Journal Article Annotations
2020, 3rd Quarter

Cardiac Psychiatry

Annotations by Timothy King, MD
July, 2020

SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients

PUBLICATION #1 — Cardiac Psychiatry

SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients

George Mawardi, Tim M Markman, Rahatullah Muslem, Minoosh Sobhanian, Maureen Converse, Holly B Meadows, Walter E Uber, Stuart D Russell, Rosanne Rouf, Bhavadharini Ramu, Daniel P Judge, Ryan J Tedford, Brian A Houston

Abstract: Heart Lung Circ. 2020 Aug;29(8):1241-1246. doi: 10.1016/j.hlc.2019.07.011. Epub 2019 Aug 8.

Background:
Gastrointestinal bleeding (GIB) is common in left ventricular assist device (LVAD) patients. Serotonin release from platelets promotes platelet aggregation, and selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) therapy inhibits the transporter responsible for re-uptake.

Methods:
We reviewed the records of LVAD (HeartMateII™, Abbott Medical, Lake Bluff, IL, USA and Heartware™, Medtronic, Minneapolis, MN, USA) patients at the Medical University of South Carolina and Johns Hopkins Hospital between January 2009 and January 2016. After exclusions, 248 patients were included for analysis. After univariate analysis, logistic regression multivariate analysis was performed to adjust for any demographic, cardiovascular, and laboratory data variables found to be associated with GI bleeding post-LVAD.

Results:
Gastrointestinal bleeding occurred in 85 patients (35%) with 55% of GIBs due to arteriovenous malformations (AVMs). Of the total cohort, 105 patients received an SSRI or SNRI during LVAD support. Forty-four (44) SSRI/SNRI (41.9%) and 41 non-SSRI/SNRI (28.7%) patients had a GIB (RR 1.46, p = 0.03). Twenty-six (26) (24.8%) of the SSRI/SNRI patients had a GIB due to AVMs versus 21 (14.7%) of the non-SSRI/SNRI patients (RR 1.69, p = 0.05). In fully-adjusted multivariate regression analysis, SSRI/SNRI therapy was independently associated with GIB (OR 1.78, p = 0.045). For GIB, the number needed to harm (NNH) was 7.6.

Conclusion:
In conclusion, SSRI/SNRI therapy is independently associated with an increased risk of GIB in LVAD patients.

Keywords:
GI bleeding; LVAD; SNRI; SSRI.

Annotation

The finding:
This retrospective cohort study adds to the limited existing literature about the increased risk of gastrointestinal bleeds with SSRIs and SNRIs on LVAD patients

Strength and weaknesses:
This larger multi-institutional study confirms previous research about the increase in risk of GI bleeds among LVAD patients on an SSRI or SNRI. Nevertheless, numbers in this study are still relatively small (n=248).

Relevance:
Because LVAD patients are usually at a higher risk of GI bleeds due to antithrombotic therapy, a careful discussion of risks and benefits should be had prior to starting this patient group on SSRI/SNRI therapy. This discussion should emphasize the possible increase risk of GI bleeds: NNH 7.6 in LVAD patients vs NNH 3,177 in the general population using an SSRI in prior studies.

Type of study (EBM guide):
Cohort study