Journal Article Annotations
2021, 1st Quarter

Cardiac Psychiatry

Annotations by Timothy Kong, MD
March, 2021

Pharmacotherapy in the Management of Anxiety and Pain During Acute Coronary Syndromes and the Risk of Developing Symptoms of Posttraumatic Stress Disorder

PUBLICATION #1 — Cardiac Psychiatry

Pharmacotherapy in the Management of Anxiety and Pain During Acute Coronary Syndromes and the Risk of Developing Symptoms of Posttraumatic Stress Disorder.

Roland von Känel, Jean-Paul Schmid, Rebecca E Meister-Langraf, Jürgen Barth, Hansjörg Znoj, Ulrich Schnyder, Mary Princip, Aju P Pazhenkottil.

Abstract: J Am Heart Assoc. 2021 Jan 19;10(2):e018762. doi: 10.1161/JAHA.120.018762. Epub 2021 Jan 12.

Background:
Benzodiazepines and morphine are given during acute coronary syndromes (ACSs) to alleviate anxiety and pain, and β-blockers may also reduce pain. ACS may induce posttraumatic stress disorder (PTSD) symptoms (PTSS). When taken during trauma other than ACS, benzodiazepines increase the risk of PTSS, but it is unknown if benzodiazepines increase the risk of PTSS in ACS. We examined the effects of drug exposure during ACS on the development of PTSS.

Methods and Results:
Study participants were 154 patients with a verified ACS. Baseline demographics, clinical variables, and psychological measures were obtained through a medical history, through a psychometric assessment, and from patient records, and used as covariates in linear regression analysis. Three months after ACS, the severity of PTSS was assessed with the Clinician-Administered PTSD Scale. During ACS, 37.7% of patients were exposed to benzodiazepines, whereas 72.1% were exposed to morphine and 88.3% were exposed to β-blockers, but only 7.1% were exposed to antidepressants. Eighteen (11.7%) patients developed clinical PTSD. Adjusting for all covariates, benzodiazepine use was significantly associated with the Clinician-Administered PTSD Scale total severity score (unstandardized coefficient B [SE], 0.589 [0.274]; partial r=0.18; P=0.032) and the reexperiencing subscore (B [SE], 0.433 [0.217]; partial r=0.17; P=0.047). Patients exposed to benzodiazepines had an almost 4-fold increased relative risk of developing clinical PTSD, adjusting for acute stress disorder symptoms (odds ratio, 3.75; 95% CI, 1.31-10.77). Morphine, β-blockers, and antidepressants showed no predictive value.

Conclusions:
Notwithstanding short-term antianxiety effects during ACS, benzodiazepine use might increase the risk of ACS-induced PTSS with clinical significance, thereby compromising patients’ quality of life and prognosis. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01781247.

Annotation

The finding:
This study examined the risk of developing posttraumatic stress disorder or symptoms after exposure to benzodiazepines, beta-blockers, or opioid medications in the setting of acute coronary syndrome. The authors followed up with patients 3 months after the acute event and found that patients who were exposed to benzodiazepines had higher rates of post-traumatic stress disorder/symptoms after controlling for other variables.

Strength and weaknesses:
The authors of the study had controlled multiple factors including depression history, and antidepressant use. However, they did not characterize baseline anxiety symptoms or disorders which may lead to post-traumatic stress symptoms/disorders later after a cardiac event and also associate with treatment decisions in the aftermath of a coronary event.

Relevance:
Use of benzodiazepines are occasionally utilized by psychiatrists in the setting of treatment of anxiety, especially in patients with cardiac conditions and potential complications, for example, with prolonged QTC. This relatively small study (n=154), should make psychiatrists reconsider the role of benzodiazepines in the treatment of anxiety in patients with acute coronary syndrome and more strongly consider alternative therapies.

Type of study:
(EBM guide): Cohort study