Potentiation of the vasospastic response to angioplasty by pretreatment with fluoxetine. A study in the atherosclerotic rabbit

SSRI Treatment—Associated Stroke: Causality Assessment in Two Cases

OBJECTIVE:

To assess the probability of cerebrovascular adverse drug reactions (CV-ADRs) due to treatment with selective serotonin-reuptake inhibitors (SSRIs) using 2 causality methods.

CASE SUMMARIES:

Two patients with the possibility of SSRI-related stroke were referred for causality assessment. Causality assessment was performed using an adverse drug reaction probability scale, as well as clinical and radiologic parameters. A 31–year-old white man, who had been receiving paroxetine 200 mg/day over a period of 3 years, developed ischemic stroke involving left middle cerebral artery. The second patient was a 46–year-old white woman with a history of recurrent depression who developed delirium and ischemic stroke while she was taking a combination of paroxetine 50 mg/day, trazodone 200 mg/day, and bupropion 150 mg/day.

DISCUSSION:

Carotid and cardiothromboembolism were found to be the major etiological factors for ischemic stroke. Accounting for the temporal relation, prior reports of SSRI treatment—associated CV-ADRs, and the pharmacologic action of serotonin on coagulation and the vascular system, the possible contribution of SSRIs to stroke in these patients was considered. An objective causality assessment using the Naranjo probability scale revealed that a CV-ADR was possible. However, the nature of the stroke, plus clinical and radiologic findings, were inconsistent with known pathophysiologic mechanisms linking SSRIs and stroke in these patients.

CONCLUSIONS:

Causality assessment may improve unbiased recognition, management, and voluntary reporting of infrequent adverse effects such as SSRI treatment—related cerebrovascular accident.

Psychosocial factors: role in cardiac risk and treatment strategies

Recent epidemiologic research has identified several psychosocial factors that impact unfavorably on prognosis among patients with established coronary heart disease (CHD). Several biologic and behavioral characteristics have been identified in patients with these psychosocial risk factors that are biologically plausible mediators of their adverse impact on prognosis. Several small-scale clinical trials offer encouraging evidence that both behavioral and pharmacologic interventions have the potential to ameliorate the health-damaging effects of psychosocial risk factors in patients with CHD. In this article we review the evidence on these points and offer recommendations as to how incorporation of this new knowledge into clinical care of the patient with CHD can lead to reduced mortality and morbidity rates in this population.