August 23, 2017 // Columns

I think I’m having a heart attack

Dr. David Kaminskas

The Catholic Doctor Is In

A 42-year-old man presents to the emergency room with acute onset of shortness of breath and chest tightness. He is in the middle of a contentious divorce and has not been sleeping well or taking very good care of himself. These symptoms occurred very suddenly, and there were no apparent precipitating factors. He is diaphoretic (sweating profusely) and his hands are shaking. Because he complains of shortness of breath and chest tightness, the emergency triage nurse promptly takes him to one of the cardiac rooms and orders a stat electrocardiogram. The ECG is immediately given to one of the Emergency Department physicians as he begins to assess the patient. The doctor indicates that the ECG is normal, other than the heart rate being fast. The patient’s symptoms continue with more complaints of chest tightness. The ED physician orders a sublingual nitroglycerin, believing this could be heart pain, and all that accomplishes is giving the man a splitting headache and making him feel worse. Six tubes of blood are drawn and sent off to the lab for various tests including cardiac markers to help exclude a heart attack. A chest X-ray is done and is normal. A chest CT scan is ordered to look for pulmonary emboli (lung clots) and is reported as normal. All the blood work comes back completely normal as well. The doctor goes back to see how the patient is feeling, and he reports he still feels like he is going to die. The doctor abruptly leaves the room to write some more orders. As he is writing, a nurse walks by and asks the doctor what is going on with the man in bed eight. He replies, “Oh nothing, he’s just having a panic attack.”

As many as one out of every three people, at some time in their life, experiences a panic attack. Most of the time they resolve on their own and an emergency room visit can be avoided. When you have recurring panic attacks, you have panic disorder. This occurs in about two to three percent of the population, most commonly between the ages of 14 and 55. The gentleman that I have just described was having his very first panic attack. His emergency room cost was going to be north of $7,000, most likely giving him another panic attack when he opens the bill. He also had to endure what so many people with this disorder have to go through — a lack of empathy from medical personnel.

A panic attack is hardly “nothing.” When you are in the middle of a panic attack you really do think that you are going to die. Other common symptoms during one of these episodes include heart palpitations, trouble swallowing or a choking feeling, nausea, abdominal pain, dizziness, paresthesia (numbness) and a feeling of impending doom. Sometimes a cardiology consultation is needed, and there are times we just can’t be sure it’s not the heart, so admission to the hospital is needed. Testing to exclude a cardiac etiology most commonly includes a stress test, but sometimes we have to go all the way to a cardiac catheterization to exclude coronary artery disease as the cause of the chest discomfort.

The immediate treatment in the emergency room is reassurance, and frequently a dose of IV antianxiety medicine to calm things down.

If you have a series of panic attacks and are diagnosed with panic disorder, then you need more than reassurance. There are two treatment options, and it is common and usually recommended that both come into play. Cognitive behavioral therapy should just about always be part of the plan (yes, you should see a therapist, or “shrink”). Finding a qualified therapist can sometimes be a challenge, but better understanding your brain’s reaction to stress is very effective at preventing future episodes. Then there are medications that work to change the brain chemistry to help prevent future episodes. The biggest error made by physicians who may not be adequately trained in this area is to start a benzodiazepine such as Xanax (alprazolam), Ativan (lorazepam) or Valium (diazepam): These meds might be used for very short-term relief but not long-term, since they do not really work well chronically and it only takes a few short weeks to develop dependence and addiction.

The most effective and inexpensive medications are usually one of the selective serotonin reuptake inhibitors. Also commonly used for depression, these meds calm the brain and can be very effective at preventing panic attacks. A few of the more commonly used SSRIs include Zoloft (sertraline), Paxil (Paroxetine) and Lexapro (escitalopram).

The incidence of panic disorder seems to be on the rise and it doesn’t take too much analysis to figure out why. I would put social media, financial pressures and deterioration of the family unit at the top of the list. My advice is to keep life simple and rely more on spiritual guidance. As it says in Philippians 4:6-7, “Dismiss all anxiety from your minds. Present your needs to God in every form of prayer and in petitions full of gratitude. Then God’s own peace, which is beyond all understanding, will stand guard over your hearts and minds in Christ Jesus.”