Is Ativan (lorazepam) safe to administer to a patient with palpitations, particularly those with a history of anxiety or panic disorders?

Can Ativan Be Given for Palpitations?

Yes, Ativan (lorazepam) can be safely administered to patients with palpitations when anxiety or panic disorder is the underlying cause, but only after excluding serious cardiac pathology through appropriate evaluation. 1, 2, 3

Critical First Step: Rule Out Cardiac Red Flags

Before considering benzodiazepines, you must immediately exclude high-risk features that require urgent cardiac evaluation 1:

• Syncope or pre-syncope with palpitations - mandates hospitalization for continuous monitoring 1
• Chest pain accompanying palpitations - requires urgent evaluation for structural heart disease and ischemia 1
• Dyspnea or severe symptoms - warrant immediate cardiology referral 1
• Pre-excitation (delta waves) on ECG - indicates WPW syndrome with sudden death risk 1
• Wide complex tachycardia - requires immediate specialist referral 1

When Lorazepam Is Appropriate

Primary Indication

Lorazepam is FDA-approved for anxiety disorders and anxiety associated with depressive symptoms, making it suitable for palpitations driven by anxiety 2. In patients with cardiovascular symptomatology and moderate to severe anxiety, lorazepam at an average dose of 3 mg/day (2 mg evening, 1 mg morning) significantly relieves anxiety symptoms 3.

Specific Clinical Scenarios

Anxiety-related palpitations without cardiac pathology:

• Patients with mitral valve prolapse (MVP) and palpitations often have no arrhythmias on continuous ECG monitoring despite symptoms 4
• 45% of patients with panic disorder have MVP, and many experience palpitations as part of panic attacks 4
• Beta-blockers are first-line for MVP patients with palpitations and increased adrenergic symptoms, but lorazepam can address the anxiety component 4

Panic disorder with palpitations:

• Lorazepam demonstrates comparable antipanic efficacy to alprazolam at mean doses of 7 mg/day 5
• Effective for acute panic attacks where palpitations are a prominent symptom 5

Dosing Strategy

Standard anxiety dosing: 2-3 mg/day divided (typically 2 mg evening, 1 mg morning) 3

Panic disorder: May require higher doses up to 7 mg/day 5

Duration: FDA labeling notes effectiveness beyond 4 months has not been systematically assessed; periodically reassess need 2

Important Caveats and Pitfalls

Do Not Use Lorazepam As First-Line When:

1. Cardiac arrhythmia is documented - treat the underlying arrhythmia, not just symptoms 1
2. Structural heart disease is present - address the cardiac pathology first 1
3. Patient has irregular palpitations with pre-excitation - this suggests atrial fibrillation in WPW syndrome with sudden death risk 1

Common Clinical Errors to Avoid:

• Never assume benign etiology without ECG documentation - many patients report palpitations when ambulatory monitoring shows no arrhythmias, but this doesn't exclude serious pathology 4, 1
• Don't overlook the anxiety-cardiac overlap - 67% of patients with unrecognized SVT fulfill criteria for panic disorder, and physicians often mislabel SVT symptoms as anxiety 4
• Avoid empiric antiarrhythmic therapy without documented arrhythmia due to proarrhythmia risk 1

Recognize the Bidirectional Relationship:

Anxiety can cause palpitations through increased adrenergic tone 4, but cardiac arrhythmias can also trigger anxiety symptoms 4. The key is obtaining ECG documentation during symptomatic episodes 1.

Adjunctive Measures

Beyond lorazepam, address modifiable factors 4:

• Eliminate stimulants: caffeine, alcohol, cigarettes
• Beta-blockers: particularly effective for MVP patients with palpitations and adrenergic symptoms 4
• Propranolol: ameliorates somatic symptoms like palpitations and tremor in anxious patients 6

Safety Profile

Lorazepam is well-tolerated in cardiovascular patients 3:

• Adverse reactions are transient and tolerable
• Safer in overdose compared to barbiturates 6
• No direct cardiac toxicity or arrhythmogenic effects 4
• Benzodiazepines show no QT prolongation in clinical use 4

The bottom line: Lorazepam is safe and effective for anxiety-driven palpitations after cardiac pathology is excluded, but never use it as a substitute for proper cardiac evaluation when red flag symptoms are present.