What is the management of a patient with myocardial infarction (MI) and an anxiety attack, considering the use of diazepam (generic name: diazepam)?

Management of Anxiety in Myocardial Infarction with Diazepam

Routine use of diazepam is not recommended for anxiety in myocardial infarction patients, as controlled trials demonstrate no advantage over placebo in reducing anxiety, blood pressure, heart rate, or ischemic chest discomfort. 1, 2

Primary Management Approach

Prioritize non-pharmacological interventions first:

• Provide psychological support and reassurance as the first-line intervention, which has been proven to decrease anxiety and depression both immediately and for up to 6 months post-MI 1, 2
• Ensure adequate pain control with titrated intravenous opioids (e.g., morphine), as pain relief often resolves anxiety without additional anxiolytics 1, 2
• Implement liberalized visiting rules for family members, which has demonstrated no harmful physiological effects and helps reduce patient anxiety 1

When Benzodiazepines May Be Considered

A mild tranquilizer (usually a benzodiazepine like diazepam) should be considered only in very anxious patients who remain severely distressed despite adequate reassurance and opioid analgesia (Class IIa recommendation, Level C evidence). 1, 2

Specific Clinical Scenarios for Use:

• Patients with severe, persistent anxiety that interferes with medical management after non-pharmacological measures have failed 1, 2
• Patients with agitation or delirium in the CCU setting, though intravenous haloperidol is preferred for agitation as it rarely produces hypotension 1
• Prior to cardioversion procedures for relief of anxiety and to diminish recall 3

Evidence Against Routine Use

The ACC/AHA guidelines explicitly cite a controlled trial by Dixon and colleagues demonstrating that anxiety, blood pressure, heart rate, and ischemic chest discomfort were no different in patients treated with diazepam compared with placebo 1, 2. This is the strongest evidence against routine pharmacological anxiolysis in MI patients.

Potential Benefits in Selected Cases

While routine use is not recommended, research suggests diazepam may have some beneficial effects in specific contexts:

• Reduced catecholamine excretion and potentially lower stress reactions, which may theoretically reduce malignant arrhythmias 4
• Decreased left ventricular end-diastolic pressure in patients with elevated filling pressures, possibly through afterload reduction 5
• Antiischemic effects through reduction in myocardial oxygen consumption 6

However, these research findings have not translated into guideline recommendations for routine use, as the clinical trial evidence shows no meaningful benefit 1, 2.

Critical Pitfalls to Avoid

• Do not routinely prescribe benzodiazepines as standard protocol for all MI patients 1, 2
• Avoid benzodiazepines when pro-arrhythmic risk is high, as sedatives carry arrhythmia concerns in the immediate post-MI period 2
• Ensure proper understanding of pharmacokinetics and pharmacodynamic properties before prescribing anxiolytics in cardiac patients 1
• Do not use benzodiazepines as a substitute for adequate pain control—address pain with opioids first 1, 2

Practical Algorithm

1. First: Provide reassurance and psychological support 1, 2
2. Second: Ensure adequate analgesia with titrated IV opioids 1, 2
3. Third: Facilitate family visitation and emotional support 1
4. Only if severe anxiety persists: Consider a mild benzodiazepine in selected patients 1, 2

The most recent and highest quality evidence (2017 ESC Guidelines) supports benzodiazepine use only as a Class IIa recommendation ("should be considered") in very anxious patients, not as routine therapy. 1