Is it safe to administer Ativan (lorazepam) to a patient with hypertension and tachycardia?

Can You Give Ativan with Increased Blood Pressure and Pulse?

Yes, Ativan (lorazepam) can be safely administered to patients with hypertension and tachycardia, and is actually recommended as first-line therapy in specific clinical contexts where sympathetic overactivity is driving the elevated vital signs.

Primary Indication: Sympathomimetic Intoxication

Benzodiazepines alone or in combination with nitroglycerin are reasonable for management of hypertension and tachycardia in patients with signs of acute cocaine or methamphetamine intoxication 1. In these situations:

• Benzodiazepines address both the central and peripheral manifestations of acute intoxication 1
• They should be initiated first before any other antihypertensive therapy 1
• Beta-blockers are contraindicated in acute cocaine/methamphetamine intoxication due to risk of unopposed alpha-stimulation and worsening coronary vasospasm 1

Cardiovascular Effects in Hypertensive Patients

Lorazepam has demonstrated favorable effects on blood pressure in hypertensive patients:

• A 2023 meta-analysis found benzodiazepines comparable to standard antihypertensive drugs in reducing both systolic and diastolic blood pressure 2
• In a controlled study of 62 hypertensive patients with anxiety, lorazepam significantly relieved anxiety symptoms without adverse cardiovascular effects, with most patients controlled on 3 mg/day 3
• However, a 2021 study showed lorazepam 1 mg at bedtime caused a slight increase (+3.7%) in nocturnal diastolic BP in mild hypertensives, though 24-hour and daytime BP remained unchanged 4

Acute Coronary Syndromes Context

In patients with acute coronary syndromes presenting with hypertension and tachycardia:

• Initial management includes morphine sulfate for pain and sedation if necessary 1
• Benzodiazepines are appropriate for managing anxiety-driven sympathetic activation 1
• They do not interfere with standard ACS therapies including beta-blockers (when not contraindicated) 1

Clinical Algorithm for Administration

When hypertension and tachycardia are present:

1. Identify the underlying cause - Is this sympathomimetic intoxication, anxiety-driven, or part of an acute medical emergency? 1

2. For suspected cocaine/methamphetamine intoxication with signs of acute intoxication (euphoria, tachycardia, hypertension):

   • Administer benzodiazepines as first-line therapy 1
   • Add nitroglycerin if needed for additional BP control 1
   • Avoid beta-blockers entirely 1

3. For anxiety-associated hypertension:

   • Lorazepam 2-3 mg/day in divided doses is effective and safe 3
   • Monitor for mild, transient side effects 3

4. For acute coronary syndromes:

   • Use sedation (including benzodiazepines) as adjunctive therapy 1
   • Prioritize definitive ACS management with appropriate antihypertensives 1

Important Caveats and Monitoring

Respiratory depression risk:

• Lorazepam can cause sleepiness, dizziness, and slow thinking/motor skills 5
• Use caution in patients with lung disease, breathing problems (COPD, sleep apnea), or when combined with other CNS depressants 5
• When combined with alcohol or other sedating drugs, lorazepam may significantly worsen sleepiness and dizziness 5

Dosing considerations:

• Standard anxiolytic dosing: 2-3 mg/day in divided doses 5, 3
• For elderly or debilitated patients: start with 1-2 mg/day in divided doses 5
• The evening dose should be increased before daytime doses when higher dosing is needed 5

Hypotension risk:

• While lorazepam can lower BP, this is generally mild and clinically beneficial in hypertensive patients 2
• Monitor orthostatic vital signs, particularly in elderly patients or those on multiple medications 6, 7

Contraindications to avoid:

• Do not use in patients with acute narrow-angle glaucoma 5
• Avoid in patients with known benzodiazepine allergy 5
• Use extreme caution with concurrent opioids due to respiratory depression risk 5

Bottom Line

Lorazepam is safe and often beneficial in patients with elevated BP and pulse, particularly when sympathetic overactivity or anxiety is contributing to the vital sign abnormalities. The key is identifying the underlying cause and using benzodiazepines as part of a rational treatment strategy rather than as monotherapy for essential hypertension.