What should I do if I experience tachycardia and chest pain for 2 hours after taking an anxiety medication, such as a Selective Serotonin Reuptake Inhibitor (SSRI) or benzodiazepine?

Immediate Management of Heart Racing and Chest Pain After Anxiety Medication

Seek emergency medical evaluation immediately—do not wait for symptoms to resolve, as chest pain lasting 2 hours requires urgent assessment to exclude life-threatening cardiac conditions regardless of recent medication use. 1

Immediate Actions Required

Call emergency services (911/ambulance) or go to the nearest emergency department now. 1 The European Heart Journal guidelines are explicit that severe prolonged chest pain of acute onset requires immediate hospital care, as the differential diagnosis includes potentially fatal conditions including acute coronary syndrome, even in patients without known heart disease. 1

While Awaiting Emergency Care

• Take 250-500 mg of fast-acting (chewable or water-soluble) aspirin immediately unless you have a true aspirin allergy or bleeding disorder. 1
• Do not drive yourself—wait for ambulance arrival or have someone drive you. 1
• Remain calm and seated; anxiety itself can worsen tachycardia and chest pain. 1

Why Emergency Evaluation Is Critical

Your symptoms could represent either a cardiac emergency or a serious adverse drug reaction—both require immediate medical assessment. 1

Cardiac Causes That Must Be Excluded

• Acute coronary syndrome (heart attack or unstable angina) presents with chest pain and can occur even without prior heart disease, particularly when combined with sympathetic activation from anxiety or certain medications. 1
• The physical examination contributes almost nothing to diagnosing a heart attack, making ECG and cardiac biomarkers essential. 1
• Supraventricular tachycardia can mimic panic attacks and may be triggered or unmasked by certain medications. 2

Medication-Related Causes

If you took an SSRI (particularly citalopram or escitalopram):

• These medications can cause QT interval prolongation and potentially life-threatening arrhythmias including Torsade de Pointes, ventricular tachycardia, and sudden death. 1, 3, 4
• Citalopram and escitalopram have FDA warnings and dose restrictions specifically due to cardiac risks. 1, 4
• SSRIs have been associated with increased risk of cardiac arrest (odds ratio 1.21). 1

If you took a tricyclic antidepressant:

• TCAs carry even higher cardiac risk (odds ratio 1.69 for cardiac arrest) and can cause ventricular tachycardia, bundle branch blocks, and life-threatening arrhythmias even at therapeutic doses. 1, 5
• Five cases of ventricular tachycardia (one fatal) have been documented with thioridazine, and cardiac arrhythmias can occur in patients without pre-existing heart disease. 5

If you took a benzodiazepine:

• Benzodiazepines do not cause QT prolongation or cardiac arrhythmias in clinical use. 1, 4
• Your symptoms are less likely medication-related and more concerning for a primary cardiac event requiring immediate evaluation. 1

What to Expect in the Emergency Department

The emergency team will perform within 5-10 minutes: 1

• 12-lead ECG to assess for ST-segment changes, arrhythmias, and QT interval prolongation
• Cardiac biomarkers (troponin) to detect myocardial injury
• Vital signs monitoring including continuous cardiac monitoring
• Electrolyte panel (potassium, magnesium, calcium abnormalities can worsen drug-induced arrhythmias)

Expected Treatment Based on Findings

If acute coronary syndrome is identified:

• Aspirin, antiplatelet therapy, anticoagulation, and possible urgent cardiac catheterization. 1
• Morphine for pain relief and anxiety reduction (reduces sympathetic activation). 1
• Nitroglycerin and beta-blockers for ischemia management. 1

If drug-induced arrhythmia is identified:

• Discontinuation of the offending medication immediately. 5
• Intravenous lidocaine for ventricular arrhythmias. 5
• Possible electrical cardioversion or temporary pacing for life-threatening rhythms. 5
• Correction of electrolyte abnormalities. 1

If severe anxiety/panic attack is confirmed after cardiac causes excluded:

• Benzodiazepines (lorazepam) may be administered for symptom relief, as they do not cause cardiac complications. 1, 4
• However, this diagnosis can only be made after comprehensive cardiac evaluation. 1, 6

Critical Pitfalls to Avoid

Do not assume your symptoms are "just anxiety"—15% of chest pain patients have severe anxiety, but they still require the same cardiac evaluation as those without anxiety. 6 Cardiac risk factors and symptoms do not differ between anxious and non-anxious patients presenting with chest pain. 6

Do not wait to see if symptoms resolve—the benefit of early treatment for acute coronary syndrome is time-dependent, with 23 lives saved per 1000 patients per hour of earlier treatment. 1

Do not dismiss the possibility of supraventricular tachycardia masquerading as a panic attack—catheter ablation has cured patients previously diagnosed with panic disorders. 2

Follow-Up After Emergency Evaluation

If cardiac causes are excluded and medication-related adverse effects are suspected:

• Discontinue the offending medication and contact the prescribing physician immediately for alternative treatment. 5
• Consider switching to benzodiazepines for short-term anxiety management if cardiac disease or QT prolongation risk factors are present, as they have no cardiac effects. 4
• Avoid citalopram, escitalopram, and tricyclic antidepressants if you have any cardiac risk factors. 3, 4
• Obtain baseline and follow-up ECGs if restarting any psychotropic medication. 1, 4