Comparative Cardiac Safety of Selective Serotonin Reuptake Inhibitors among Individuals Receiving Maintenance Hemodialysis

J Am Soc Nephrol. 2019 Apr;30(4):611-623. doi: 10.1681/ASN.2018101032. Epub 2019 Mar 18.


Background: Individuals receiving maintenance hemodialysis may be particularly susceptible to the lethal cardiac consequences of drug-induced QT prolongation because they have a substantial cardiovascular disease burden and high level of polypharmacy, as well as recurrent exposure to electrolyte shifts during dialysis. Electrophysiologic data indicate that among the selective serotonin reuptake inhibitors (SSRIs), citalopram and escitalopram prolong the QT interval to the greatest extent. However, the relative cardiac safety of SSRIs in the hemodialysis population is unknown.

Methods: In this retrospective cohort study, we used data from a cohort of Medicare beneficiaries receiving hemodialysis included in the US Renal Data System registry (2007-2014). We used a new-user design to compare the 1-year risk of sudden cardiac death among hemodialysis patients initiating SSRIs with a higher potential for prolonging the QT interval (citalopram, escitalopram) versus the risk among those initiating SSRIs with lower QT-prolonging potential (fluoxetine, fluvoxamine, paroxetine, sertraline). We estimated adjusted hazard ratios using inverse probability of treatment weighted survival models. Nonsudden cardiac death was treated as a competing event.

Results: The study included 30,932 (47.1%) hemodialysis patients who initiated SSRIs with higher QT-prolonging potential and 34,722 (52.9%) who initiated SSRIs with lower QT-prolonging potential. Initiation of an SSRI with higher versus lower QT-prolonging potential was associated with higher risk of sudden cardiac death (adjusted hazard ratio, 1.18; 95% confidence interval, 1.05 to 1.31). This association was more pronounced among elderly individuals, females, patients with conduction disorders, and those treated with other non-SSRI QT-prolonging medications.

Conclusions: The heterogeneous QT-prolonging potential of SSRIs may differentially affect cardiac outcomes in the hemodialysis population.

Keywords: SSRIs; Safety; Sudden cardiac death; hemodialysis.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Cardiac Conduction System Disease / epidemiology
  • Citalopram / adverse effects*
  • Death, Sudden, Cardiac / epidemiology*
  • Depression / drug therapy
  • Electrocardiography
  • Female
  • Fluoxetine / adverse effects
  • Fluvoxamine / adverse effects
  • Humans
  • Kidney Failure, Chronic / therapy*
  • Male
  • Middle Aged
  • Peroxidase / adverse effects
  • Registries
  • Renal Dialysis
  • Retrospective Studies
  • Risk Factors
  • Selective Serotonin Reuptake Inhibitors / adverse effects*
  • Sertraline / adverse effects
  • Sex Factors
  • United States / epidemiology


  • Serotonin Uptake Inhibitors
  • Fluoxetine
  • Citalopram
  • Peroxidase
  • Fluvoxamine
  • Sertraline