Angst or Angina?

-Sai Lavanya Patnala, Intern, Apollo Institute of Medical Sciences and Research, Hyderabad


Chest pain is a very common symptom that patients present with to out patient services or emergency rooms. The causes of chest pain are vast and may include both cardiac and non-cardiac causes. It is important to take a thorough history of the patient’s symptomatology to determine whether and administer emergent intervention wherever needed.

Approximately one quarter of patients who present to physicians for treatment of chest pain have panic disorder. Panic disorder frequently goes unrecognized and untreated among patients with chest pain. (1)

Both panic attack and a potential heart attack may cause functional disability and require medical intervention. The cost of misdiagnosing non-cardiac chest pain is high. It is important for physicians to be able to recognise panic attacks and to distinguish them from cardiac disease, thus avoiding unnecessary use of healthcare resources.(2)


Heart attacks can be sudden and intense, but most start slowly, with mild pain or discomfort that usually radiates to the arm, jaw or shoulder blades and gradually worsens over a few minutes. These episodes might come and go several times before the actual heart attack occurs. They typically presents as a squeezing pain and pressure in the chest and onset may occur during or following physical activity (i.e., climbing the stairs). They are often associated with shortness of breath, near fainting, sweating, nausea and vomiting.

Panic attacks come on quickly with increased or racing heart rate and generally reach peak intensity in about 10 minutes and pain may get better over time with complete resolution within 20 to 30 minutes. They can be triggered by a traumatic event or major life stress, but they also can occur for no apparent reason. They are often associated with tingling of hands, sensation of choking, palpitations and tremulousness. Similar to heart attacks, they also present with chest pain or pressure, sweating, dizziness or light-headedness and dyspnea.

And while a panic attack might make one feel like they’re having a heart attack, an actual heart attack is a medical emergency. (4,5,6)


There are many postulated mechanisms which are known to cause chest pain in a person with panic attack. These include cardiac mechanisms (in which pain is caused by coronary spasm or ischemia) and noncardiac mechanisms (in which pain is caused by musculoskeletal, esophageal, or other processes unrelated to the heart). Evidence suggests multiple causes of chest pain—both cardiac and noncardiac—may be at work in any given patient.

Esophageal dysmotility caused by acute anxiety may lead to esophageal spasm and cause noncardiac chest pain. Hyperventilation during panic attacks may lead to musculoskeletal chest pain, with strain or spasm of intercostal chest wall muscles. Both autonomic activation and hyperventilation (via alkalosis) during panic attacks can lead to coronary artery spasm and sympathetic activation causes increased microvascular tone in coronary arteries. Additionally, panic attacks can provoke ischemic pain in patients with coronary disease simply by increasing myocardial oxygen demand through increases in heart rate and blood pressure, mediated by the autonomic nervous system.

Whether because of decreased heart rate variability, microvascular angina, or coronary artery disease, ischemia is believed to be the cause of chest pain during panic attacks. Similarly, myocardial ischemia could cause panic attacks via increased catecholamines or cerebral carbon dioxide levels secondary to lactate. (1)



Anxiety disorders are associated with the onset and progression of cardiac disease, and in many instances have been linked to adverse cardiovascular outcomes, including mortality. Both physiologic (autonomic dysfunction, inflammation, endothelial dysfunction, changes in platelet aggregation) and health behavior mechanisms may help to explain the relationships between anxiety disorders and cardiovascular disease. Recent meta-analyses found a 26% lifetime prevalence of Generalized anxiety disorder in CAD patients and 14% prevalence in Heart failure patients. (8)

In 1 to 4 out of every 100 people, recurrent panic attacks may occur along with persistent worry or behavior change due to the attacks called a panic disorder. (1) A relationship between panic disorder and CAD could exist through a relationship between panic disorder and cardiac risk factors. Panic disorder occurs in 0% to 53% of patients with CAD and that CAD occurs in 4% to 55% of patients with panic disorder. Panic disorder is linked to elevations in both systolic and diastolic blood pressures and 9% to 32% of patients with chest pain and normal results of coronary angiograms have hypertension.

Elevations in cholesterol may be because of increased catecholaminesand may explain a correlation between total cholesterol and fear of dying in patients with panic disorder. In addition, panic disorder may cause the increased catecholamines, which lead to hypertension and hyperlipidemia via activation of lipoprotein lipase. (9)



Not only would a panic-CAD association lead to serious consequences, but because the respective characteristics of the chest pain do not accurately distinguish between them, panic symptoms could overshadow those typically linked to CAD, obscuring its presence. Not only can diagnosing panic disorder result in failure to recognize CAD, but panic disorder itself is often unrecognized, leading to increased social disability, medical costs, and disease progression. (9)

Hence, it is of utmost importance to evaluate a patient appropriately when an attack ensues and provide long-term support to ensure both mental and physical well-being.


  1. Huffman JC, Pollack MH, Stern TA. Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management. Prim Care Companion J Clin Psychiatry. 2002 Apr;4(2):54-62. doi: 10.4088/pcc.v04n0203. PMID: 15014745; PMCID: PMC181226.
  • Potokar JP, Nutt DJ. Chest pain: panic attack or heart attack? Int J Clin Pract. 2000 Mar;54(2):110-4. PMID: 10824366.

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