Initiating Escitalopram in Patients with Pre-existing Bradycardia

Key Safety Considerations

A heart rate of 50 bpm is considered minimally symptomatic bradycardia if the patient is not experiencing dizziness, syncope, chest pain, dyspnea, or fatigue, according to the American Heart Association, as published in Circulation 1
Asymptomatic bradycardia at 50 bpm does not require treatment or preclude starting escitalopram, but symptomatic bradycardia would require evaluation first, as recommended by the American Heart Association, as published in Circulation 1

The American Heart Association recommends avoiding the combination of escitalopram with beta-blockers, such as atenolol, metoprolol, and propranolol, as this can cause additive bradycardia, as published in Circulation 4
The American Heart Association also recommends avoiding the combination of escitalopram with calcium channel blockers, such as diltiazem and verapamil, as this can slow AV node conduction, as published in Circulation 4

The American Heart Association recommends discontinuing escitalopram immediately if the patient develops a heart rate below 40 bpm at rest, as published in Circulation 1
The American Heart Association also recommends discontinuing escitalopram immediately if the patient experiences dizziness, lightheadedness, or near-syncope episodes, as published in Circulation 1