The chest pain / panic connection

28 Apr

by Carolyn Thomas    @HeartSisters     April 28, 2019

For most of us, feelings of anxiety or panic are generally occasional, mild and brief – normal responses to being worried or scared. I never thought of myself as a person who was prone to experience anxiety or panic – until I survived a heart attack. I can now tell you quite confidently that there are few things in life that are more anxiety-producing than being in the middle of a frickety-frackin’ heart attack. . .

During this heart attack, I had two particularly terrifying cardiac episodes on a 5-hour flight returning to the west coast after my mother’s 80th birthday weekend. But at no time did I call the flight attendant over for help. I didn’t want to be one of those passengers who force the plane to turn around due to a medical emergency!

Besides, I already knew that it wasn’t my heart. A man with the letters MD after his name had told me so quite clearly earlier in the Emergency Department before he’d sent me home with an acid reflux misdiagnosis – despite my textbook Hollywood Heart Attack symptoms.

I survived that flight, and I did go back to Emergency when I returned home, this time to a correct diagnosis after a different ER doc called in a cardiologist (“You have significant heart disease!”)

But five months later, despite feeling very reluctant to walk onto a plane ever again, I found myself flying east to the wide open cornfields of Minnesota to attend the WomenHeart Science & Leadership patient advocacy training.  Only the thought that I was en route to the world-famous Mayo Clinic propelled me onboard that plane, heel marks scuffing behind me all the way.

It was on that flight that I got a taste of what a panic attack might feel like. But I wasn’t even sure what it was at first.

Several minutes into the first leg of the trip to Minneapolis, I started sweating and shaking as I slowly realized that there didn’t seem to be enough oxygenated air circulating on our plane. The air felt too thin! I could hardly breathe. Something was not right.

But I could see the flight crew near me, acting normally, starting their beverage service, casually chatting with my fellow passengers. They seemed genuinely unconcerned that we were all going to die.

Of course, none of us died that day.

It turns out that this feeling of being smothered is apparently common during a panic attack, according to Canada’s Centre for Addiction and Mental Health (CAMH).

A panic attack is a type of anxiety disorder with sudden feelings of intense fear or discomfort that usually peak within several minutes. Anybody can experience a panic attack, especially when feeling stressed or overtired.

Within several minutes of my own episode on the plane (minutes that felt like hours at the time), I was finally breathing normally again (although an exhausted and sweat-stained wreck after this odd episode).

Panic attacks become more serious if you’re increasingly worried about having another attack, or if you’re afraid that something bad will happen because of a panic attack (e.g. having a heart attack). That’s how it can become a panic disorder.

These attacks often include stressful physical and cognitive symptoms as well as behavioural signs. Here are some as identified by the CAMH:

Physical symptoms can include:

  • pounding heart
  • sweating
  • trembling or shaking
  • shortness of breath
  • feelings of choking
  • chest pain or discomfort
  • dizziness or nausea
  • sensations of heat or cold
  • numbness or tingling
  • feelings of unreality or being detached.

Cognitive symptoms can include thoughts such as:

  • “I’m having a heart attack.”
  • “I’m suffocating.”
  • “I’m losing control.”
  • “I’m going crazy.”

Behavioural signs can include:

  • avoiding places where you have had anxiety symptoms in the past (e.g. a certain grocery store) or similar places (e.g. all grocery stores)
  • avoiding strenuous activities (e.g., exercise)
  • avoiding travel, malls, line-ups

My deep reluctance to board that flight to Mayo (or – even worse, the return flight home five days later) was an example of behavioural avoidance.

People who are not heart patients but who do suffer with anxiety or panic often believe that they are having a massive heart attack.

Even when chest pain symptoms subside, and have not resulted in a heart attack at all, the fear that another horrible episode will happen often remains, and worse, the fear that this time it just might be a real heart attack.

This threat feels as real to a person experiencing anxiety or panic symptoms as my sudden inability to breathe enough oxygenated air on that plane felt to me at the time. It wasn’t real, of course. There was in reality plenty of clean safe air in the plane’s ventilation system, but it sure felt (temporarily) real to me.

