Background and objective <p>Patients with coronary heart disease (CHD) often have comorbid depression and anxiety, which worsen prognosis. Escitalopram, a selective serotonin reuptake inhibitor, is used for these symptoms, but evidence on its psychological and cardiovascular effects in CHD is limited. This systematic review and meta-analysis evaluated its effects on psychological symptoms and cardiovascular outcomes in CHD.</p> Methods <p>We systematically searched five databases for randomized controlled trials (RCTs) of escitalopram vs. control in adults with CHD. Data were extracted to avoid double counting; extended follow-up data were analyzed separately. Outcomes included depression/anxiety scale changes, major adverse cardiovascular events (MACE), all-cause mortality, myocardial infarction, and revascularization. Random-effects models and sensitivity analyses were used.</p> Results <p>Five RCTs were included. Overall depression score change was not significant (SMD = -0.70, 95% CI -1.57 to 0.18), but medium-term (12–24&#xa0;weeks) follow-up showed improvement (SMD = -0.39, 95% CI -0.58 to -0.20). Anxiety scores significantly decreased with escitalopram (SMD = -0.64, 95% CI -1.12 to -0.17). Pooled data from two studies were compatible with reductions in MACE (RR = 0.74, 95% CI 0.59 to 0.94) and myocardial infarction (RR = 0.53, 95% CI 0.29 to 0.96), however, approximately 90% of the pooled weight came from the post-treatment follow-up of a single trial, so these findings are hypothesis-generating. No statistically significant between-group differences were observed for all-cause mortality or revascularization.</p> Conclusion <p>Escitalopram appears effective for selected psychological symptoms in CHD without evidence of major cardiovascular harm; current evidence is insufficient to establish a cardiovascular benefit, and the observed MACE and myocardial infarction reductions are hypothesis-generating. Treatment should aim primarily to improve psychological well-being and quality of life.</p>