CMAJ: Combined with antiplatelet therapy, SSRIs increase post-MI bleeds

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Administering selective serotonin reuptake inhibitors (SSRIs) in combination with antiplatelet therapy increases bleeding risk in patients post-acute MI, according to a study published Sept. 26 in the Canadian Medical Association Journal (CMAJ). The authors warned that physicians should exhibit caution when administering SSRIs for depression after MI.

While aspirin and clopidogrel are commonly prescribed to patients post-acute MI, there has been reported concerns with bleeding. “This risk may be increased further by the frequent concomitant use of other medications associated with an increased risk of bleeding, such as anticoagulant therapy and selective serotonin reuptake inhibitors (SSRIs),” Christopher Labos, MD, of McGill University in Montreal, and colleagues wrote. SSRIs are prescribed in nearly 20 percent of cardiovascular patients who suffer from depression.

Because the bleeding risk associated with combining SSRI therapy with single or dual antiplatelet therapy remains uncertain, Labos et al conducted a retrospective study using data from 27,058 patients who received medications at discharge. Of the full patient complement, 14,426 received aspirin; 2,467 clopidogrel; 9,475 both aspirin and clopidogrel; 406 aspirin and an SSRI; 239 aspirin, clopidogrel and an SSRI; and 45 clopidogrel and an SSRI.

Patients observed in the study were above the age of 50 and were discharged from the hospital following acute MI between January 1998 and March 2007.

Labos and colleagues reported that patients on aspirin and an SSRI were more likely to be older, have renal failure and to have previously taken antihypertensive agents or antidepressants.

The study comprised 80,991 patient-years, and 1,070 bleeding episodes occurred.

The researchers reported that the combined use of an SSRI with antiplatelet therapy was associated with an increased risk of bleeding compared with aspirin alone. Compared with dual antiplatelet therapy alone (aspirin plus clopidogrel), a combination of an SSRI and dual antiplatelet therapy was also associated with an increased risk of bleeding.

Additionally, it was found that the risk of bleeding linked to clopidogrel was similar to aspirin use alone. The combination of clopidogrel and aspirin increased the bleeding risk beyond aspirin alone by 49 percent.

“Ultimately, clinicians must weigh the benefits of SSRI therapy against the risk of bleeding in patients with major depression following acute myocardial infarction. Clinicians should exercise caution when prescribing SSRIs to their patients with major depression following acute myocardial infarction,” Labos and colleagues concluded. “The potential for drug interactions must be evaluated to guide the choice of medication.”