit Health Services (CHS) during 1.1.2003–31.12.2013. Patients with severe psychiatric, cardiac or systemic diseases, or pre-enrollment antidepressants were excluded. Cases that had a first ACS during the study period were matched in 1:30 ratio with controls. The association between antidepressants use and ACS was tested by adjusted multivariable conditional logistic regression. Results: The cohort included 535,315 individuals 128,550 of whom met the exclusion/inclusion criteria. 3391 Cases with first ACS, (incidence rate of 24.6/10,000 person years) were matched with 88,016 controls. ACS was not associated with use of either SSRI_S/SNRI_S or TCA_s compared with no antidepressants use. However, treatment by SSRI_S/SNRI_S was associated with a 36% decreased risk ACS compared to TCA_s, OR = 0. 64, 95%CI (0.43–0.95), p = 0.029. Age 40–64 years, male gender and metabolic syndrome associated with reduced risk of ACS among SSRI_S/SNRI_S compared to TCA_s users. Conclusion: In this study of patients without prior cardiovascular disease– neither antidepressant group imposed excess risk for ACS, compared to-no treatment. SSRIs treatment seemed safer compared to TCAs in regard of ACS. This study probably adds to our confidence of preferring SSRIs over TCAs in patients without prior cardiovascular disease.