Benzodiazepines Given For Acs Anxiety, Pain May Trigger Posttraumatic Stress Symptoms

In patients with acute coronary syndrome (ACS), use of benzodiazepines to manage stress and anxiety is associated with an increased risk of posttraumatic stress symptoms (PTSS), researchers say.

"The study was prompted by literature showing that patients who experienced a potentially traumatic event such as an accident or those who survived a critical illness, which required a stay on the intensive care unit, developed PTSS when they had received benzodiazepines at or around the time of the trauma or on the ICU," Dr. Roland von Kanel of University Hospital Zurich, Switzerland told Reuters Health by email.

"As patients often receive benzodiazepines when referred to the hospital with a heart attack (often perceived traumatic by patients)," he said, "we wondered whether benzodiazepines would also be associated with an increased risk of developing PTSS after a heart attack."

As reported in the Journal of the American Heart Association, the team analyzed data from a previously terminated trial (NCT01781247) of a behavioral intervention to prevent ACS-induced PTSS.

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Study participants were 154 ACS patients (mean age, about 56; about 87% men) with stable circulation and high peri-traumatic distress, defined by numeric rating scores (range, 0-10) of five or more for pain plus five or more for fear of dying and/or helplessness during ACS.

Three months after ACS, PTSS severity was assessed with the Clinician-Administered PTSD Scale.

During ACS, 37.7% of patients were given benzodiazepines; 72.1%, morphine; 88.3% beta-blockers; and 7.1%, antidepressants.

Eighteen (11.7%) developed clinical PTSD. Adjusting for all covariates, benzodiazepine use was significantly associated with the Clinician-Administered PTSD Scale total severity score and the re-experiencing subscore.

Patients taking benzodiazepines had an almost four-fold increased relative risk of developing clinical PTSD, adjusting for acute stress disorder symptoms (odds ratio, 3.75). Use of morphine, beta-blockers, and antidepressants showed no predictive value.

The authors conclude, "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."

Dr. von Kanel said, "As this was not a randomized controlled trial with a classic double-blind design, the potentially adverse effects of a benzodiazepine versus placebo in the development of PTSS in the aftermath of a heart attack cannot be proven."

Therefore, he added, it would be "premature" to issue guidelines stating that benzodiazepines should not be prescribed in that setting.

Dr. Ian Kronish, co-director of the ColumbiaDoctors Hypertension Center in New York City, commented in an email to Reuters Health, "This was a relatively small sample with a low number of patients with PTSS, which can lead to imprecise estimates of the association between benzodiazepine use and risk for subsequent PTSS."

"Also, the study may have not fully controlled for selection factors that led those prescribed benzodiazepines to be at higher risk of PTSD," he noted. "That said, they did include some measures of acute anxiety and fear. And even after controlling for these factors, benzodiazepine use still appeared to be a risk factor. So while it is not a slam dunk, it is suggestive of caution."

"Given that these data fit a pattern seen with benzodiazepines prescribed after other types of traumatic events, and given that there are often alternatives to benzodiazepines for helping anxious patients, the study should lead physicians to try to avoid prescribing benzodiazepines if possible," he said.

"There are often other ways to reduce anxiety in patients - most notably, taking the time to communicate with patients, to explain what is going on with their body, and what next steps to expect," he added. "There is also a need for research into behavioral interventions to reduce anxiety in the setting of acute medical events like ACSs or trauma."

—Marilynn Larkin

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