Propranolol Dosing for Panic Attacks in a Young Female with Bradycardia

Assessment of Current Situation

• Propranolol is a non-selective beta-blocker that reduces heart rate, AV node conduction, and blood pressure; it is a negative inotrope that can worsen bradycardia 1
• The American College of Cardiology notes that propranolol is contraindicated or should be used with extreme caution in patients with bradycardia, as it can further decrease heart rate 3, 4

Risks of Increasing Propranolol Dose

• Increasing propranolol dosage could lead to worsening bradycardia 1, hypotension 4, and potential masking of hypoglycemia symptoms 2

Alternative Management Approaches for Panic Attacks

• The American College of Cardiology recommends considering alternative medication options for panic attacks that don't further reduce heart rate, such as selective serotonin reuptake inhibitors (SSRIs) which are first-line for panic disorder and don't typically cause bradycardia 3
• If beta-blockade is still desired for somatic symptoms of anxiety, consider a more cardioselective beta-blocker (like atenolol or metoprolol) which may have less impact on bronchial function while still addressing peripheral symptoms 3, 4

Monitoring Recommendations

• The American College of Cardiology suggests monitoring heart rate and blood pressure regularly if continuing current propranolol dosing, and educating the patient about symptoms of excessive beta-blockade (dizziness, extreme fatigue, syncope) 2