Wolff-Parkinson-White (WPW) syndrome is a congenital disorder characterised by a macro-reentrant arrhythmia caused by preexcitation of the ventricles. A significant proportion of cases are detected incidentally in asymptomatic patients during routine checkups. Because little is known about the use of selective serotonin reuptake inhibitors in youths with preexisting cardiac disease, we report here a 15-year-old adolescent with asymptomatic WPW syndrome and severe depressive symptoms. An improvement in depressive symptoms was observed with sertraline therapy and the absence of cardiac adverse effects after 5 months of treatment suggested that sertraline could be used at therapeutic doses in adolescents with preexisting but asymptomatic WPW syndrome

Chen, Fei

D'Andrea, Géraldine

Eap Chin, B.

Grandjean, Christophe

Richard, Sandra

Serveur académique lausannois

CASE REPORT 94Accidentally detected asymptomatic Wolff-Parkinson-White syndromeWolff-Parkinson-White syndrome in an adolescent with depressionFei Chena, Sandra Richarda, Géraldine d’Andreaa, Christophe Grandjeana, Chin B. Eapb,ca  Service de psychiatrie pour enfants et adolescents (SPEA), Secteur psychiatrique nord (SPN), Département de psychiatrie, Centre hospitalier universitaire vaudois (CHUV), Yverdon-les-Bains, Switzerlandb  Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerlandc  School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, SwitzerlandIntroductionDepression is reported to affect 6% of adolescents aged from 13 to 18 years [1] with high suicidality,  recurrence and chronicity [2, 3]. In adolescents with moderate to severe depression, pharmacological treatment in com-bination with a psychological therapy is often indi-cated [4]. As a result of lack of clinical trials in  children and adolescents, the off-label use of anti depressant drugs is widespread (about 49% of all antidepressant drugs prescribed) in this population [5]. Among these off-label prescriptions, the use of the  selective seroto-nin reuptake inhibitors (SSRIs) is becoming preferred because of their safer cardiac  profiles compared with older medications such as tricyclic antidepressants.Wolff-Parkinson-White (WPW) syndrome is a macro-reentrant arrhythmia with an estimated prevalence of 2–4 per 1000. A significant proportion of cases are found incidentally in asymptomatic patients present-ing for routine checkups [6]. Conduction through an accessory pathway may cause preexcitation of the ven-tricles leading to supraventricular  tachycardia, atrial SummaryWolff-Parkinson-White (WPW) syndrome is a congenital disorder charac-terised by a macro-reentrant arrhythmia caused by preexcitation of the ventricles. A significant proportion of cases are detected incidentally in asymp tomatic patients during routine checkups. Because little is known about the use of selective serotonin reuptake inhibitors in youths with  preexisting cardiac disease, we report here a 15-year-old adolescent with asymptomatic WPW syndrome and severe depressive symptoms. An im-provement in depressive symptoms was  observed with sertraline therapy and the absence of cardiac adverse effects after 5 months of treatment suggested that sertraline could be used at therapeutic doses in adoles-cents with preexisting but asymptomatic WPW  syndrome.Key words: adolescent; depression; Wolff-Parkinson-White syndrome; sertralinefibrillation, ventricular fibrillation and even cardiac  arrest [6].In adolescents with preexisting cardiac disease,  depression and anxiety are commonly reported [7].  SSRIs are generally recommended as first-line psycho-tropic agents for depressed patients with heart failure [8] and improvement in depression was reported to be asso ciated with improved adherence to cardiovascular drug therapy in adults [9]. However, little is known about the use of SSRIs in youths with preexisting  cardiac disease, in particular, no cases have been pub-lished on the use of SSRIs in adolescents with WPW syndrome. Case reportWe report here the case of a 15-year-old girl who was admitted to our outpatient consultation for a severe depressive episode without psychotic symptoms (F32.2, ICD-10). She had a depressed mood from more than 1 year together with disturbed sleep, loss of energy and of body weight, diminished ability to con centrate and a feeling of worthlessness. Recurrent thoughts of death were present. She scored six on the Clinical Global  Impression-Severity (CGI-S) scale, which classified her as “severely ill”. As past medical history, she was born prematurely and had been diagnosed with infantile  pyloric stenosis, which is rare in preterm infants  according to the literature [10, 11]. She was treated med-ically at birth during a prolonged hospitalisation of 3 weeks, but no additional information about her  initial treatment could be obtained. She later had sev-eral standard electrocardiogram (ECG) recordings with normal results, according to the family. As she had no known history of substance use and cardiac disease, cardiac  arrest or related risk-factor, antidepressant treatment with sertraline was prescribed. The daily dose was increased gradually every six days from the  initial dose of 25 mg to 50 mg, and then to the mainte-nance dose of 100 mg. The combination of psychologi-SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY 2016;167(3):94–96CASE REPORT 95cal and pharmacological treatment resulted in a