A 61-year-old attorney comes to the office with his wife for follow-up. Two months ago, the patient experienced an acute myocardial infarction while presenting a case in court and went into cardiac arrest. He was resuscitated in the emergency department, and a drug-eluting stent was placed. The patient recovered without complications and was discharged. He recently returned to work part-time, although his wife thinks he needs more time to rest. She states that he has been very stressed for the past month and worries that he is overworking. The patient has been sleeping restlessly and frequently wakes up startled and diaphoretic. While practicing a case presentation a few days ago, he had to stop and sit down because he felt overwhelmed. The patient plans to "take things slowly" and has asked his partner to cover upcoming court appearances. He has had no chest pain, palpitations, shortness of breath, or syncope. Medications include metoprolol, simvastatin, aspirin, and ticagrelor. Vital signs are within normal limits. Physical examination shows no abnormalities. ECG reveals no acute changes. Which of the following is the best next step in management of this patient?

Question

A 61-year-old attorney comes to the office with his wife for follow-up.  Two months ago, the patient experienced an acute myocardial infarction while presenting a case in court and went into cardiac arrest.  He was resuscitated in the emergency department, and a drug-eluting stent was placed.  The patient recovered without complications and was discharged.  He recently returned to work part-time, although his wife thinks he needs more time to rest.  She states that he has been very stressed for the past month and worries that he is overworking.  The patient has been sleeping restlessly and frequently wakes up startled and diaphoretic.  While practicing a case presentation a few days ago, he had to stop and sit down because he felt overwhelmed.  The patient plans to "take things slowly" and has asked his partner to cover upcoming court appearances.  He has had no chest pain, palpitations, shortness of breath, or syncope.  Medications include metoprolol, simvastatin, aspirin, and ticagrelor.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  ECG reveals no acute changes.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d776_d966_bc81_fd6af343b53e_MD0003_00 This patient's monthlong history of feeling stressed and overwhelmed, experiencing sleep disturbance with possible nightmares, and engaging in avoidance behavior following an acute myocardial infarction (MI) and cardiac arrest is suggestive of posttraumatic stress disorder (PTSD). Life-threatening medical events, such as acute MI, may be experienced as traumatic and result in PTSD in some patients. Symptoms include feelings of helplessness or horror in response to the cardiac event, reexperiencing of the event (eg, intrusive thoughts, nightmares, or flashbacks of the MI, cardiac arrest, or medical procedures), psychologic distress (eg, feeling overwhelmed) and physiologic reactivity when reminded of the event, and avoidance of activities or places related to the trauma (eg, this patient avoiding returning to the courtroom, where he had a cardiac arrest). The development of PTSD following acute MI is associated with increased risk of recurrence of cardiac events and mortality. Trauma-focused cognitive-behavioral therapy (CBT) is the preferred initial treatment for PTSD. CBT combines cognitive techniques to help correct maladaptive thoughts about the trauma and exposure-based techniques to target avoidance behaviors and help the patient process the trauma emotionally. Pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is an alternate option that is generally safe in patients with cardiovascular disease. (Choice A) The hypothetical association of beta blockers with depression has not been substantiated by rigorous studies, and there is no evidence that beta blockers exacerbate symptoms of PTSD. In addition, beta blockers provide known survival benefit following acute MI; therefore, discontinuing metoprolol is not indicated. (Choice B) SSRI and SNRI antidepressants are first-line pharmacotherapy for PTSD. Mirtazapine, a sedating antidepressant, may help with restless sleep, but it has not demonstrated efficacy in the treatment of PTSD. (Choice C) Echocardiography is commonly performed several months after acute MI to evaluate for a persistent reduction in left ventricular ejection fraction; however, this patient had no complications at the time of MI and has no new symptoms to suggest heart failure. (Choice D) Although this patient can be reassured that his cardiac condition is stable, it would be inappropriate to defer treatment of his PTSD, which causes significant distress and increases his risk for recurrent cardiovascular events. Educational objective: Life-threatening medical events may be experienced as traumatic and result in posttraumatic stress disorder. Trauma-focused cognitive-behavioral therapy is the preferred initial treatment. References: Post-traumatic stress disorder among cardiac patients: prevalence, risk factors, and considerations for assessment and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25545708) Post-traumatic stress disorder and cardiovascular disease. (http://www.ncbi.nlm.nih.gov/pubmed/27566327) Psychological mechanisms of effective cognitive-behavioral treatments for PTSD. (http://www.ncbi.nlm.nih.gov/pubmed/25749748)

A 61-Year-Old Attorney Comes to the Office with His Wife