Can Ativan (lorazepam) be used to treat anxiety in a patient with chest pain?

Use of Ativan (Lorazepam) for Anxiety in Patients with Chest Pain

Ativan (lorazepam) should not be the first-line treatment for anxiety in patients presenting with chest pain until cardiac causes have been ruled out, but may be considered after cardiac evaluation is complete and anxiety is determined to be the cause of symptoms.

Evaluation of Chest Pain: First Rule Out Cardiac Causes

When a patient presents with chest pain, the primary concern must be to rule out life-threatening cardiac conditions:

1. Initial cardiac evaluation is mandatory

   • All patients with chest pain require evaluation for cardiac causes before attributing symptoms to anxiety 1
   • A negative stress test, anatomic cardiac evaluation, or low-risk designation by a clinical decision pathway should be established first 1

2. Non-cardiac causes should be considered when:

   • Persistent or recurring symptoms despite negative cardiac workup
   • Low-risk designation by clinical decision pathway
   • Similar recurrent presentations with prior negative evaluations

Management of Anxiety-Related Chest Pain

After cardiac causes have been ruled out and anxiety is determined to be a likely cause:

Non-Pharmacological Approaches (First-Line)

• Cognitive-behavioral therapy is recommended for patients with recurrent chest pain presentations with no evidence of physiological cause (Class 2a, Level B-R recommendation) 1
  • CBT has been shown to reduce chest pain frequency by 32% over a 3-month period 2

Pharmacological Approaches (Including Lorazepam)

• Lorazepam (Ativan) is FDA-approved for anxiety disorders or short-term relief of anxiety symptoms 3

  • May be appropriate after cardiac causes have been ruled out
  • Should be used short-term only, as effectiveness beyond 4 months has not been assessed by systematic clinical studies 3

• Other benzodiazepines have shown some benefit:

  • Clonazepam has demonstrated modest improvement in panic disorder patients with recurrent chest pain and normal coronary arteries 4

Important Considerations and Cautions

• Misdiagnosis risk: Anxiety can mimic cardiac symptoms, but cardiac conditions can also present with anxiety-like symptoms 5

• Under-recognition of psychological factors: Patients with non-cardiac chest pain often undergo extensive and repetitive cardiac testing without appropriate psychological evaluation 1, 6

• Anxiety-cardiac relationship: Stress and anxiety may contribute to the development of myocardial infarction with non-obstructed coronary arteries (MINOCA) 5

• Prevalence: Approximately 8% of emergency department chest pain patients self-identify stress or anxiety as the cause of their symptoms 6

• Comorbidity: Generalized anxiety disorder is common in patients with chest pain and normal coronary arteries, with 48% of GAD patients reporting chest pain 7

Decision Algorithm for Using Lorazepam in Chest Pain

1. Complete cardiac evaluation first

   • Rule out acute coronary syndrome, pulmonary embolism, and other cardiac/pulmonary causes

2. If cardiac causes ruled out and anxiety symptoms are present:

   • Consider referral to cognitive-behavioral therapy (first-line approach)
   • Consider short-term lorazepam for acute anxiety symptoms
   • Monitor for response and side effects
   • Plan for limited duration of benzodiazepine use

3. Avoid lorazepam if:

   • Cardiac evaluation is incomplete or inconclusive
   • Patient has respiratory depression
   • History of substance abuse
   • Long-term use is anticipated

Remember that anxiety and cardiac conditions can coexist, and treating anxiety does not eliminate the need for appropriate cardiac evaluation and monitoring.