What are the management options for palpitations after taking Ativan (lorazepam)?

Post-Ativan Palpitations: Management

Immediately discontinue lorazepam and assess for hemodynamic stability, as benzodiazepines can paradoxically trigger arrhythmias through altered L-type calcium channel function, though this is rare. 1

Immediate Assessment and Stabilization

Obtain a 12-lead ECG immediately to identify the rhythm, assess for pre-excitation (delta waves indicating Wolff-Parkinson-White syndrome), and determine if the tachycardia is regular or irregular. 2, 3 This single test provides the most critical diagnostic information and guides all subsequent management decisions.

Hemodynamic Status Determines Next Steps

• If the patient is unstable (hypotension, altered mental status, chest pain, acute heart failure), proceed immediately to DC cardioversion regardless of rhythm type. 4, 3
• If the patient is stable, you have time for rhythm characterization and targeted pharmacologic intervention. 4

Understanding the Mechanism

Benzodiazepines, including lorazepam, have been documented to alter L-type Ca2+ channel function, which can account for dysrhythmias including first- and second-degree atrioventricular block and palpitations. 1 While palpitations were more commonly associated with chlordiazepoxide than lorazepam in comparative studies, both benzodiazepines can trigger cardiac symptoms. 5

Paradoxical excitation is a rare but recognized phenomenon with lorazepam that can manifest with various symptoms including cardiovascular effects. 6 The American Heart Association recognizes that many widely used medications, including psychotropic agents, can trigger arrhythmias ranging from benign palpitations to life-threatening ventricular arrhythmias. 7

Rhythm-Specific Management Algorithm

For Regular Palpitations (Likely PSVT/AVNRT)

• Teach vagal maneuvers immediately (Valsalva, carotid massage) as first-line intervention, as termination with these maneuvers confirms re-entrant tachycardia involving AV nodal tissue. 4, 2, 3
• If vagal maneuvers fail, administer adenosine 6 mg IV rapid push followed by 20 mL saline flush; repeat with 12 mg if needed. 4
• If adenosine fails or PSVT recurs, use longer-acting AV nodal blocking agents: diltiazem 15-20 mg (0.25 mg/kg) IV over 2 minutes, with additional 20-25 mg in 15 minutes if needed. 4
• Alternative to calcium channel blockers: beta-blockers such as metoprolol 5 mg IV over 1-2 minutes, repeated every 5 minutes to maximum 15 mg. 4

For Irregular Palpitations (Likely Atrial Fibrillation/Flutter)

• Use AV nodal blocking agents for rate control: diltiazem or beta-blockers as dosed above. 4
• Never use AV nodal blockers if pre-excitation is present on ECG, as this indicates an accessory pathway and can precipitate life-threatening rapid ventricular rates. 4

Critical Exclusions and Red Flags

Immediately refer to cardiac electrophysiology if any of the following are present:

• Pre-excitation (delta waves) on ECG, indicating Wolff-Parkinson-White syndrome with risk of sudden death. 2, 3
• Wide complex tachycardia of unknown origin. 2, 3
• Severe symptoms during palpitations (syncope, presyncope, dyspnea, chest pain). 2, 3
• Irregular cannon A waves and irregular variation in S1 intensity during tachycardia, strongly suggesting ventricular origin. 3

Addressing the Underlying Trigger

Eliminate all potential cardiac stimulants beyond just discontinuing lorazepam, including caffeine (coffee, energy drinks, supplements), as caffeine is a well-established trigger for tachyarrhythmias particularly in patients with anxiety disorders. 2 Since lorazepam is typically prescribed for anxiety, and 45% of panic disorder patients have mitral valve prolapse with heightened sensitivity to cardiac stimulants, comprehensive stimulant elimination is essential. 2

Monitoring Strategy Post-Episode

• If palpitations are still occurring: 24-48 hour Holter monitor for daily symptoms. 2, 3
• If palpitations are infrequent (less than daily): event recorder or wearable loop recorder. 2
• If symptoms completely resolve after lorazepam discontinuation and no concerning ECG findings: no further cardiac workup needed beyond what has been completed. 2

Common Pitfalls to Avoid

• Do not rely on automatic ECG interpretation systems, as they are unreliable and commonly suggest incorrect diagnoses. 3
• Do not start class I or III antiarrhythmics empirically without documented arrhythmia. 3
• Do not use verapamil or diltiazem for wide-complex tachycardias or in patients with heart failure. 4
• Do not use beta-blockers in patients with asthma or decompensated heart failure. 4

Long-Term Considerations

If lorazepam was being used for alcohol withdrawal, recognize that palpitations are more common with chlordiazepoxide than lorazepam in this setting. 5 Consider alternative benzodiazepines or non-benzodiazepine strategies for ongoing management if cardiac symptoms persist. 5

Address underlying anxiety disorder definitively, as depression, poor self-rated health, and anxiety are significant predictors of palpitations independent of medication effects. 2