From the Guidelines
For a patient with sustained heart rate in the 130s who denies chest pain but reports anxiety, I would recommend starting with vagal maneuvers and/or IV adenosine as the first line of treatment, as suggested by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. This approach is based on the patient's presentation of a rapid heart rate without chest pain, which may indicate supraventricular tachycardia (SVT). The guideline recommends vagal maneuvers and/or IV adenosine as a Class I treatment for hemodynamically stable patients with SVT. Some key points to consider when treating this patient include:
- The patient's anxiety may be contributing to the tachycardia, but the primary treatment should focus on addressing the potential underlying cardiac cause.
- Vagal maneuvers, such as the Valsalva maneuver or carotid massage, can help terminate SVT by stimulating the vagus nerve and slowing the heart rate.
- If vagal maneuvers are unsuccessful, IV adenosine can be administered to help convert the SVT to a normal sinus rhythm.
- Before administering any medication, it's essential to obtain vital signs, including blood pressure, respiratory rate, and oxygen saturation, and consider obtaining an ECG to rule out any arrhythmias or cardiac causes of tachycardia.
- Benzodiazepines, such as lorazepam or diazepam, may be considered for anxiety management, but they should not be the primary treatment for the tachycardia.
- Beta-blockers, such as metoprolol, may be considered if the patient has a contraindication to adenosine or if the SVT is recurrent, but they should be used with caution in patients with asthma, COPD, or heart failure.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital. The patient's presentation of a heart rate sustaining 130's and denial of chest pain, but endorsement of anxiety, does not directly align with the indications for metoprolol tartrate as described in the drug label.
- The patient does not have a suspected acute myocardial infarction.
- Metoprolol tartrate is not indicated for the treatment of anxiety in this context. The FDA drug label does not answer the question.
From the Research
Patient Assessment
- The patient's heart rate is sustained at 130's, but they deny any chest pain.
- The patient endorses having anxiety but does not normally take any medication for it.
Relevant Studies
- A study published in the European journal of cardiovascular nursing 2 found that elevated heart rate and blood pressure do not accurately reflect the level of anxiety in patients with heart failure or acute myocardial infarction, and healthy individuals.
- Another study published in Psychopharmacology 3 found that lorazepam induced a dose-dependent decrease in heart rate and had no effect on blood pressure in healthy individuals.
- A review published in Current cardiology reports 4 highlighted the importance of recognizing and treating anxiety in patients with cardiovascular disease, as anxiety can increase the risk of incident cardiovascular disease and portend adverse prognosis in persons with established cardiovascular disease.
Potential Treatment Options
- Lorazepam may be considered as a treatment option for the patient's anxiety, as it has been shown to be effective in reducing anxiety and agitation in various studies 3, 5.
- However, it is essential to consider the potential effects of lorazepam on heart rate and blood pressure, as well as its potential to reduce cardiac vagal modulation 6.
- The patient's sustained heart rate of 130's should be carefully monitored and managed, taking into account the potential effects of lorazepam on heart rate and the lack of correlation between anxiety and heart rate or blood pressure 2.