To Your Good Health: How to distinguish heart disease symptoms from panic attacks

How can you tell with at least a moderate degree of certainty that you might really have a heart or blood pressure problem, as opposed to just having an anxiety attack that is less serious?

A panic attack is an abrupt change in mental state. It is usually unexpected, sometimes with or without identifiable triggers.

Symptoms of a panic attack vary from person to person, but among the most common are feelings of heart palpitations; sweating; trembling or shaking; shortness of breath; chest pain or discomfort; dizziness; numbness or a “pins and needles” feeling; abdominal pain or nausea; feeling abnormally hot or cold; feeling detached from oneself or from reality; and a fear of dying, losing control or “going crazy.”

Most of us have had some of these feelings from time to time, and some of these symptoms are identical to ones of heart disease, specifically of angina pectoris — the classic symptom of poor blood flow to the heart.

There are many conditions, both medical and psychiatric, that can cause these symptoms, as well, so acquiring a moderate degree of certainty isn’t always easy.

A very careful history exam helps. With chest pain due to heart disease, for example, symptoms are commonly brought on by exertion; whereas with a panic disorder, there might not be a trigger, or it may be triggered by psychological stress.

Some people have highly specific triggers, such as open spaces or needles. Some people can trigger a panic attack just by worrying that they are going to have one.

The time course of the symptoms can be very helpful. With a panic attack, the attack starts, and chest discomfort, for example, will then occur. In people with heart disease, chest discomfort starts, and then people will get anxious.

I had a wise cardiology professor who told me to always consider heart disease even if a person’s history is suggestive of a panic attack.

I generally check their blood pressure and order an electrocardiogram, blood testing, including thyroid tests, and sometimes other tests when considering the diagnosis of a panic attack.

There is very effective treatment available for people with panic disorder — people with recurrent unexpected panic attacks that lead to avoidant behaviors — both through therapy and medication.

But your question implies that being pretty sure of the diagnosis is wise before dismissing the possibility of cardiac disease or other medical diseases.

I’m sure you’ve answered this question before, but how important do you think the digital rectal exam is for a 70-year-old man with normal findings in his PSA tests? My previous doctor who retired would routinely do them during my annual physical, but my current doctor said it’s my choice. So, I’ve opted not to have it done. Thoughts?

The PSA test is much better at diagnosing than a finger is. There are cases where a clinician felt a tumor that would have been missed by the PSA test, so there is some small benefit to the digital rectal exam. But the benefit is quite modest.

There are men who have come to expect that part of the exam and feel unsatisfied without it, just as there are some men who absolutely refuse it. So, a wise clinician gives the patient the choice after explaining the small benefit and nonexistent risk.