What is the best course of action for a 64-year-old male with a history of heart failure, presenting with a sensation of throat closure, chest tightness, and a globus sensation, who has not responded to Ativan (lorazepam)?

Immediate Cardiac Evaluation and Acute Heart Failure Workup

This patient requires urgent evaluation for acute decompensated heart failure (AHF) with immediate ECG, cardiac biomarkers, chest X-ray, and echocardiography, as his symptoms of throat closure and chest tightness in the context of known heart failure represent potential cardiac decompensation rather than a primary anxiety disorder. 1

Critical Initial Assessment

The combination of globus sensation, chest tightness, and known heart failure mandates immediate cardiac evaluation rather than continued anxiolytic therapy:

• Obtain 12-lead ECG immediately to exclude acute coronary syndrome (ACS), which can present with atypical symptoms including throat discomfort, and to identify arrhythmias that may precipitate heart failure decompensation 1
• Measure cardiac troponins and natriuretic peptides (BNP or NT-proBNP) immediately, as elevated levels help differentiate cardiac from non-cardiac causes of dyspnea and throat symptoms 1, 2
• Perform continuous monitoring including pulse oximetry (target SpO2 >90%), blood pressure, respiratory rate, and continuous ECG within minutes of evaluation 1
• Assess for signs of hypoperfusion including mental status, peripheral perfusion, and urine output, as these indicate hemodynamic compromise requiring intensive care 1

Why Ativan Failed and What This Means

The ineffectiveness of lorazepam strongly suggests an organic cardiac etiology rather than anxiety:

• Benzodiazepines do not treat cardiac symptoms and may mask underlying serious pathology while providing false reassurance 3, 4
• The globus sensation with chest tightness in a heart failure patient represents a red flag for pulmonary congestion or cardiac ischemia, not anxiety 1
• Left shoulder pain for 3 weeks raises concern for ongoing cardiac ischemia, as ACS can present with referred pain to the shoulder and throat 1

Urgent Diagnostic Workup

Perform chest X-ray to assess for pulmonary congestion, pleural effusion, or cardiomegaly, though note that up to 20% of AHF patients may have normal chest radiographs 1

Obtain immediate echocardiography if the patient shows any hemodynamic instability (hypotension, tachycardia, altered mental status) or if cardiac structure/function is unknown or may have changed 1

Laboratory assessment must include:

• Electrolytes (sodium, potassium), creatinine, and BUN to assess renal function 1, 2
• Complete blood count to exclude anemia as a precipitant 1
• Glucose and liver function tests 1
• Arterial blood gas if respiratory distress develops 1

Identify Life-Threatening Precipitants

The ESC guidelines mandate urgent identification of specific precipitants requiring immediate intervention 1:

• Acute coronary syndrome: The combination of chest tightness and left shoulder pain for 3 weeks requires troponin measurement and consideration of urgent catheterization if ACS is confirmed 1
• Rapid arrhythmias: Atrial fibrillation or ventricular arrhythmias can cause both throat sensations and heart failure decompensation, requiring urgent rate control or cardioversion 1
• Acute valvular dysfunction: New murmurs or signs of acute regurgitation require immediate echocardiography 1

Initial Management Based on Findings

If AHF is confirmed with adequate blood pressure (SBP >90 mmHg):

• Initiate IV loop diuretics (furosemide 20-40 mg IV bolus if diuretic-naïve, or equivalent to oral dose if already on diuretics) 2, 5
• Consider IV vasodilators if SBP >90 mmHg to reduce preload 1, 2
• Provide supplemental oxygen if SpO2 <90% 1, 2

If hemodynamic instability is present:

• Transfer immediately to ICU/CCU for potential need of non-invasive ventilation, inotropic support, or mechanical circulatory support 1, 5

Critical Pitfalls to Avoid

Do not attribute cardiac symptoms to anxiety in a patient with known heart failure, especially when anxiolytics have failed 1

Do not delay cardiac workup for psychiatric evaluation—the globus sensation can represent pulmonary congestion causing laryngeal edema or referred cardiac pain 1

Recognize that speaking in full sentences does not exclude serious cardiac pathology—early AHF can present with subtle symptoms before frank respiratory distress develops 1

Consider pulmonary embolism in the differential, as it can present with chest tightness, throat discomfort, and can mimic ACS on ECG, particularly given the history of heart failure 1, 6

Disposition Decision

Admit to monitored bed (telemetry unit minimum, ICU/CCU if any signs of instability) for continuous cardiac monitoring and serial troponin measurements 1

Do not discharge until cardiac etiology is definitively excluded and symptoms are explained by a benign alternative diagnosis with appropriate follow-up arranged 1