Benzos may promote PTSD symptoms in ACS patients

Administering benzodiazepines during an acute coronary syndrome (ACS) may spell trouble for patients, with a recent study showing that despite rapidly relieving anxiety, the drug can also contribute to increased risk of post-traumatic stress disorder (PTSD) symptoms.

“Patients who received a benzodiazepine within hours of acute myocardial infarction (MI) had more severe PTSD symptoms 3 months later compared with patients not exposed to [the drug],” according to the investigators.

For individual PTSD symptom clusters, benzodiazepine use particularly led to re-experiencing aspects of MI, for instance in thoughts or dreams, they added.

The analysis included 154 patients (mean age, 58.7 years; 84.4 percent male) with a verified ACS, during which 37.7 percent of patients were given benzodiazepines, 72.1 percent received morphine, 88.3 percent took beta‐blockers, and 7.1 percent were exposed to antidepressants. There were 18 patients (11.7 percent) who developed PTSD.

In multivariable linear regression models, benzodiazepine use was significantly associated with the Clinician‐Administered PTSD Scale total severity score (p=0.032) and the re-experiencing subscore (p=0.047). [J Am Heart Assoc 2021;doi:10.1161/JAHA.120.018762]

Patients who received benzodiazepines were almost four times as likely as those who did not receive the drugs to develop clinically significant PTSD (odds ratio [OR], 3.75, 95 percent confidence interval [CI], 1.31–10.77). The effect was independent of demographic factors, clinical and psychosocial variables, and concomitant exposure to morphine, beta‐blockers, and antidepressants.

On the other hand, neither morphine (OR, 1.02, 95 percent CI, 0.34–3.09) nor antidepressant (OR, 3.39, 95 percent CI, 0.79–14.43) use conferred a risk increase.

The findings were consistent with those of a meta-analysis involving other patient populations. Specifically, benzodiazepines appeared to significantly increase the risk of incident PTSD when used after recent trauma. Nevertheless, the investigators pointed out that the short‐term antianxiety and pain‐alleviating effects of the drugs should not be discounted. [Crit Care Med 2015;43:1121-1129; J Psychiatr Pract 2015;21:281-303]

“In addition, benzodiazepines may have beneficial cardiovascular effects, directly or indirectly, via anxiety reduction; these include vasodilation, anti‐ischaemic and antiarrhythmic properties, platelet inhibition, and lowering of catecholamine levels,” they said. [J Emerg Med 2003;25:427-437] 

Acute anxiety during ACS occurs due to fear of dying and pain. These affect two out of three patients and are strongly associated with chest pain. As an alternative to benzodiazepine treatment, anxiety can be addressed by reassuring the patients and their significant others, according to the investigators. [Am J Cardiol 2005;96:1512-1516; Eur Heart J 2018;39:119-177]

“Unfortunately, this recommendation is often not sufficiently implemented in everyday clinical practice because of time constraints and lack of awareness. Moreover, in a previous study, nonpharmacological management of anxiety by clinicians [did little to reduce] anxiety levels in patients admitted with ACS, whereas pharmacological management [proved successful],” they acknowledged. [Heart Lung 2002;31:411-420]

That being said, the investigators recommended that clinicians prescribe benzodiazepines in the setting of an acute MI only with a clear indication, “knowing that infarction‐induced post-traumatic stress [compromises] quality of life and prognosis.”

Searching for effective and early behavioral in‐hospital interventions to prevent ACS‐induced PTSD symptoms is just as important, they added. “Targeted means, such as avoiding emergency department crowding, could also counteract potentially adverse effects of benzodiazepine use.” [JAMA Intern Med 2013;173:472-474]