As Dr. David Katerndahl wrote in his comprehensive literature review on chest pain in people with panic disorders:(1)

“Compared to patients with ischemic heart disease, those with normal cardiac angiogram tests have similar levels of pain and psychosocial stress, and use similar coping strategies.

“Thus, although certain atypical features may suggest panic disorder, many of the characteristics classically associated with coronary artery disease are common in patients with panic disorder or anxiety.”

Even if a person with such conditions finds that taking nitroglycerin works to relieve symptoms (nitro is a heart drug that helps to relax and dilate a heart patient’s coronary arteries to relieve the chest pain of angina), that relief itself is, ironically, not always a sign that the pain is heart-related at all, warns Dr. Katerendahl.

That’s because nitro also seems to help reduce the pain of esophageal spasm, a condition that is experienced by many people living with anxiety and panic disorders, and the kind of chest pain easily mistaken for cardiac pain. He cites studies, in fact, suggesting that nitro helps to relieve chest pain in up to two-thirds of these non-cardiac patients.

Many people living with anxiety or panic disorders have been to the Emergency Department, often more than once, convinced that their racing hearts, shortness of breath or chest pain mean they’re having a heart attack. Almost always, they are not.

Some studies suggest that one-quarter of all patients who seek medical care for chest pain actually have panic disorder.(2)

Trying to reduce the frightening symptoms of anxiety or panic is key to calming those responses. Cognitive Behavioural Therapy (CBT) is widely considered the most effective method of talk therapy to help calm them. An important part of CBT is helping people to identify, question and correct their tendencies to overestimate danger, and their perceived inability to cope with danger.

Psychotherapist Dr. Elvira Aletta is the author of the eBook 7 Rules for Living Well with Chronic Illness, and also a person who experienced her first severe panic attack as a child. One of the many helpful coping tools she describes on her helpful blog, Explore What’s Next, is to begin early interventions when she gets even a whiff that a panic attack may be starting:

“Don’t wait until the panic already has a hold. Most of us can tell when one is building up. Have a strategic list of things to do when the panic monster tries to get in your head.

“Put things on the list that will engage all five senses. My list included deep breathing, telling my husband how I was feeling and just talk, play with my dog or my children, take a hot shower, play some music (didn’t matter what) and dance, keep breathing, use aromatherapy by putting a bit of essential oil on a tissue and breathing the scent in, or watch a favorite old movie with happy associations.”

The topics of panic, anxiety and depression often come up in heart patient support groups because of the inherent emotional, mental and spiritual upset that’s part of so many cardiac events.

Yet mental health issues like anxiety, panic or depression are rarely even mentioned to heart patients in most hospital discharge instructions.   See also: When are cardiologists going to start talking about depression?

Although almost half of female heart patients report suffering from significant mental health issues, for example, fewer than 10% are appropriately identified and treated. All heart patient should be told before hospital discharge that these issues – situational depression, anxiety or panic – are common, usually temporary and almost always treatable.

NOTE FROM CAROLYN: I wrote much more about the link between heart disease and mental health issues in Chapter 5 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 20% off the list price when you order).

.

1. Katerndahl, David A. “Chest pain and its importance in patients with panic disorder: an updated literature review.” Primary Care Companion to the Journal of Clinical Psychiatry, Vol. 10,5 (2008): 376-83.
2. Huffman, Jeff C. et al. “Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management.” Primary Care Companion to the Journal of Clinical Psychiatry vol. 4,2 (2002): 54-62. 

Q:  How were you able to tell that your heart attack was not panic or anxiety?

See also:

21 Responses to “The chest pain / panic connection”

  1. Rubie May 3, 2019 at 2:27 pm #

    I have suffered from anxiety and occasional panic attacks for years. However in 2009 at the age of 28 and 4 months pregnant I began suffering from “heart” symptoms.

    I spent the duration of my pregnancy and the first year of my daughter’s life being shuffled from cardiologist to gastroenterologist all to be told it was anxiety and digestive issues. Fast forward to a year later when I visited the women’s heart center at Stanford and had the appropriate testing done. My diagnosis was small vessel disease due to endothelial dysfunction. No blockages of the small vessels, just constructing of the vessels.

