title: Effect of escitalopram on mental stress-induced myocardial ischemia: results of the REMIT trial.
abstract: OBJECTIVE
  Mental 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.
  
  
  OBJECTIVE
  To examine the effects of 6 weeks of escitalopram treatment vs placebo on MSIMI and other psychological stress-related biophysiological and emotional parameters.
  
  
  METHODS
  The 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.
  
  
  METHODS
  Eligible 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.
  
  
  METHODS
  Occurrence 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.
  
  
  RESULTS
  Of 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
  Among 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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00574847.
authors.affiliation: Department of Medicine, Duke University Medical Center, DUMC Box 3366, Durham, NC 27710, USA. jiang001@mc.duke.edu
authors.forename: Wei
authors.initials: W
authors.lastname: Jiang
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.forename: Maragatha
authors.initials: M
authors.lastname: Kuchibhatla
authors.forename: Zainab
authors.initials: Z
authors.lastname: Samad
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Boyle
authors.forename: Cynthia
authors.initials: C
authors.lastname: Kuhn
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Ortel
authors.forename: Redford B
authors.initials: RB
authors.lastname: Williams
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Rogers
authors.forename: Christopher
authors.initials: C
authors.lastname: O'Connor
mesh_terms: D000368:Aged; D015283:Citalopram / Q000627:therapeutic use*; D003327:Coronary Disease / Q000188:drug therapy* / Q000523:psychology*; D018450:Disease Progression; D004311:Double-Blind Method; D004562:Electrocardiography; D004644:Emotions; D015444:Exercise / Q000502:physiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000517:prevention & control* / Q000523:psychology*; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D013315:Stress, Psychological; D016277:Ventricular Function, Left
chemical_list: D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors