A 74-year-old man comes to the office for a scheduled follow-up after hospitalization for a myocardial infarction 4 weeks ago. The patient has had no new cardiac symptoms and has adhered to his outpatient medication regimen. When asked how he has been, he says, "I just don't feel like my old self." The patient's usual routine has been "disrupted" since he was discharged; he is not meeting with friends and has not been able to read the newspaper all the way through. He naps on his couch during the day and wakes up earlier than he wants to in the morning. The patient's medical history includes diet-controlled diabetes mellitus, hypertension, and obesity. Medications include aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin as needed. Vital signs are within normal limits. Physical examination is unremarkable except for moderate obesity. He reports low mood and appears slowed and subdued. The patient declines psychotherapy. Which of the following is the most appropriate pharmacotherapy?

Question

A 74-year-old man comes to the office for a scheduled follow-up after hospitalization for a myocardial infarction 4 weeks ago.  The patient has had no new cardiac symptoms and has adhered to his outpatient medication regimen.  When asked how he has been, he says, "I just don't feel like my old self."  The patient's usual routine has been "disrupted" since he was discharged; he is not meeting with friends and has not been able to read the newspaper all the way through.  He naps on his couch during the day and wakes up earlier than he wants to in the morning.  The patient's medical history includes diet-controlled diabetes mellitus, hypertension, and obesity.  Medications include aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin as needed.  Vital signs are within normal limits.  Physical examination is unremarkable except for moderate obesity.  He reports low mood and appears slowed and subdued.  The patient declines psychotherapy.  Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec25c8_d752_3b42_bc81_7946ba79e7fc_MD0003_00 The patient exhibits symptoms of major depressive disorder (MDD), which include low mood, anhedonia, impaired concentration, sleep disturbance, and psychomotor retardation. MDD may occur in up to one-fifth of patients who have had a recent myocardial infarction (MI). It may affect adherence to post-MI medical treatments and can increase the risk of cardiac mortality. Treatment options include psychotherapy and antidepressant medication. Combination therapy is likely to be more effective and is therefore recommended. Selective serotonin reuptake inhibitors (SSRIs) are used as first-line treatments after an acute MI because they are generally well tolerated and, compared with other classes of antidepressants, less likely to cause adverse cardiac effects. Among SSRIs, sertraline is preferred because it carries a very low risk of adverse drug interactions, especially with cardiac medications. The SSRI citalopram is generally avoided in patients with a recent MI due to its potential for dose-dependent QT prolongation (Choice A). (Choice B) Tricyclic antidepressants such as desipramine can slow cardiac conduction by inhibition of fast sodium channels and therefore are not indicated in patients with severe cardiovascular disease. (Choice C) Although mirtazapine, an atypical antidepressant with noradrenergic and serotonergic effects, is not contraindicated in patients with cardiovascular disease, its propensity to cause sedation and weight gain make it a poor choice for this patient. (Choice D) Monoamine oxidase inhibitors such as phenelzine are not considered first-line treatment for MDD due to their side effect burden (eg, sedation, weight gain) and potential for drug and food interactions (eg, serotonin syndrome, tyramine hypertensive crisis). (Choice F) Trazodone, a serotonin-modulating antidepressant, is extremely sedating. It is used at a low dose primarily for sleep induction rather than for its antidepressant effects. Its orthostatic effects are problematic in the elderly. (Choice G) Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, is associated with tachycardia and increased blood pressure; therefore, it is not recommended in a patient with a recent MI. Educational objective: Depression after myocardial infarction can increase the overall risk of cardiac mortality. Psychotherapy and antidepressant treatment (especially in combination) are likely to be effective. The selective serotonin reuptake inhibitor sertraline is considered a first-line treatment. References: Treatment of affective disorders in cardiac disease. (http://www.ncbi.nlm.nih.gov/pubmed/26246788) Treatment of depression in cardiovascular disease. (http://www.ncbi.nlm.nih.gov/pubmed/23293051) QT prolongation, torsades de pointes, and psychotropic medications: a 5-year update. (http://www.ncbi.nlm.nih.gov/pubmed/29275963)

A 74-Year-Old Man Comes to the Office for a Scheduled