What to give to a patient with Generalized Anxiety Disorder (GAD) presenting with sinus tachycardia?

Management of Sinus Tachycardia in GAD Patients

For a GAD patient with sinus tachycardia at 120 bpm, beta-blockers (specifically metoprolol or propranolol) are the first-line treatment, as they simultaneously address both the anxiety-related sympathetic overdrive and the elevated heart rate. 1, 2

Initial Assessment

Before initiating rate control, you must confirm this is true sinus tachycardia and identify any reversible causes:

• Verify sinus rhythm on 12-lead ECG with positive P waves in leads I, II, and aVF, negative in aVR 1, 3
• Rule out secondary causes: fever, dehydration, anemia, hypoxia, hyperthyroidism, pain, heart failure 1, 2
• Review medications: caffeine, albuterol, aminophylline, stimulants, anticholinergics 2, 3
• Assess hemodynamic stability: at 120 bpm without ventricular dysfunction, the tachycardia is likely secondary to anxiety rather than the cause of instability 4, 2

Pharmacologic Treatment Strategy

First-Line: Beta-Blockers

Beta-blockers are the optimal choice because they treat both GAD and sinus tachycardia simultaneously 1, 2:

• Propranolol: Particularly effective for anxiety-related tachycardia due to its lipophilic properties allowing CNS penetration 5
• Metoprolol: Start 50 mg once daily, titrate to 200 mg daily as tolerated 3
• Alternative beta-blockers: Atenolol 25-100 mg once daily or bisoprolol 2.5-10 mg once daily 3

Second-Line: Non-Dihydropyridine Calcium Channel Blockers

If beta-blockers are contraindicated or not tolerated:

• Diltiazem or verapamil are effective alternatives for rate control 1, 2
• Particularly useful if beta-blockers cause unacceptable side effects 2

Adjunctive Anxiolytic Therapy

For the underlying GAD, consider adding:

• SSRIs (escitalopram) or SNRIs (duloxetine, venlafaxine): First-line pharmacotherapy for GAD 6, 7
• Benzodiazepines (lorazepam): Only for short-term relief due to abuse potential, tolerance, and withdrawal risks; inappropriate for chronic GAD management 8, 9
• Buspirone: Alternative first-line agent for GAD without the cardiovascular effects 9

Critical Pitfalls to Avoid

• Never suppress sinus tachycardia before identifying the underlying cause 2, 3
• Do not use adenosine - it is ineffective for sinus tachycardia 3
• Avoid benzodiazepines as monotherapy for chronic GAD due to cognitive impairment, abuse potential, and withdrawal phenomena 8, 9
• Do not normalize heart rate if it represents compensatory tachycardia where cardiac output depends on elevated rate 2

Special Considerations

• Distinguish from inappropriate sinus tachycardia (IST): If tachycardia persists despite treating anxiety and shows excessive rate increase with minimal activity plus nocturnal normalization on 24-hour Holter, consider IST 4, 2
• For refractory IST: Ivabradine (5-7.5 mg twice daily) may be superior to metoprolol for symptom relief 4, 3, 10
• Age-adjusted upper limit: Maximum expected sinus rate is approximately 220 minus patient's age 4, 2

Treatment Algorithm

1. Confirm diagnosis and rule out secondary causes 1, 3
2. Initiate beta-blocker (propranolol or metoprolol) for dual benefit 1, 2
3. Add SSRI/SNRI for long-term GAD management 6, 7
4. Consider calcium channel blocker if beta-blockers contraindicated 1, 2
5. Reserve benzodiazepines only for acute exacerbations, not chronic use 8, 9