Effect of Escitalopram on Mental Stress–Induced Myocardial Ischemia

ImportanceMental stress can induce myocardial ischemia and also has been implicated in triggering cardiac events. However, pharmacological interventions aimed at reducing mental stress–induced myocardial ischemia (MSIMI) have not been well studied.ObjectiveTo examine the effects of 6 weeks of escitalopram treatment vs placebo on MSIMI and other psychological stress–related biophysiological and emotional parameters.Design, Setting, and ParticipantsThe REMIT (Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment) study, a randomized, double-blind, placebo-controlled trial of patients with clinically stable coronary heart disease and laboratory-diagnosed MSIMI. Enrollment occurred from July 24, 2007, through August 24, 2011, at a tertiary medical center.InterventionsEligible participants were randomized 1:1 to receive escitalopram (dose began at 5 mg/d, with titration to 20 mg/d in 3 weeks) or placebo over 6 weeks.Main Outcomes and MeasuresOccurrence of MSIMI, defined as development or worsening of regional wall motion abnormality; left ventricular ejection fraction reduction of 8% or more; and/or horizontal or down-sloping ST-segment depression of 1 mm or more in 2 or more leads, lasting for 3 or more consecutive beats, during 1 or more of 3 mental stressor tasks.ResultsOf 127 participants randomized to receive escitalopram (n = 64) or placebo (n = 63), 112 (88.2%) completed end point assessments (n = 56 in each group). At the end of 6 weeks, more patients taking escitalopram (34.2% 95% CI, 25.4%-43.0%) had absence of MSIMI during the 3 mental stressor tasks compared with patients taking placebo (17.5% 95% CI, 10.4%-24.5%), based on the unadjusted multiple imputation model for intention-to-treat analysis. A significant difference favoring escitalopram was observed (odds ratio, 2.62 95% CI, 1.06-6.44). Rates of exercise-induced ischemia were slightly lower at 6 weeks in the escitalopram group (45.8% 95% CI, 36.6%-55.0%) than in patients receiving placebo (52.5% 95% CI, 43.3%-61.8%), but this difference was not statistically significant (adjusted odds ratio; 1.24 95% CI, 0.60-2.58; P = .56).Conclusions and RelevanceAmong patients with stable coronary heart disease and baseline MSIMI, 6 weeks of escitalopram, compared with placebo, resulted in a lower rate of MSIMI. There was no statistically significant difference in exercise-induced ischemia. Replication of these results in multicenter settings and investigations of other medications for reducing MSIMI are needed.Trial Registrationclinicaltrials.gov Identifier: NCT00574847 .