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Tricyclic Antidepressants in Nine Heart Transplant Recipients
Letters
o/Disease. 3rd Edition. Philadelphia, WB Saunders, 1984 5. Biesalski HK: Comparative assessment of the toxicology of vitamin A and retinoids in man. Toxicology 57: 117161. 1989
Tricyclic Antidepressants in Nine Heart Transplant Recipients SIR: Kay et aLI recently reported in this journal the safe use of tricyclic antidepressants in nine heart transplant recipients, but I believe they have made an error on an important point. They state that transplanted hearts "are externally paced. so the conduction disturbances that can complicate use of tricyclic antidepressants are not a hazard"(p, 169), Because the transplanted heart is denervated. heart rate is under the control of the intrinsic atrial pacemaker (sinoatrial node) and is free of external neurogenic influence. As a result. heart rate remains relatively constant. although circulating catecholamines still have some influence. 2 It does seem logical to infer that tricyclic antidepressants would have less chronotropic effects in transplanted hearts compared with normal hearts. but actual data on this point are scarce. 3 Kay et al. are mistaken in concluding that conduction disturbances are not a hazard. Conduction disturbances are related to tricyclic antidepressants' quinidine-like (Type IA antiarrhythmic) effects that occur at the A-V node and His bundle. Therefore. conduction disturbances with tricyclics are at least as likely in the transplanted heart as they are in the normal heart. James L. Levenson. M.D. Virginia Commonwealth University Richmond, Virginia
References I. Kay J, Bienenfeld D. Siomowitz M.et al: Use of tricyclic antidepressants in recipients of hean transplants. Psychosomatics32:165-170,1991 2. Shapiro PA, Sloan RP. Hom E. et al: Differential effects of psychological stress on innervated and denervated SA node activity after cardiac transplantation (abstract). Psychosom Med 52:222-223. 1990 3. Trzepacz PT. Levenson JL. Tringali RA: Psychopharmacology and neuropsychiatric syndromes in organ transplantation. Gen Hosp Psychiatry 13:233-245. 1991
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In Reply SIR: Dr. Levenson raises an important issue about the caution advisable in using tricyclic antidepressants (TCAs) in denervated hearts. Our point. in passing. was that in externally paced hearts. the conduction defects that can occur with TCAs are of less concern than they are in unpaced hearts. The ventricular pacemakerdoes not in any way prevent atrioventricular node or His bundle effects of TCAs, but it does protect against untoward results of these effects. Even in the unlikely event of TCA-induced complete atrioventricular block. the ventricular pacer assures rhythmic ventricular contraction. In unpaced hearts, this "safety net" is missing. and all usual cautions apply. In our series of nine cases and in several more cases subsequently treated with TCA. antidepressants have been both safe and effective. We stand by our conclusion that TCAs are reliable agents for use in heart transplant recipients. We thank Dr. levenson for his reminder that these agents should always be used with respect. David Bienenfeld. M.D. Jerald Kay. M.D. Wright State University School of Medicine Dayton. Ohio
Response to Letter "Mania and Paranoid Psychosis" SIR: Rif S. EI-Mallakh. M.D.• suggests that mania. paranoid psychosis. and cognitive decline share a similar pathophysiology that forecasts a worsened prognosis in AIDS I. This hypothesis is supported by a major role in the modulation of mood for the basal region of the right temporal lobe 2 dysregulating frontal function. 3 hence a network of structures as in the case of right frontoparietal mediation of directed attention to extrapersonal space. 4 In contrast. focal enhancement of the left parietal lobe on CT scan in a 33-year-old homosexual man who died 5 months after a violent outburst is supported by violence linked to the left hemisphere,S in which the metabolic rate is higher in males. 6 PSYCHOSOMATICS
o/Disease. 3rd Edition. Philadelphia, WB Saunders, 1984 5. Biesalski HK: Comparative assessment of the toxicology of vitamin A and retinoids in man. Toxicology 57: 117161. 1989
Tricyclic Antidepressants in Nine Heart Transplant Recipients SIR: Kay et aLI recently reported in this journal the safe use of tricyclic antidepressants in nine heart transplant recipients, but I believe they have made an error on an important point. They state that transplanted hearts "are externally paced. so the conduction disturbances that can complicate use of tricyclic antidepressants are not a hazard"(p, 169), Because the transplanted heart is denervated. heart rate is under the control of the intrinsic atrial pacemaker (sinoatrial node) and is free of external neurogenic influence. As a result. heart rate remains relatively constant. although circulating catecholamines still have some influence. 2 It does seem logical to infer that tricyclic antidepressants would have less chronotropic effects in transplanted hearts compared with normal hearts. but actual data on this point are scarce. 3 Kay et al. are mistaken in concluding that conduction disturbances are not a hazard. Conduction disturbances are related to tricyclic antidepressants' quinidine-like (Type IA antiarrhythmic) effects that occur at the A-V node and His bundle. Therefore. conduction disturbances with tricyclics are at least as likely in the transplanted heart as they are in the normal heart. James L. Levenson. M.D. Virginia Commonwealth University Richmond, Virginia
References I. Kay J, Bienenfeld D. Siomowitz M.et al: Use of tricyclic antidepressants in recipients of hean transplants. Psychosomatics32:165-170,1991 2. Shapiro PA, Sloan RP. Hom E. et al: Differential effects of psychological stress on innervated and denervated SA node activity after cardiac transplantation (abstract). Psychosom Med 52:222-223. 1990 3. Trzepacz PT. Levenson JL. Tringali RA: Psychopharmacology and neuropsychiatric syndromes in organ transplantation. Gen Hosp Psychiatry 13:233-245. 1991
118
In Reply SIR: Dr. Levenson raises an important issue about the caution advisable in using tricyclic antidepressants (TCAs) in denervated hearts. Our point. in passing. was that in externally paced hearts. the conduction defects that can occur with TCAs are of less concern than they are in unpaced hearts. The ventricular pacemakerdoes not in any way prevent atrioventricular node or His bundle effects of TCAs, but it does protect against untoward results of these effects. Even in the unlikely event of TCA-induced complete atrioventricular block. the ventricular pacer assures rhythmic ventricular contraction. In unpaced hearts, this "safety net" is missing. and all usual cautions apply. In our series of nine cases and in several more cases subsequently treated with TCA. antidepressants have been both safe and effective. We stand by our conclusion that TCAs are reliable agents for use in heart transplant recipients. We thank Dr. levenson for his reminder that these agents should always be used with respect. David Bienenfeld. M.D. Jerald Kay. M.D. Wright State University School of Medicine Dayton. Ohio
Response to Letter "Mania and Paranoid Psychosis" SIR: Rif S. EI-Mallakh. M.D.• suggests that mania. paranoid psychosis. and cognitive decline share a similar pathophysiology that forecasts a worsened prognosis in AIDS I. This hypothesis is supported by a major role in the modulation of mood for the basal region of the right temporal lobe 2 dysregulating frontal function. 3 hence a network of structures as in the case of right frontoparietal mediation of directed attention to extrapersonal space. 4 In contrast. focal enhancement of the left parietal lobe on CT scan in a 33-year-old homosexual man who died 5 months after a violent outburst is supported by violence linked to the left hemisphere,S in which the metabolic rate is higher in males. 6 PSYCHOSOMATICS