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Antidepressant use and risk of cardiovascular outcomes in people aged 20 to 64: cohort study using primary care database

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1350 (Published 22 March 2016) Cite this as: BMJ 2016;352:i1350

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Venlafaxine, citalopram and escitalopram: risk of adverse cardiovascular effects and of overdose deaths.

Coupland et al found no evidence that selective serotonin reuptake inhibitors are associated with an increased risk of arrhythmia … or that citalopram is associated with a significantly increased risk of arrhythmia …(1) They should have questioned why?

The study cohort was selected a primary care database with longitudinal health records of more than 12 million patients from more than 600 general practices across the United Kingdom. As quality rarely fits with quantity, the use of the motto "garbage in, garbage out" could be part of the answer.

Prescrire, the international independent drug bulletin just re-warned: Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, carries an increased risk of adverse cardiovascular effects and of overdose deaths, compared with most other serotonin reuptake inhibitors (SRIs), whereas the efficacy of all SRIs is similar and limited. Venlafaxine shares the adverse effects of SRIs, but is associated with additional adverse effects, especially cardiovascular – tachycardia, hypertension, severe cardiac arrhythmia – which are foreseeable, given its pharmacological profile. These adverse effects are generally fatal in the case of overdose or risk factors (eg. hypokalaemia), with no compensation in terms of efficacy. Citalopram and its derivative escitalopram too, ought also to be ruled out as well because they too expose patients to an increase in adverse cardiovascular effects, whereas they offer no benefit in terms of efficacy.(2)

The bibliography must be questioned too as it ignored the cases of citalopram and venlafaxine overdoses published, even from "core clinical journals". (3,4)

1 Coupland C, Hill T, Morriss R, Moore M, Arthur A, Hippisley-Cox J. Antidepressant use and risk of cardiovascular outcomes in people aged 20 to 64: cohort study using primarycare database. BMJ 2016;352:i1350.
2 Prescrire. Venlafaxine: more dangerous than most "selective" serotonergic antidepressants. Prescrire Int 2016; 25 (170): 96-99.
3 Batista M, Dugernier T, Simon M et al. The spectrum of acute heart failure after venlafaxine overdose. Clin Toxicol (Phila). 2013;51(2):92-5.
4 Kelly CA, Dhaun N, Laing WJ, Strachan FE, Good AM, Bateman DN. Comparative toxicity of citalopram and the newer antidepressants after overdose.J Toxicol Clin Toxicol. 2004;42(1):67-71

Competing interests: No competing interests

01 April 2016
Alain Braillon
senior consultant
University Hospital. 80000 Amiens. France