signif-icant improvement from baseline in depressive symptoms. Her suicidal thoughts almost disappeared. After 3 months of treatment, she scored four on the CGI-S scale (“moderately ill”) and two on the Clinical Global Impression-Improvement (CGI-I) scale (“much improved”). Six months after starting sertraline, she underwent an endoscopic examination in order to investigate some recurrent gastric symptoms. The endoscopy  revealed no anomalies; however, asymptomatic WPW syndrome was found incidentally on ECG monitoring during the examination. She was  referred to a cardiol-ogist for a further cardiovascular investigation. Holter monitoring revealed sinus rhythm with no QTc prolon-gation, and a mean heart rate of 76 per minute but with a range from 42 to 167 leading to variable prolongation of the QRS complex, suggesting a left lateral accessory pathway. A few isolated supra ventricular and ventricu-lar arrhythmias were observed. Such isolated paroxys-mal arrhythmias did not allow measurement of the more specific anterograde characteristics of the acces-sory pathway (in order to  assess its clinical gravity) with noninvasive evaluation (for example, the shortest preexcited R-R  interval on the ECG [SPERRI]). Echo-cardiography was normal.  Electrophysiology studies were scheduled to investigate further the accessory pathway (with a subsequent radio frequency catheter ablation, if necessary). She received flecainide (100 mg/day) as an antiar rhythmic treatment. Her residual depressive symptoms did not appear more important with the newly diagnosed cardiac dis-ease. She ruminated a great deal on a theory of fatal-ism, without any intentional suicidal thought or plan. She became sometimes more anxious, showing in-tense emotional outbursts. The antidepressant treat-ment with sertraline was estimated by the cardiologist as unlikely to be a cause for the development and evo-lution of the asymptomatic WPW syndrome found in this patient. In addition, to our knowledge, WPW syn-drome is considered to be a congenital condition and no cases of WPW syndrome induced by an SSRI are de-scribed in the literature. Considering her residual  depressive symptoms and anxiety symptoms related to the newly diagnosed WPW syndrome, we proposed her to continue her psychological therapy and pharma-cological treatment with sertraline (100 mg/day).DiscussionIn this case report, our patient was an adolescent girl presenting severe depressive symptoms before being diagnosed incidentally with WPW syndrome, a macro-reentrant arrhythmia disorder with an estimated prevalence of 2–4 per 1000. A significant proportion of patients with asymptomatic WPW syndrome are found incidentally when presenting for routine checkups [6]. Population studies yielded variable but very low inci-dences of sudden death [12]. Various recommendations on the management of asymptomatic young patients with WPW syndrome have been published [12].The question arises on the choice of antidepressant treatment when psychological treatment alone is not adequate. In the USA, fluoxetine and escitalopram are approved by the Food and Drug Administration (FDA) for treatment of depression in paediatric patients (starting from 8 years and 12 years, respectively). In Switzerland, none of the SSRIs has been approved by Swiss Agency for Therapeutic Products (Swissmedic) for use in children and adolescents with depression. Fluvoxamine was approved by Swissmedic for use in children 8 years and older and sertraline in children 6 years and older, but only for the treatment of obses-sive-compulsive disorders. For this reason, but also  because of a  favourable cardiac safety profile, sertra-line appears to be often used for the treatment of ado-lescent depression in Switzerland (off-label). Of note, although the  SSRIs are considered to have generally safe cardiac  profiles, SSRI-related QTc prolongation and/or “torsades de pointes” have been reported [13, 14]. However, a recent meta-analysis [14] concluded that QTc pro longation produced by SSRIs (other than citalo-pram) seemed to be relatively small and was consid-ered to be clinically insignificant for most patients. Sertraline, compared with other SSRI antidepressants, has been found to be safe for use in adult patients with preexisting cardiac disease [15, 16] and no torsades de pointes has been reported to be associated with single use of  sertraline [13]. In children and adolescents, the absence of cardiovascular adverse effects has been  reported for sertraline use at doses up to 200 mg [17]. It has been recommended that a baseline ECG is per-formed when the patient has a suspicious medical  history or related risk factors for arrhythmia, or when the medication to be prescribed is documented to cause prolongation of the QTc interval at therapeutic doses [13]. Although careful risk-benefit analysis is  always necessary when antidepressant treatment is proposed, in particular in infants and adolescents [9, 15], an ECG check is not considered necessary be-fore prescribing sertraline in the absence of a known history of cardiac disease or related risk factors [13]. In addition, persistent depression increases mortality in patients with cardiac disease and improvement in depression was reported to be associated with  improved adherence to cardiovascular drug therapy SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY 2016;167(3):94–96CASE REPORT 96[9]. The improvement in depressive symptoms and  absence of cardiac adverse effects in our adolescent pa-tient after 5 months of antidepressant treatment with sertraline suggests the cardiac safety of sertraline at therapeutic doses in adolescents with preexisting but asymptomatic cardiac disease such as WPW syndrome. This is in accordance with early reports in adults with  preexisting heart disease [15, 16]. However, because of this single case, it is important to  emphasise necessary caution, in particular when combining psychotropic treatments, which could lead to severe cardiac events as demonstrated recently with sertraline plus mirta-zapine [18], although single use of mirtazapine has been  reported to be efficient in treating depression in an  adolescent with preexisting cardiomyopathy and  arrhythmia [8].    