Tricyclic antidepressants, particularly amitriptyline, can worsen existing heart‑conduction defects by further slowing impulse propagation, increasing the risk of bradyarrhythmias, heart block, and sudden cardiac death.
Amitriptyline’s sodium‑channel blockade can precipitate high‑grade heart block.
Baseline and follow‑up ECGs are mandatory.
Use alternative antidepressants (e.g., SSRIs) in patients with significant conduction disease.
Immediate discontinuation and cardiac evaluation if new arrhythmia or syncope occurs.
Amitriptyline blocks fast sodium channels in myocardial tissue, prolonging the QRS interval. In patients with baseline conduction delay, this additive sodium‑channel blockade can precipitate higher‑grade atrioventricular block or ventricular arrhythmias. Additionally, anticholinergic effects may exacerbate sinus node dysfunction.
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