Dear Dr. Roach: 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?
D.S.
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 behaviours), 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.
Dear Dr. Roach: 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?
Anon.
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.
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
