Do Not Give Hydroxyzine to This Patient
Hydroxyzine is contraindicated in this elderly patient with recent NSTEMI, CHF, and valve stenosis due to significant risk of QT prolongation, cardiac arrhythmias, and sudden death. 1
Critical Cardiac Contraindications
The FDA label explicitly warns that hydroxyzine should be used with caution in patients with:
- Recent myocardial infarction 1
- Uncompensated heart failure 1
- Pre-existing heart disease 1
- Risk factors for QT prolongation and ventricular arrhythmia 1
This patient has ALL of these high-risk features, making hydroxyzine particularly dangerous.
Specific Cardiac Risks in This Patient
QT Prolongation and Arrhythmias: Hydroxyzine can cause QT prolongation and Torsade de Pointes, with the majority of cases occurring in patients with pre-existing heart disease 1. Case reports document supraventricular tachycardia 2 and abnormal ventricular repolarization that may increase likelihood of dysrhythmias and sudden death 3.
Recent NSTEMI: The FDA specifically cautions against use in patients with recent myocardial infarction 1. This patient's history of NSTEMI places them at substantially elevated risk for cardiac complications.
CHF and Valve Stenosis: Uncompensated heart failure is a specific contraindication 1. The combination of CHF with valve stenosis creates hemodynamic instability that hydroxyzine could worsen through its cardiovascular effects.
Geriatric-Specific Concerns
- Elderly patients should be started on low doses and observed closely due to increased risk of confusion and over-sedation 1
- Sedating drugs may cause confusion and over-sedation in the elderly 1
- The European Society of Cardiology emphasizes that elderly patients with cardiovascular disease require careful consideration of drug safety profiles, particularly avoiding medications that increase fall risk, hypotension, or cardiac complications 4
Alternative Approach for Anxiety and Shortness of Breath
The shortness of breath requires immediate cardiovascular assessment, not anxiolytic treatment. 4
- In elderly patients with CHF presenting with dyspnea, the priority is evaluating for acute decompensation, volume status, and cardiac ischemia 4, 5
- Anxiety in the context of cardiac disease may represent underlying cardiac distress rather than primary anxiety disorder 6
- The patient needs urgent PCP evaluation today as planned, but hydroxyzine should not be administered beforehand 1
Safer Management Strategy
- Immediate assessment: Evaluate vital signs, oxygen saturation, volume status, and signs of acute cardiac decompensation 4
- Non-pharmacologic interventions: Positioning, supplemental oxygen if hypoxic, reassurance 5
- If anxiolytic truly needed: Consider very low-dose benzodiazepine with shorter half-life only after cardiac causes excluded, though this still carries risks in elderly patients with cardiac disease 4
- Expedite PCP follow-up: Given the symptom complex, same-day evaluation is appropriate but hydroxyzine administration beforehand adds unnecessary cardiac risk 1
Common Pitfall to Avoid
Do not treat presumed anxiety with hydroxyzine in elderly cardiac patients without first excluding cardiac causes of dyspnea and anxiety. The combination of recent MI, CHF, valve disease, and current dyspnea represents a high-risk scenario where hydroxyzine's cardiac effects could precipitate life-threatening arrhythmias or worsen heart failure 1, 3.