What is the most appropriate next step in managing a 50-year-old woman with a 1-week history of anxiety, palpitations, and nausea, with a history of hypertension and diabetes, taking metoprolol (beta blocker) and metformin (biguanide), presenting with hypertension and a random glucose level within normal limits?

From the Guidelines

The most appropriate next step in the management of this patient is to obtain an ECG (option D). This 50-year-old woman presenting with palpitations, anxiety, and nausea requires cardiac evaluation before assuming her symptoms are purely psychiatric in nature. Her elevated blood pressure (168/72 mmHg) despite being on metoprolol is concerning, and palpitations could indicate an underlying cardiac arrhythmia or other cardiac condition. According to the 2020 international society of hypertension global hypertension practice guidelines 1, patients with hypertension should be evaluated for potential cardiac causes, especially if they are experiencing symptoms such as palpitations.

While her symptoms might suggest anxiety, it's essential to rule out cardiac causes first, especially given her age and history of hypertension and diabetes, which are risk factors for cardiovascular disease. Administering lorazepam or additional metoprolol without understanding the underlying cause could be inappropriate or potentially harmful. The 2007 guidelines for the management of arterial hypertension 1 also emphasize the importance of evaluating patients with hypertension for potential cardiac causes, and the 2004 British Hypertension Society guidelines 1 recommend that all patients with high blood pressure should be advised on lifestyle modifications and evaluated for potential cardiac causes.

Similarly, psychiatric consultation would be premature before excluding medical causes. Talking with the spouse separately wouldn't address the immediate clinical concern. An ECG is a quick, non-invasive test that can provide valuable information about cardiac rhythm, ischemia, or other abnormalities that might explain her symptoms. The guidelines for the diagnosis and treatment of chronic heart failure 1 also recommend evaluating patients with potential cardiac causes, especially if they are experiencing symptoms such as palpitations.

Some key points to consider in this patient's management include:

• Evaluating the patient for potential cardiac causes of her symptoms
• Considering the patient's history of hypertension and diabetes, which are risk factors for cardiovascular disease
• Avoiding administering medications such as lorazepam or additional metoprolol without understanding the underlying cause of the patient's symptoms
• Obtaining an ECG to evaluate the patient's cardiac rhythm and potential ischemia or other abnormalities.

From the Research

Patient Assessment

The patient is a 50-year-old woman with a 1-week history of anxiety, palpitations, and nausea. Her past medical history includes hypertension and diabetes, for which she takes metoprolol and metformin. Vital signs show a blood pressure of 168/72 mmHg and a heart rate of 72/min.

Management Options

The following options are considered for the management of this patient:

• Administer intramuscular lorazepam
• Administer oral metoprolol
• Obtain a psychiatric consultation
• Obtain an ECG
• Talk with the patient's spouse separately

Relevant Studies

Studies have investigated the effects of lorazepam on anxiety and cardiovascular parameters:

• A study from 1978 2 found that lorazepam significantly relieved symptoms of anxiety associated with hypertension.
• A study from 1994 3 found that lorazepam had a dose-dependent decrease in heart rate and an increase in low-frequency band power of heart rate.
• A study from 1996 4 found that lorazepam reduced cardiac vagal modulation in normal subjects.
• A study from 2021 5 found that oral administration of lorazepam as a hypnotic increased nocturnal heart rate and diastolic blood pressure in patients with mild hypertension.
• A study from 2025 6 found that heart rate-lowering drugs reduced coronary heart disease, heart failure, and cardiovascular mortality, but increased adverse event-driven discontinuations.

Next Steps

Based on the patient's symptoms and medical history, the most appropriate next step would be to:

• Obtain an ECG to rule out any cardiac abnormalities that may be contributing to the patient's symptoms, as the patient is experiencing palpitations and has a history of hypertension.
• Consider administering intramuscular lorazepam to help alleviate the patient's anxiety symptoms, as studies have shown that lorazepam can be effective in reducing anxiety associated with hypertension 2. However, the potential effects of lorazepam on cardiovascular parameters should be taken into account 3, 4, 5.
• The patient's heart rate is currently within a normal range, but the benefits of heart rate-lowering drugs in reducing cardiovascular outcomes should be considered in the context of the patient's overall medical history and current symptoms 6.