Managing depression in patients with advanced heart failure awaiting transplantation.

PURPOSE: The relative merits of various forms of antidepressant therapy in patients with heart failure (HF) are discussed, including disease-specific pharmacokinetic changes and drug-interaction challenges in current or likely future candidates for heart transplantation.

SUMMARY: There is a growing emphasis on the use of antidepressants in patients with chronic HF, as depression can have a negative impact on HF progression and morbidity and mortality after heart transplants or other invasive cardiac surgery. Evidence from one small study of patients with concomitant end-stage HF and major depression indicated a reduced risk of cardiovascular death in those receiving β-blockers in combination with selective serotonin-reuptake inhibitor (SSRI) therapy. In addition to pharmacokinetic changes caused by HF itself, which can decrease medication absorption and distribution, other issues to consider in the drug selection process include the potential for antidepressants to interact with posttransplant immunosuppressive therapy and the possible effects of antidepressant use on surgical transfusion requirements. The SSRIs are generally recommended as first-line therapies for depressed patients with HF; however, fluvoxamine and fluoxetine should be avoided due to interactions with immunosuppressant agents. If SSRI therapy is not well tolerated or adjunctive therapy is required, bupropion, mirtazapine, venlafaxine, and duloxetine may be suitable alternatives for certain patients.

CONCLUSION: Key considerations in antidepressant selection in the context of advanced HF include HF-related changes in drug pharmacokinetics that may affect initial dosing or dosage adjustment, possible drug interactions, adverse effects that may potentiate those induced by immunosuppressants added after transplantation, and tolerability issues.