How should I manage a patient with anxiety, a normal chest radiograph (X‑ray), and sinus tachycardia, and what follow‑up is recommended with the primary‑care physician (PCP)?

Management of Anxiety-Related Sinus Tachycardia with Normal Chest X-Ray

For a patient with anxiety, normal chest radiograph, and sinus tachycardia, the primary treatment is addressing the underlying anxiety disorder through mental health referral and cognitive behavioral therapy, with beta-blockers (metoprolol 50-200 mg daily or propranolol) for symptomatic relief of palpitations while the anxiety is being treated. 1

Immediate Clinical Assessment

Before attributing sinus tachycardia solely to anxiety, rule out secondary causes:

• Verify true sinus rhythm on 12-lead ECG showing positive P waves in leads I, II, and aVF, negative in aVR 2
• Exclude physiological triggers: fever, dehydration, anemia, hypoxia, hyperthyroidism, pain, heart failure 2
• Review medications and substances: caffeine, albuterol, aminophylline, stimulants, anticholinergics 2, 3
• Confirm hemodynamic stability: a heart rate of 120 bpm without ventricular dysfunction is likely secondary to anxiety rather than the cause of instability 2

Treatment Algorithm

First-Line: Address the Underlying Anxiety

• Refer to mental health services for anxiety management as the mainstay of treatment, since physiological sinus tachycardia from emotional stress resolves with correction of the underlying anxiety disorder 1
• Cognitive behavioral therapy should be initiated as part of comprehensive anxiety management 1
• Anxiolytic medications may be appropriate as determined by mental health providers 1

Symptomatic Relief with Beta-Blockers

• Metoprolol 50 mg once daily, titrating to 200 mg daily as tolerated, is first-line for symptomatic relief 2
• Propranolol is an alternative beta-blocker that works by blunting the sympathetic response driving tachycardia during anxiety episodes 1, 2
• Alternative beta-blockers include atenolol 25-100 mg once daily or bisoprolol 2.5-10 mg once daily if metoprolol is not tolerated 2
• Beta-blockers are particularly helpful for patients with distressing palpitations while anxiety triggers are being addressed 1

Critical Distinction: Anxiety-Induced vs. Inappropriate Sinus Tachycardia

• Anxiety-triggered sinus tachycardia is physiological, resulting from appropriate autonomic influences during emotional responses 1
• Inappropriate sinus tachycardia (IST) occurs without physiological justification—elevated heart rate at rest or disproportionate to stress level 1, 3
• Treating anxiety-induced tachycardia as IST leads to overtreatment with medications that may be ineffective or poorly tolerated 1
• IST primarily affects women (90%) with mean presentation age of 38 years and may require different treatment such as ivabradine 5-7.5 mg twice daily 2, 3

PCP Follow-Up Plan

• Monitor response to anxiety treatment and beta-blocker therapy for symptom resolution 1
• Reassess if symptoms persist despite adequate anxiety management, as this may indicate IST rather than anxiety-induced tachycardia 1, 4
• Coordinate with mental health providers to ensure comprehensive anxiety disorder treatment 1
• No cardiac monitoring is required beyond initial ECG confirmation, as anxiety-triggered sinus tachycardia carries no risk of tachycardia-induced cardiomyopathy 1

Important Clinical Caveats

• The prognosis is excellent when underlying anxiety is appropriately managed, with no cardiac complications expected from anxiety-triggered sinus tachycardia 1
• Avoid missing IST by being aware that patients with multiple incapacitating complaints including palpitations, general fatigue, elevated resting heart rate, or disproportionate heart rate increase with minimal exertion may have IST rather than anxiety 4
• Anxiety is common in patients with cardiac arrhythmias, so don't dismiss all tachycardia as anxiety-related without proper ECG documentation 5
• Maximum expected sinus rate is approximately 220 minus the patient's age 2