    I had to pop nitroglycerin throughout the day and it only took the edge off of the symptoms. I was miserable and convinced I was dying. Two years later I found out I was pregnant (surprise) and had to stop the nitro.

    I was frightened since what first triggered these heart issues was in my pregnancy. Surprisingly during my pregnancy I rarely had any pain and in the years that have followed I have found that I usually get these symptoms the week prior to my period.

    Every time it acts up it always links up to my cycle. I wonder if anyone else has experienced this?

    I am so baffled as to how I ever developed this horrid disease. I don’t have any of the risk factors. My blood pressure is perfect, I’m fit and in shape and eat a healthy diet. Nobody in my family has heart disease.

    Anyways I have found that taking L. Arginine pills and juicing beets has helped my symptoms immensely. The bad thing is as soon as I start to feel better I slack off on taking the supplements.

    Lately I have worried that something has changed because my last cycle, this pain has been more constant and prominent than in the last years.

    I no longer have the same health insurance and I’m at a loss at what to do. Not sure if I should follow up with a cardiologist and if they will even be able to help me. I felt I lucked out finally finding the dr at the Stanford heart center.

    Anyways I came here as a way to connect with other women with the same diagnosis. I am 38 years old and I have never met anyone my age suffering from this condition.

    Rubie

    Like

    • Carolyn Thomas May 3, 2019 at 3:34 pm #

      Hello Rubie – I’m sorry you’ve been going through this for so long. I’m not a physician so cannot comment on your specific situation, but I can tell you generally that your experience with increased symptoms before your period is actually quite common in a number of women. Some researchers in the U.K. who have studied this call it “menstrual angina”. You can find out more about it in this blog post called “Premenopausal Women and Cardiac Symptoms“.

      It also seems you have answered some of your own questions about how to help yourself (e.g. the L-Arginine and beets that you described as helping you “immensely”) – so you already have that option available. If you are truly needing relief, you might want to seriously reconsider going back to that option.

      Other than taking nitro, I’m wondering if there were other treatment recommendations for small vessel disease from the Stanford doctor (was that Dr. Jennifer Tremmel, by the way?) For example, some commonly prescribed treatments include medications to slow down the heart, or to relax the muscles around the coronary arteries.

      If you now have to see a new cardiologist because of your health insurance change, request that your medical records from your Stanford visit are forwarded to your new cardiologist to help with continuity of care and treatment.

      Finally, you might want to visit this WomenHeart online support community to learn more and to connect with other women diagnosed with small vessel disease/endothelial dysfunction. It’s free to join and there are many many other women online in the same boat. Best of luck to you…

      Like

      • Rubie May 3, 2019 at 4:47 pm #

        Thank you so much for taking the time to respond. And yes! The Dr. who diagnosed me was Dr. Tremmel.

        I have started back up on my L.arginine. I guess I am just more concerned that this pain feels a little different and more intense and in the back of my mind I worry. I think because recently I have read articles that talk about artery spasms and how it can cause sudden death and maybe I’ve started that worry cycle in my mind. No fun.

        Earlier today I sent in a request for my records so I can be prepared should I see a new cardiologist.

        The community that you have directed me to is exactly what I have been looking for. Thank you so much!

        Liked by 1 person

        • Carolyn Thomas May 3, 2019 at 5:58 pm #

          Hi again – glad you found the WomenHeart support group useful. And also good news that you’re back on L-arginine because you already have personal experience with this amino acid supplement and you know it’s worked for you (so why stop a protocol that can relax blood vessels?)

          Given your past history with anxiety and panic attacks, it’s not surprising at all that you’re on a ‘worry cycle’ about spasms. I hope you will see your physician or a therapist for help in managing this cycle – which, ironically, can end up hurting your heart far more than a spasm that may or may not ever even happen. Look into cognitive behavioural therapy (CBT – check out the link to the CAMH free online class at the end of this article) so that you can help stop yourself from spiraling down into a panic state. You have two areas to focus on that are equally important now: your physical symptoms, and your tendency to anxiety/panic that accompanies your fear around the physical symptoms…

          Like

      • Rubie May 3, 2019 at 4:52 pm #

        I also forgot to mention that the only treatment that was given to me was the nitroglycerin. Looking back now, I wonder why I wasn’t prescribed anything else. Although it was a hectic time in my life with a new baby, and perhaps I did not follow up the way I should have.

