How to manage a patient with congestive heart failure (CHF) on furosemide (Lasix) 20mg, experiencing increasing panic attacks and shortness of breath, who is currently euvolemic?

Management of Panic Attacks with Dyspnea in Euvolemic CHF Patient

This patient requires treatment of panic disorder with cognitive-behavioral therapy and/or SSRIs (specifically citalopram or paroxetine), while maintaining current euvolemic status with the existing furosemide regimen. 1

Immediate Clinical Assessment

First, confirm true euvolemia by examining for:

• Jugular venous distention and hepatojugular reflux (sustained JVP increase with abdominal pressure) 2
• Peripheral and sacral edema 1
• Pulmonary rales on anterior and posterior lung auscultation 1
• Recent weight trends 1

The absence of these findings in a patient on furosemide 20mg three times weekly confirms euvolemic status and indicates the dyspnea is not cardiac in origin. 1

Distinguishing Cardiac vs. Panic-Related Dyspnea

The key clinical distinction: Panic-related dyspnea in euvolemic CHF patients presents as episodic breathlessness attacks with fear of dying, chest discomfort, paresthesias, and choking sensations, rather than exertional dyspnea from volume overload. 3

• Panic disorder patients commonly experience respiratory symptoms that mimic cardiac dyspnea, including shortness of breath and chest pain 3
• These patients fulfill respiratory panic disorder subtype criteria in 70-75% of cases 3
• The euvolemic status on examination definitively rules out volume overload as the cause 1

Management Algorithm

Step 1: Maintain Current Diuretic Regimen

Continue furosemide 20mg Monday, Wednesday, Friday as the patient is euvolemic. 1

• Maintenance of euvolemic status is appropriate and palliates HF symptoms even in advanced disease 1
• Do not increase diuretics in the absence of volume overload, as this risks dehydration and hypotension 1
• The current 20mg three times weekly dosing is appropriate for maintenance therapy in compensated CHF 4

Step 2: Treat Panic Disorder Directly

Initiate SSRI therapy as first-line pharmacologic treatment:

• Paroxetine is specifically effective for panic disorder management in CHF patients 1
• Citalopram or other SSRIs are considered safe alternatives in heart failure 1
• Avoid tricyclic antidepressants as they can provoke orthostatic hypotension, worsening HF, and arrhythmias 1
• Monitor for QT prolongation with SSRIs, though risk is acceptable compared to alternatives 1

Step 3: Non-Pharmacologic Interventions

Implement breathing-relaxation training and cognitive-behavioral therapy, which have demonstrated efficacy for both breathlessness and anxiety in CHF patients. 1

• Relaxation techniques and breathing-relaxation training are potentially helpful for episodic breathlessness 1
• Cognitive-behavioral therapy improves depressive symptoms, physical function, and self-management skills 1
• Use of hand-held fans during panic episodes may provide symptomatic relief 1

Step 4: Assess for Depression and Anxiety

Screen using validated tools such as Hospital Anxiety and Depression Scale (HADS) or PHQ-9, as anxiety and depression are common in CHF and worsen outcomes. 1

• Depression is more prevalent in HF than the general population and requires active screening 1
• Anxiety is associated with poor physical functioning due to ineffective coping strategies 1
• An integrated multidisciplinary team approach is recommended 1

Critical Pitfalls to Avoid

Do not increase diuretics in euvolemic patients experiencing panic-related dyspnea, as this causes volume depletion without addressing the underlying panic disorder. 1

Do not use oxygen therapy in normoxemic patients, as data do not support its use for breathlessness in those who are not hypoxemic. 1

Do not consider opioids (such as low-dose morphine) for this patient, as they are indicated for chronic breathlessness syndrome despite optimal HF treatment, not for panic-related episodic dyspnea in a euvolemic patient. 1

Avoid dismissing symptoms as purely psychiatric without confirming euvolemic status through physical examination, as this could miss true cardiac decompensation. 5

Monitoring Plan

Reassess at each visit:

• Volume status (weight, JVD, hepatojugular reflux, edema, lung sounds) 1, 2
• Panic attack frequency and severity 1
• Response to SSRI therapy (typically requires 4-6 weeks for full effect) 1
• Depressive symptoms and anxiety levels using validated scales 1

Adjust furosemide only if volume status changes, not based on panic symptoms. 1, 4