What is the management approach for a patient with a history of chronic alcoholism (alcohol use disorder) experiencing withdrawal, who develops catatonia and myocardial infarction (heart attack)?

From the Guidelines

A chronic alcoholic in withdrawal who develops catatonia and myocardial infarction requires immediate comprehensive management, prioritizing benzodiazepines for alcohol withdrawal and catatonia, alongside cardiac stabilization with aspirin, dual antiplatelet therapy, oxygen, nitrates, and urgent cardiac catheterization. The management approach should be guided by the most recent and highest quality evidence, focusing on reducing morbidity, mortality, and improving quality of life.

Management of Alcohol Withdrawal and Catatonia

For the alcohol withdrawal and catatonia, benzodiazepines, such as lorazepam 1-2mg IV every 2-4 hours as needed, are recommended 1. This is based on the strong agreement (G1+/STRONG AGREEMENT) for symptomatic alcohol withdrawal treatment with benzodiazepines until symptoms disappear. Monitoring using the CIWA-Ar scale is crucial to guide benzodiazepine dosing. Additionally, thiamine 500mg IV three times daily, folate 1mg daily, and multivitamins should be administered to prevent Wernicke's encephalopathy.

Management of Myocardial Infarction

For the myocardial infarction, aspirin 325mg should be chewed immediately, followed by dual antiplatelet therapy (aspirin 81mg daily plus clopidogrel 75mg daily or ticagrelor 90mg twice daily). Oxygen should be administered if saturation is below 94%, nitrates provided for chest pain, and urgent cardiac catheterization arranged. This approach is supported by guidelines for the management of acute coronary syndromes without persistent ST-segment elevation, which recommend initial medical treatment including aspirin, clopidogrel, and nitrates, alongside risk stratification and further treatment strategies based on clinical, electrocardiographical, and biochemical data 1.

Comprehensive Approach

The comprehensive management approach should address both the cardiac emergency and the neuropsychiatric complications of alcohol withdrawal. Benzodiazepines reduce autonomic hyperactivity that could worsen cardiac stress while simultaneously treating the catatonic symptoms. Maintaining fluid and electrolyte balance, particularly monitoring magnesium, potassium, and phosphate levels, is also crucial. If catatonia persists despite benzodiazepines, electroconvulsive therapy should be considered.

This management strategy prioritizes the reduction of morbidity, mortality, and improvement of quality of life, based on the most recent and highest quality evidence available, specifically from the study by Louvet et al. in 2022 1, which provides strong recommendations for the management of alcohol withdrawal and related complications.

From the Research

Management Approach for Alcohol Withdrawal with Catatonia and Myocardial Infarction

• The management of a patient with a history of chronic alcoholism experiencing withdrawal, who develops catatonia and myocardial infarction, requires a comprehensive approach that addresses both the alcohol withdrawal and the cardiac condition 2, 3.
• Benzodiazepines, such as lorazepam, are commonly used to manage alcohol withdrawal syndrome, and may be effective in reducing the risk of complications, including delirium tremens and seizures 3, 4.
• In patients with severe alcohol withdrawal, a symptom-triggered approach with benzodiazepines may be preferred, and adjunctive pharmacotherapy, such as phenobarbital, may be considered in certain cases 5, 4.
• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scoring system can be used to assess the severity of alcohol withdrawal symptoms and guide treatment decisions 4, 6.
• In patients with myocardial infarction, it is essential to monitor for potential complications, such as reinfarction, and to manage the cardiac condition accordingly 2.
• Catatonia, a rare but potentially life-threatening condition, requires prompt recognition and treatment, and may be managed with benzodiazepines, such as lorazepam, or other medications, such as electroconvulsive therapy (ECT) in severe cases 3.

Treatment Considerations

• The choice of treatment for alcohol withdrawal syndrome should be individualized, taking into account the patient's medical history, the severity of withdrawal symptoms, and the presence of any comorbid conditions 3, 4.
• Phenobarbital may be a reasonable alternative to lorazepam in the management of alcohol withdrawal syndrome, particularly in patients with severe withdrawal symptoms or those who are resistant to benzodiazepines 5.
• The use of anticonvulsants, beta-blockers, and antihypertensives may also be considered in the management of alcohol withdrawal syndrome, particularly in patients with a history of seizures or cardiovascular disease 4.