Is Atarax (hydroxyzine) contraindicated in cardiac surgery patients?

Hydroxyzine (Atarax) Contraindications in Cardiac Surgery Patients

Hydroxyzine is contraindicated in cardiac surgery patients due to its QT-prolonging effects, which can increase the risk of potentially fatal arrhythmias like Torsade de Pointes.

Specific Contraindications

• The FDA label explicitly states that hydroxyzine is contraindicated in patients with a prolonged QT interval 1
• Cardiac surgery patients are at higher risk for QT prolongation due to:
  • Electrolyte disturbances common during surgery
  • Potential bradycardia during perioperative period
  • Concomitant use of other QT-prolonging medications

Evidence of Risk

A case report documented Torsade de Pointes occurring in an 82-year-old patient with complete atrioventricular block who received just a small dose (12.5 mg) of hydroxyzine during pacemaker implantation 2. This demonstrates the potential for serious cardiac complications even with low doses in vulnerable patients.

Cardiac Surgery Considerations

Cardiac surgery patients have several risk factors that make hydroxyzine particularly dangerous:

• Electrolyte abnormalities: Common during cardiac surgery and can potentiate QT prolongation
• Hemodynamic instability: May occur during perioperative period
• Bradycardia: Often present in cardiac surgery patients, increasing risk of QT-related arrhythmias
• Polypharmacy: Multiple medications that may interact with hydroxyzine or independently prolong QT interval

Alternative Medications

For patients requiring anxiolysis or sedation before cardiac surgery, safer alternatives include:

• Benzodiazepines: Midazolam has been shown to better inhibit sympathetic activation at anesthesia induction compared to hydroxyzine 3
• Alpha-2 agonists: May be considered for perioperative control of hypertension in patients with coronary artery disease 4

Management Algorithm

1. Preoperative assessment:

   • Screen for QT prolongation on baseline ECG
   • Identify medications that may prolong QT interval
   • Check electrolyte levels (especially potassium, magnesium, calcium)

2. If anxiolysis/sedation needed:

   • Use benzodiazepines (e.g., midazolam) instead of hydroxyzine
   • Consider beta blockers for patients with coronary heart disease if not contraindicated

3. Monitoring:

   • Continuous ECG monitoring for any patient with risk factors for QT prolongation
   • Regular assessment of electrolyte levels during perioperative period

Important Caveats

• Even a small dose of hydroxyzine (12.5 mg) has been documented to cause Torsade de Pointes in vulnerable patients 2
• The risk is particularly high in patients with bradycardia, which is common in cardiac surgery patients
• The contraindication applies to all forms of hydroxyzine administration (oral, intramuscular, or intravenous)

The evidence clearly demonstrates that the risks of using hydroxyzine in cardiac surgery patients outweigh any potential benefits, especially when safer alternatives are readily available.