San Antonio Express-News (Sunday)
How to distinguish between symptoms of heart disease and a panic attack
Q: How can you actually 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: A panic attack is an abrupt change in mental state. They are 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 the heart racing; 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. In 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 they are going to have one.
The time course of the symptoms can be very helpful. With a panic attack, the attack starts, and then chest discomfort (for example) occurs. In people with heart disease, chest discomfort starts, and then people get anxious.
I had a wise cardiology professor who told me to always consider heart disease, even if the history is suggestive of a panic attack. I generally check blood pressure and order an electrocardiogram, blood testing (including thyroid tests) and sometimes other tests when considering the new diagnosis of a panic attack.
There is very effective treatment available for people with panic disorder (people with recurrent unexpected panic attacks, which 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 another medical disease.
Q: 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?
A: 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. However, there are certainly 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.
Q: I’m a 77-year-old female in reasonably good health other than having had an overactive bladder issue for several years. Recently, I was told that I have stage 3 chronic kidney disease (CKD). I am not overweight, do not have diabetes and have no history of CKD in my family. I try to keep up my hydration level, but I live in a dry, desert area and, with my OAB, tend to expel a lot of the fluids I put in each day. My question concerns kidney disease.
I’ve done some research online and with my primary care doctor. She really had no advice other than to stay as hydrated as much as I can and avoid all NSAIDs. I think a visit with a nephrologist could help me understand how to control this and keep it from advancing to stage 4 or worse. Unfortunately, I can’t get an appointment until December due to a lack of specialists in the area where I live. Can you offer some suggestions of what to do?
A: Stage 3 chronic kidney disease sounds scary, but it may not be as bad as you think. Older adults lose kidney function with aging, and there is an overlap between normal aging and kidney disease. How fast the kidney function has decreased and whether you have excess amounts of protein are critical information.
I completely agree that a nephrologist is the ideal consultant to help understand whether your kidney disease will worsen, as well as to give advice on what you can do. But I can give some general advice.
The first is to look carefully at your blood pressure. Having kidney disease makes blood pressure control more important, especially for people with protein in the urine. Blood pressure levels that wouldn’t normally be treated in a person with normal kidneys may still need to be treated in a person with CKD. People with high amounts of protein benefit from medicines called sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as empagliflozin, which slows progression to the end stage of kidney disease where dialysis or a transplant becomes life-preserving. ACE inhibitors and angiotensin receptor blockers protect the heart and kidneys. I agree with minimizing or eliminating antiinflammatory drugs like ibuprofen.
Switching from animal sources of protein to plant-based protein has been shown to preserve kidney function. Even small changes can do some good. Reducing sodium intake to 2.3 g per day (about 5.8 g of table salt) slows kidney disease progression and reduces heart risk.
Q: I’m 81 with an A1c test of 7.1%. My primary care doctor doesn’t see a problem with it, but my cardiologist does. Research online tells me this is normal. Who’s right?
A: A level of 7.1% in the A1c test indicates diabetes. If you have diabetes, 7.1% is a reasonable level for a person in their 80s. However, I’m concerned you may not know you have diabetes. Your primary care doctor should at least be giving you the diagnosis, recommending a proper diet, discussing exercise options and looking carefully at your medications to make sure none of them are potentially affecting your blood sugar. You might benefit from a consultation with a diabetes educator, a registered dietitian or an endocrinologist.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.