Panic Disorder or Acute Coronary Syndrome?

Abstract

Turkish Abstract

Introduction

Chest pain is one of the most common symptoms directing patients to the  emergency department. In approximately half of the cases, chest pain is of either ischemic or non-ischemic  cardiac origin. Additionally, research indicates that in 50% of people diagnosed with non-cardiac chest pain, 30% suffer from panic disorder ¹. In this article, we want to emphasize that patients admitted to a hospital?s emergency department with panic disorder should be treated carefully while creating a differential diagnosis for chest pain, without pre-judgement, keeping also in mind the possibility of an organic cause.

Case Report

A 51-year-old male with a 20-year history of panic disorder presented to the emergency room with complaints of chest pain, dyspnea, palpitations, dizziness, nausea, and  numbness. The patient did not exhibit other physical symptoms or show physical signs with the exception of high  triglycerides. During his previous ED visit, his symptoms lasted approximately 15 min and the patient was admistered  sedatives  and discharged home. During his current visit, the patient was diagnosed with an acute coronary syndrome based on electrocardiography, coronary angiography was performed. Total stenosis of the right coronary artery (RCA) and  left anterior descending artery (LAD) was noted (Figure 1)  and the patient was scheduled for an urgent coronary artery bypass graft procedure .

Figure 1 Coronary angiography of the patient (Black arrow indicates a completely occluded LAD and the white arrow indicates a completely occluded and retrograde-filling RCA).

On echocardiography, the patient was found to have an ejection fraction of 42% and segmental wall motion dysfunction. Three  coronary arteries of the patient were bypassed; LAD-left internal mammary artery (LİMA), RCA- saphenous vein graft, diagonal-saphenous vein graft. The patient  had an uneventful post-operative course, and  was discharged from the hospital.

Discussion

Acute coronary syndrome (ACS) is a life-threatening condition which benefits from prompt evaluation and proper treatment, such that it would be considered negligent for a physician not to consider it as a possible diagnosis in any patient presenting with acute symptoms of chest tightness or discomfort, palpitations, dyspnea, diaphoresis, nausea and vomiting.

It is particularly important (and difficult) to distinguish  chest pain caused by panic disorder and that caused by  coronary artery disease (CAD). But are panic disorder and CAD really independent? Currentlypsychiatrists disapprove of mental illness being labeled as?functional?, and physical illness as ?organic?, because of an increasing body of literature that demonstrating a definitive link between mental and physiological processes ².

Panic disorder and CAD often coexist, and chest pain in panic disorder may be caused by true CAD. Additionally, panic disorder is common in many organic diseases ³. (Table 1).

Table 1 Possible medical conditions including panic disorder.

Although myocardial ischemia can cause panic attacks via increased catecholamines or by increasing cerebral carbon dioxide levels secondary to lactate, panic disorder is more likely to promote CAD through its relationship with cardiac risk factors. However, the nature of the exact relationship between panic disorder and cardiac risk factors is unclear ⁴.

Two useful basic investigations in the diagnosis of ACS are the electrocardiogram (ECG) and serum enzyme bio-markers. Dynamic T-wave changes and ST elevation/depression aresome of the features which may be detected on ECG, but it is important to note that an unremarkable ECG does not exclude ACS. Various serum enzymes can serve as biomarkers for myocardial necrosis, with troponin I as the biomarker of choice given its high sensitivity and specificity ².

In our case, the patient was seen in the emergency department once or twice in a month over the years with panic attacks. However, until his last visit, an accurate investigation for the potential causes of cardiac origin was not carried out. Coronary angiographydemonstratedcomplete occlusion of the right and left coronary artery, and collateral arteries were present indicating that the disease process was not acute with coronary occlusion developing over several years. It is interesting that patients presenting to the emergency room with panic disorder, may, in fact, have a diagnosis of ACS. The most important reason for misdiagnosis is likely the incorrect perception of the disease process formed by patients presenting to the emergency department with complaints of panic disorder.

In conclusion, the cause of chest pain must be accurately diagnosed; and treatment must be pursued based on the etiology of symptoms, especially if the pain is of cardiac origin.

References

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