What medications can be considered for a 51-year-old male with anxiety and a history of multiple ER visits for perceived heart attacks, despite negative cardiac workups?

Management of Anxiety in a Patient with Recurrent Cardiac Fears and Negative Workup

Primary Recommendation

For this 51-year-old male with recurrent chest pain concerns, multiple ER visits, and consistently negative cardiac workups, initiate sertraline as first-line pharmacotherapy while simultaneously referring to cognitive-behavioral therapy. 1

Diagnostic Confirmation Required First

Before initiating anxiety treatment, you must definitively exclude cardiac pathology:

• Obtain high-sensitivity cardiac troponin levels if not done recently, as a normal ECG alone misses 5-40% of acute myocardial infarctions 2
• Review all prior cardiac workups to confirm they included troponin testing, stress testing, or coronary imaging 1, 2
• Document the pattern: recurrent, similar presentations with no physiological cause on prior evaluations qualifies this patient for anxiety-focused treatment 1

Pharmacological Treatment Algorithm

First-Line: SSRIs

Sertraline is the preferred SSRI for patients with cardiac concerns due to:

• Extensive safety data in coronary heart disease and heart failure patients 1
• Lower risk of QTc prolongation compared to citalopram or escitalopram 1
• Effective for both anxiety and depression commonly co-occurring in this population 1, 3

Dosing: Start sertraline 25-50 mg daily, titrate to 50-200 mg daily as tolerated 4

Critical timing expectation: Inform the patient that SSRIs require up to 6 weeks for full effect 1

Alternative SSRIs if Sertraline Not Tolerated

• Fluoxetine (Prozac) 20-40 mg daily 4
• Escitalopram 10-20 mg daily (note: higher QTc risk than sertraline) 1

Medications to AVOID

Do NOT use the following in this cardiac-anxious patient:

• Tricyclic antidepressants: significant cardiovascular side effects including hypertension, hypotension, and arrhythmias 1
• Monoamine oxidase inhibitors: significant cardiovascular side effects 1
• SNRIs at high doses: cause hypertension, making them less preferable than SSRIs 1

Acute Anxiety Management (Bridge Therapy)

While waiting for SSRI onset, short-term benzodiazepines may be used cautiously:

• Lorazepam 0.5-1 mg as needed for acute panic episodes, maximum 2 mg 5
• Limit duration to 2-4 weeks to minimize dependence risk 5
• Avoid in elderly or those with fall risk due to increased fall hazard 5

Important caveat: Routine prophylactic anxiolytics are neither necessary nor recommended for most patients 1

Non-Pharmacological Treatment (Essential Component)

Cognitive-behavioral therapy (CBT) is NOT optional—it is a core treatment modality:

• CBT demonstrates 32% reduction in chest pain frequency over 3 months in patients with noncardiac chest pain and psychological disorders 2
• CBT is the most effective psychotherapy modality for this presentation 2
• Refer immediately rather than waiting to see if medication alone works 1, 2

The mechanism: CBT addresses central nervous system-visceral interactions, low pain thresholds, hyperbody vigilance, and sympathetic activation that perpetuate symptoms 1

Critical Reassurance Strategy

Provide definitive reassurance once cardiac workup is negative:

• Explicitly state: "Your heart is healthy. These symptoms are real but caused by anxiety, not heart disease" 2
• Demonstration of normal cardiac workup reduces hospitalization needs and healthcare utilization 2
• Avoid ordering repetitive cardiac testing, as this reinforces illness behavior and delays appropriate psychiatric treatment 2

Monitoring and Follow-Up

• Schedule follow-up in 2-4 weeks to assess SSRI tolerability and early response 4
• Monitor for worsening anxiety, agitation, panic attacks, or suicidal ideation especially in first weeks of SSRI treatment 4
• Assess for abnormal bleeding risk if patient takes NSAIDs, aspirin, or anticoagulants concurrently with SSRIs 4
• Confirm CBT engagement and coordinate care between psychiatry/psychology and primary care 1

Return Precautions (Safety Net)

Instruct the patient to return immediately for:

• Chest pain with diaphoresis, nausea, or radiation to arm/jaw 2
• Dyspnea at rest 2
• Syncope or presyncope 2
• Chest pain lasting >20 minutes despite rest 2

This safety net acknowledges that while anxiety is the diagnosis, new cardiac symptoms still warrant evaluation 6

Prognosis and Expectations

Set realistic expectations:

• Prognosis of noncardiac chest pain is largely devoid of cardiac complications 1
• In low-risk chest pain patients without cardiac disease, depression and anxiety each exceed coronary artery disease by almost 10-fold 2
• Untreated anxiety leads to continued healthcare utilization and disability 2
• With appropriate treatment (SSRI + CBT), most patients experience significant improvement in symptoms and quality of life 3, 7

Common Pitfall to Avoid

The most dangerous error is dismissing cardiac symptoms solely based on psychiatric history 6, 2. Women and patients with anxiety are at particular risk for underdiagnosis of acute coronary syndrome 6, 2. Always ensure troponin testing has been performed before attributing symptoms exclusively to anxiety 2.