        Liked by 1 person

        • Carolyn Thomas May 3, 2019 at 5:38 pm #

          FYI, here’s a Mayo Clinic article with a list (scroll down to Treatment) of the types of meds that are often prescribed for small vessel disease – just to give you an idea of the range that’s commonly considered.

          Like

          • queenmumquipsandquotes May 4, 2019 at 8:54 am #

            Where is the Mayo Clinic article on treatment for small vessel disease? I cannot locate it and would love to see what they are using. I am trying to get my treatment plan in order.

            Like

  2. Meghan April 30, 2019 at 5:01 am #

    Wow Carolyn, I can’t believe you posted this THIS week.

    I am having extreme anxiety facing starting a new job tomorrow after being out of the workforce homeschooling my kids since 2000 (I still can’t believe anyone wants to hire me!).

    I don’t think I’ve ever had a real panic attack, but I can so relate to moments of shortness of breath, and it is scary because that was the main symptom I had before getting both of my stents. It’s only been recently that I’ve really seen that I have anxiety, or put that word on it; I know I’ve had many fears all my life.

    My three grown children all suffer from anxiety and depression; two are on medication for this and the other one should be too. My 21 yo daughter (on daily medication) especially has major panic attacks. She recently had one that lasted over three hours when a deer jumped out in front of her boyfriend’s car. Boyfriend swerved and avoided an accident, no one hurt, but she totally freaked out. I believe that her problems stem from post-traumatic stress which began when her dad had a car accident back in 2009, a major trauma for our whole family but especially for her for many reasons.

    I am sure of this because her anxiety really centers around cars and driving, and consistently gets worse when her dad goes away twice a year to drive his snowbird mom between NY and FL — which is where he was when this deer incident happened. She still lives at home and I’m hoping she can get her drivers’ license this summer and her own car, but she resists driving (so guess who chauffeurs her to the 3 jobs she is juggling right now — causing ME stress!). I am not sure how to cope with this myself or set boundaries around requiring her to drive. She was in counseling for a long time but I believe she (amazingly!) never even discussed the accident with her counselor.

    I can CLEARLY see the link, she is blind to it. Perhaps everyone with panic and anxiety issues should (A) try to find someone who can help them see what they can’t and (B) begin by figuring out what may have caused trauma in their life — because that is probably the key to it all.

    Anyway — for me, I do tend to have fear thinking that, after avoiding a heart attack twice, the third time might not be a charm (if there is one, but I also worry about stroke since I have atrial fibrillation too).

    I would be willing to bet that some form of post-traumatic stress is the underlying problem with panic and anxiety every time. You touched on this quite a bit in this post — avoiding places and situations that make you feel that stress, for instance.

    I also wonder if highly sensitive people are more prone to anxiety and panic — those of us with a greater need to feel safe and who have huge imaginations — like me and my daughter. I learned about highly sensitive people several years ago and it has helped me make sense of a lot of things in my life.

    Perhaps a future topic for your blog!

    Liked by 1 person

    • Carolyn Thomas April 30, 2019 at 6:17 am #

      Hello Meghan – first of all, congratulations on your new job. Considering your situation (out of the workforce for so long) it is not surprising that you are feeling anxious. Even those with no history of anxiety feel worried and frightened by starting a new job! It’s so exhausting and overwhelming to be the “new kid”. I hope you’ll be able to build in lots of rest and recuperation time before and after each work day as you ease into it.

      I’m not a mental health professional, but I agree – your daughter will continue to resist driving as long as you continue to drive her everywhere she needs to go. And it may not be as important to examine the original cause of panic attacks as it is to develop practical tools to manage the symptoms as they arise. Read Dr. Aletta’s excellent post on her own panic attacks for her helpful suggestions on how she has managed to control them over the years.