Disclosure statementCBE received research support from Takeda and The Roche Trans-plantation Research Foundation in the past 3 years. CBE received  honoraria for conferences or teaching CME courses from Advisis,  Astra Zeneca, Lundbeck, MSD, Otsuka; Sandoz, Servier and Vifor-Pharma in the past 3 years. CG received honoraria for conferences about ADHD from Eli Lilly in the past 4 years. All authors declare  no conflict of interest in relation to the content of the paper.References 1 Costello EJ, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatr. 2006;47:1263–71.  2 Dunn V, Goodyer IM. Longitudinal investigation into childhood- and adolescent-onset depression: psychiatric outcome in early adulthood. Br J Psychiatry. 2006;188:216–22.  3 Fombonne E, Wostear G, Cooper V, Harrington R, Rutter M.  The Maudsley long-term follow-up of child and adolescent  depression. 1. Psychiatric outcomes in adulthood. Br J Psychiatry. 2001;179:210–7.  4 Hopkins K, Crosland P, Elliott N, Bewley S; Clinical Guidelines  Update Committee B. Diagnosis and management of depression in  children and young people: summary of updated NICE guidance. BMJ. 2015;350:h824. 5 Dörks M, Langner I, Dittmann U, Timmer A, Garbe E. Antidepres-sant drug use and off-label prescribing in children and adolescents in Germany: results from a large  population-based cohort study. Eur Child Adolesc Psychiatry. 2013;22:511–8. 6 Liu A, Pusalkar P. Asymptomatic Wolff-Parkinson-White  syndrome: incidental ECG diagnosis and a review of literature  regarding current treatment. BMJ Case Reports. 2011; doi:10.1136/bcr.05.2011.4192. 7 Wang Q, Hay M, Clarke D, Menahem S. The prevalence and predic-tors of anxiety and  depression in adolescents with heart disease. J Pediatr. 2012;161:943–6.  8 Tanidir C, Tanidir IC, Tuzcu V. Treatment of depression in an  adolescent with cardiomyopathy and arrhythmia. Cardiology in the Young, in press. 9 Glassman AH, Bigger JT Jr, Gaffney M. Psychiatric characteristics associated with long-term mortality among 361 patients having  an acute coronary syndrome and major depression: seven-year follow-up of SADHART participants. Arch Gen Psychiatry. 2009;66(9):1022–9.10 Georgoula C, Gardiner M. Pyloric stenosis a 100 years after  Ramstedt. Arch Dis Child. 2012;97:741–5.11 Cascio S, Steven M, Livingstone H, Young D, Carachi R.  Hypertrophic pyloric stenosis in premature infants: evaluation  of sonographic criteria and short-term outcomes. Pediatr Surg Int. 2013;29:697–702.12 Cohen MI, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff- Parkinson-White (WPW, ventricular preexcitation) electrocardio-graphic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012; 9(6):1006–24.13 McNally P, McNicholas F, Oslizlok P. The QT interval and psycho-tropic medications in children: recommendations for clinicians. Eur Child Adolesc Psychiatry. 2007; 16(1):33–47.14 Beach SR, Kostis WJ, Celano CM, Januzzi JL, Ruskin JN, Noseworthy PA, Huffman JC. Meta-analysis of selective serotonin reuptake  inhibitor-associated QTc prolongation. J Clin Psychiatry. 2014; 75(5):e441–9.15 Jiang W, O’Connor C, Silva SG, Kuchibhatla M, Cuffe MS, Callwood DD, et al. SADHART-CHF Investigators. Safety and efficacy of  sertraline for  depression in patients with CHF (SADHART-CHF):  a randomized, double-blind, placebo-controlled trial of  sertraline for major  depression with congestive heart failure. Am Heart J. 2008;156(3):437–44.16 Glassman AH, O’Connor CM, Califf RM, Swedberg K, Schwartz P, Bigger JT Jr, et al. Sertraline Antidepressant Heart Attack  Randomized Trial (SADHEART) Group. Sertraline treatment of  major depression in patients with acute MI or unstable angina. JAMA. 2002;14-288(6):701–9.17 Wilens TE, Biederman, J, March JS, Wolkow R, Fine CS, Millstein RB, et al. Absence of cardiovascular adverse effects of sertraline in children adolescents. J Am Acad Child Adolesc Psychiatry. 1999;38(5):573–7.18 Atmaca M, Mermi O. A case of ventricular tachycardia and  cardiac arrest associated with sertraline and mirtazapine combination. Iranian J Psychiatry. 2014;9(1):45–6.Correspondence: Fei Chen, Ph.D., BMed Service de psychiatrie  pour enfants et adolescents (SPEA),  Secteur psychiatrique nord, Département de psychiatrie, CHUV Rue du Valentin 12 CH-1400 Yverdon-les-Bains fei.chen[at]chuv.chSWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY 2016;167(3):94–96

Wolff-Parkinson-White syndrome in an adolescent with depression

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Wolff-Parkinson-White syndrome in an adolescent with depression

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