A 48-year-old woman comes to the emergency department due to "fluttering" in her chest and 10/10 nonradiating chest pain. She feels as if "someone is sitting on my chest." The patient has had similar episodes during the past 6 months that occur at rest and with exertion. In addition to the chest pain, she experiences dyspnea, dizziness, paresthesias, and abdominal cramping. She has also noticed that she fears and avoids being in public places such as crowded shopping malls and restaurants. The patient now insists that her husband drive her to work due to fear of having an attack while driving alone. Over the past month, she has left work on multiple occasions due to the episodes and worries that she will have to stop working or be fired for repeated absences. The patient is an administrative assistant with an approximately 20-year smoking history. She does not use other substances and her medical history is insignificant. She is postmenopausal. Her father and paternal uncle suffered myocardial infarctions in their 50s.
Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 94/min, and respirations are 18/min. The patient is a well-developed woman who appears her stated age. She is anxious and diaphoretic. Physical examination is otherwise normal.
ECG shows no evidence of an ischemic event. Laboratory studies, including complete blood count, chemistries, liver function, and urinalysis, are within normal limits. The patient has negative serial troponin and CK-MB levels.
Which of the following is the most appropriate pharmacotherapy for this patient's symptoms?

Question

A 48-year-old woman comes to the emergency department due to "fluttering" in her chest and 10/10 nonradiating chest pain.  She feels as if "someone is sitting on my chest."  The patient has had similar episodes during the past 6 months that occur at rest and with exertion.  In addition to the chest pain, she experiences dyspnea, dizziness, paresthesias, and abdominal cramping.  She has also noticed that she fears and avoids being in public places such as crowded shopping malls and restaurants.  The patient now insists that her husband drive her to work due to fear of having an attack while driving alone.  Over the past month, she has left work on multiple occasions due to the episodes and worries that she will have to stop working or be fired for repeated absences.  The patient is an administrative assistant with an approximately 20-year smoking history.  She does not use other substances and her medical history is insignificant.  She is postmenopausal.  Her father and paternal uncle suffered myocardial infarctions in their 50s.
Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 94/min, and respirations are 18/min.  The patient is a well-developed woman who appears her stated age.  She is anxious and diaphoretic.  Physical examination is otherwise normal.
ECG shows no evidence of an ischemic event.  Laboratory studies, including complete blood count, chemistries, liver function, and urinalysis, are within normal limits.  The patient has negative serial troponin and CK-MB levels.
Which of the following is the most appropriate pharmacotherapy for this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_98a9_b8d4_853d_1f72980c95f8_MD0002_00 This patient's history of recurrent, unexpected anxiety attacks with classic physical symptoms (palpitations, chest pain, dyspnea, dizziness, sweating, paresthesias, and gastrointestinal symptoms) is consistent with panic disorder. Her development of agoraphobia (ie, avoidance of situations in which she fears having a panic attack) is a common complication. Treatment of panic disorder includes cognitive-behavioral psychotherapy, antidepressants, and benzodiazepines. Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) and serotonin-norepinephrine reuptake inhibitors are preferred first-line pharmacotherapy due to their relatively benign side effect profile but typically require 2-4 weeks to take effect. Benzodiazepines (eg, clonazepam) have the advantage of rapid onset of action and are appropriate in acutely symptomatic patients, such as this patient, who require rapid relief. They are also useful in those who cannot tolerate antidepressants, or as short-term therapy while waiting for SSRIs to take effect. Benzodiazepines should be avoided in patients with an active substance use disorder. (Choices A and D) Antipsychotic medications such as aripiprazole and risperidone are not used to treat panic disorder. Propranolol has a role in treating the performance-only subtype of social anxiety disorder but has very limited evidence for efficacy in panic disorder. (Choice B) The use of 2 antidepressants is not considered first-line treatment for panic disorder. Bupropion is a norepinephrine-dopamine reuptake inhibitor. Although it is an effective antidepressant, it tends to be stimulating and has no established efficacy in treating panic disorder. (Choice E) Buspirone is a second-line agent for anxiety disorders due to its weaker anxiolytic effect compared with benzodiazepines. It is used in generalized anxiety disorder but is not effective in panic disorder. Educational objective: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line medications for treatment of panic disorder. Benzodiazepines can provide immediate relief and are appropriate for patients experiencing acute and distressing symptoms while waiting for the antidepressant to take effect. __________ References: Evidence-based pharmacotherapy of panic disorder: an update. (http://www.ncbi.nlm.nih.gov/pubmed/21733234)

A 48-Year-Old Woman Comes to the Emergency Department Due to "Fluttering