      Good luck tomorrow!

      Like

  3. Kathy April 28, 2019 at 7:42 am #

    Thank you for being there. You have and continue to help me. I loved your book.
    Thank you again, and again and again

    Liked by 1 person

  4. Dr. Barbara Keddy April 28, 2019 at 6:39 am #

    Dearest Carolyn,

    Right on, as usual. This blog is so poignant for me right now, coming from a 2 month episode of multiple panic attacks. Having survived an MI 6 years ago with a stent, on beta blocker, low dose of statin and low dose of candesartan, I was doing fairly well. I have several blockages on my right side but damaged heart seemed to be functioning well.

    I met with an internist for another issue when she reviewed my meds and said to come off the beta blocker. Her exact word were that beta blockers were “awful things” and I should have been off of then after one year.I complied. I was to see her in 3 months again.

    By the end of three months my blood pressure was becoming elevated, and I was becoming more and more anxious. When I met with her again she increased my candesartan slightly and gave me a script for an anti-anxiety med. Three days later my systolic was 250. Called 911 and was in Emerg for 20 hours on a stretcher until a bed was found for me on cardiology.

    A MIBI showed I had not had a stroke or another MI. I was discharged after 3 days of observation, now on 11 medications, one of which was the usual aspirin and my 30 year thyroid med, so, in fact I was on 9 heart related meds.

    That in and of itself was shocking. None of the staff including the cardiologist mentioned my emotional state, but then neither did the CCU staff 6 years ago or the 3 month cardiac rehab program, except for one 45 minute lecture which addressed anxiety in general.

    Now in February, at home I began having panic attacks and one look at the blood pressure apparatus raised my blood pressure. I became phobic about it.

    Several strategies helped me during this two month of hell:
    1) Your older blog on post-hospitalization syndrome
    2) My husband who is now used to my 6 year awakening shouting out “I’m having a heart attack.I can’t breathe”.
    3) A therapist who spent many hours re-teaching me breathing exercises, CBT, and ‘proper’ mindfulness (all of which I knew but in my panic state I wasn’t able to respond to on my own).
    4) The family doctor who was unbelievably supportive, a locum whom I will miss dreadfully when the physician she is replacing will return from mat leave. I saw her every week and at the office I go into a quiet, darkened room alone for 10 minutes while the blood pressure is automatically taking several readings. I no longer check my own at home.It is a trigger for me now. Last reading the systolic was 120!
    5) My son who turned me on to old You-tube morning and evening meditations of Louise Hay, which at first seemed rather syrupy to me but, nonetheless are helpful.
    6) My women friends.
    7) My exercise bike.
    8) Avoiding becoming over stimulated

    There were other strategies which I worked with repeatedly, and eventually I have recovered enough not to have had another panic attack in a month!

    I have always been prone to anxiety and a few panic attacks but this was an horrific 2 months of non stop shaking, loss of voice, cognitive problems, teeth shattering. Phew!

    The key is to nip it in the bud before it becomes full blown. If only health professionals were as concerned with emotions as much as they are with medications we would be more prepared for the aftermath that follows a cardiac event!

    Love to all my comrades dealing with heart issues and thank you once again, Carolyn.

    Liked by 1 person

    • Carolyn Thomas April 28, 2019 at 8:57 am #

      Hello Barbara – I’m so sorry to hear of your two month ordeal… After that hypertensive crisis in the ER, it’s no surprise to me that you didn’t want to even look at your blood pressure monitor!

      I really appreciated your list of strategies that have helped to address your panic attacks. Every person has to discover what works for them, but it seems like your list covered a really wide range of options.

      I can also see how nipping it in the bud is, as Dr. Aletta writes, SO important. Best wishes to you, and take care…

      Like

  5. Andrea Rosenhaft April 28, 2019 at 6:37 am #

    The first (male) cardiologist who I went to see for my chest pain told me after 5 minutes that I had anxiety.

    Thank goodness I sought a second opinion from a female cardiologist and was correctly diagnosed with Prinzmetal’s Angina. I also have asthma and that cardiologist told me that low O2 stats from asthma can trigger an episode of coronary spasms.

    I’ve been in the ER being treated for a severe asthma attack more than once, then a coronary spasm starts. I ring the bell, tell the VOICE at the other end what’s happening, and no one shows up. I start to panic and of course the panic attack makes the pain worse and a vicious cycle ensues.

    I take an antidepressant and I find when you have a psychotropic medication on the list of medications that you take, ER staff tends to treat you differently, judging you and pre-forming an opinion before even meeting you. There is actually a term for this – “diagnostic overshadowing.”

    Although this article from the New York Times was written several years ago, it still holds true.

    Liked by 1 person

    • Carolyn Thomas April 28, 2019 at 8:46 am #

      Good grief, Andrea! Your Prinzmetal’s was misdiagnosed as anxiety in five minutes? That might be a world record, even in cardiology…

      You raise such an important point: a patient who becomes increasingly distressed (e.g. nobody’s coming to help! – Who would NOT be distressed!?!) WILL show signs of panic, which worsens physical symptoms and starts a predictable downward spiral. Thus you end up with both an emotional and a physical problem…

      Thanks for that link to the NYTimes post on diagnostic overshadowing – I hadn’t seen it yet – “World Health Organization called the stigma and discrimination endured by people with mental health conditions a hidden human rights emergency.”

      Like

  6. Isabella Quigley Moriarty April 28, 2019 at 4:53 am #

    Dear Carolyn,

    Although I have not experienced a heart attack (thank goodness)…I have experienced anaphylactic shock (severe allergic reactions that require hospital treatment). I have also witnessed my sister experiencing heart symptoms.

    I would say there is a certain quality to the panic that is ‘serious’ requiring interventional help from doctors. I have seen it and I have experienced it.

    There is a kind of animal/primal quality to ‘I need help’ when it is a heart attack/stroke/something else needing professional action and care. How do I know this?

    When I have acted upon this or encouraged others to act on their primal feelings/intuition, I have been right. It has been ‘witnessed’ as what I thought was going on within me and in others.

    With my sister, her panic attacks were an impending stroke (she was told she was perimenopausal) and she was sadly dismissed, as you were.

    I always believed she was right and her anxiety was from a physical thing needing attention. After the third trip to the emergency room over several months, she experienced a full aortic dissection and died.

    I think we women need to trust our intuition… For me, there is certain quality of the anxiety that is like a red flashing light…except it feels more like primal human ‘magma’ (to borrow a volcanic term).

    Thanks, as always, for your caring for our hearts and the opportunity to think about this. Self care is a new frontier for all of us.

    Liked by 1 person

    • Carolyn Thomas April 28, 2019 at 5:45 am #

      Thanks for sharing this unique perspective, Isabella. You are so right: we need to trust our intuition. (During my own heart attack, I think I was in such a profound state of denial despite alarmingly increasing symptoms, it was only in hindsight that my own reluctance to return to the ER for help looks so clearly dangerous!)

      That ‘animal/primal’ quality behind “I need help!” is a good analogy. I’m guessing that people who live with ongoing panic episodes would also feel that same insistence – that something is terribly, terribly wrong, I’m dying, I’m having a heart attack – even when that’s not the reality at all.

      So much of medicine is trying to figure out what the problem is NOT, to rule out issues that are unlikely, and to pay closer attention to issues like your sister’s that really are red flags. I’m so sorry for your loss – her story is indeed tragic.

      Like

      • DWW May 1, 2019 at 6:54 am #

        Thanks for this Carolyn. At first i thought my heart attack signs were just panic symptoms (I had experienced panic attacks many years earlier in college) but there was one big difference and that was this bizarre but unmistakable conviction that something very very very bad was happening this time And i was right. Always Listen to that little voice inside.

        Liked by 1 person

        • Carolyn Thomas May 1, 2019 at 3:53 pm #

          Hello DWW – it’s so important to trust that ‘little voice’. Many times we ignore it at our peril, only to look back later and say “I wish I had paid attention…”

          Like

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