ELI5: Chest pain during a panic attack can be mistaken for a heart attack. What happens during heightened anxiety that causes chest pain in the absence of a cardiac event?

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Psychiatrist here. Think of a panic attack as your body wrongly believing that you are in a life or death situation. Your brain goes into full fight or flight and prepares you for potentially disastrous scenarios. Your blood vessels tighten to keep your blood pressure up if you begin to bleed, your heart rate increases to make sure your muscles have what they need to run fast or fight, your gut wants to purge everything because you don’t want to waste energy digesting when you’re running or fighting, your sensitivity to pain begins to filter for worst case scenarios (i.e it is safer to assume the worst thing is happening when interpreting physical sensations so your brain will assign the worst possible causes to things your body senses in an attempt to keep you safe). Lots of other things happen but these are the easiest to understand as causing chest pressure. Your blood pressure is up and your heart is working hard. Additionally a lot of people have nausea and reflux which can be interpreted as chest pain, especially when you’re in a heightened state.


I had it once. The paramedic explained it to me but I’ll try to make it ELI5. Your brain and body are so stressed that the body is on high alert even if no actual threat is near. But the anxiety and stress builds up! Till your body has enough and pushes the big red emergency button! We have to fight of the threat! FULL BATTLESTATIONS! Your body increases the heart rate, we need more oxygen to fight so you hyperventilate, deploy ALL the chemicals such as adrenaline, send the brain in OVERDRIVE! But they aren’t helping the non-existent threat, all it does is increasing a loop. Your body is being pushed to the max, especially your chest region and it keeps doing it until you can’t sustain it anymore.


When we talk about chest pain in this context, we’re actually not talking about a heart attack *per se*, we’re talking about something called *angina pectoris.* Angina pectoris is caused by an insufficiency of blood to the heart. Your heart is a muscle and it requires the oxygen and nutrients in the blood to function, just like any other muscle. When it doesn’t get that, the heart muscle begins yelling that something’s wrong—i.e., you feel pain. A heart attack—a myocardial infarction—is caused by the *localized death due to deoxygenation* (infarction) of heart tissue (the myocardium). As you might expect, there’s a relationship between these two: if your heart is getting insufficient bloodflow to the heart muscle, it’s getting insufficent oxygen, which means that it’s at risk for tissue death due to lack of oxygen, which is, of course, an MI (heart attack). So the two are linked. But they’re not *absolutely linked.* Consider that there are two kinds of angina: stable angina and Prinzmetal’s angina. The first (also called “exertional angina”) is when the oxygen supply to your heart becomes insufficient *only in cases of exertion* but resolves when at rest. The second (Prinzmetal’s angina) is when you have chest pain regardless of exertional activity. So we have a circumstance where the heart is basically going “I can’t get sufficient oxygen to pump at the rate that you want,” and a circumstance where the heart is going “I flat out can’t get enough oxygen period.” Now, consider a panic attack. Your body has two “modes”: the sympathetic and parasympathetic. These are unconsciously controlled by your brain and are survival mechanisms constantly operating in the background. The parasympathetic regulates your body when it’s at rest (“feed and breed”) and the sympathetic nervous system regulates your body under stress (“fight or flight”). When your body senses, for whatever reason, an imminent threat, it activates the sympathetic nervous system and basically puts your entire body on a war footing. Your digestion slows (“stop processing fuel”), you hear less acutely (“we already have a threat, we need to focus on that, not listen for more”), you salivate (“save the moisture, we’re not eating anything”), our pupils dilate (“get as much light as you can so we can see what’s happening”), but we get tunnel vision (“screw the stuff happening off to the side, we’ll deal with this threat”). Your body gets ready to launch an all-out response to this threat. A chemical called “cortisol” is released, which takes stored glucose (your fuel) and dumps it into your blood stream. Epinephrine (adrenaline) bonds to your liver and stimulates production of glucose in your liver for *even more* fuel. These chemicals also dilate (widen) your blood vessels to make sure you can deliver *loads* of that fuel wherever it needs to go. Imagine you’re on an old-timey steam ship and it’s an emergency. You get all of the coal out of the holds and into to the boiler room so you have access to fuel; you stop lunch service and turn every spare hand into serving the engines; you break up the furniture to serve as emergency fuel. If necessary, you man the guns and even get the cook loading a cannon if you need to. It’s *all hands on deck.* Now, our body needs that blood pumped quick throughout our body so the fuel can get where the fuel needs to be. So one of the *other* things we do is jack up the heartrate so we can get that blood pumping so we can deal with that threat. This is where things can go slightly awry. At this point you might have been breathing normally. Suddenly, your heart rate might have *doubled* from 65 to 130 or whatnot. When you’re running or exercising, you ramp up your breathing and oxygen intake to match your slowly rising heartrate. But here, your heart might be going “nope, get to 150 bpm *right the hell now*” without your respirations catching up. So what happens? Your heart is beating faster, so it needs more oxygen, so it’s trying to get as much as it can from the blood… but it’s not enough since your lungs might not have begun to match the effort. So your heart is going “whooa we don’t have the oxygen to do all this extra work!” Boom, pain. Boom, angina. So you *may very well* be having actual angina in a panic attack! But that angina doesn’t signify that you’re having a heart attack because there’s no tissue death. *So what about a heart attack?* Well, recall that angina only means there’s not enough oxygen getting to your heart muscle right then. That’s not *great,* but your heart muscle only starts dying after a sustained period of lack of oxygen, almost always caused by some form of obstruction in the vessels that actually *feed* the heart. Your body will *eventually* catch up to the oxygen demands that the heart is making. (For those of you who have had panic attacks and noticed you’ve begun *gasping* as they come on, this is what your body is trying to head off!) So your heart is going “we need more oxygen, boss” and then it gets more oxygen and then your heart is like “cool, thanks” and continues doing what it does. Again, the MI is caused by a *sustained* lack of oxygenation. For periodic bursts of deoxygenation, your heart muscle can use a non-oxygen based method to create energy until the period resolves. So that’s why, even if you have angina during a panic attack, that *usually* doesn’t signal a heart attack: it’s just a sign that your oxygen consumption with the heart is outpacing your supply. *However!* If you’re having chest pains, *always* go to the ER or Urgent Care. *You may well be actually having a heart attack during a panic attack! An already-oxygen-deprived heart may well be incapable of handling the additional oxygen demands of the panic attack!* It’s difficult to separate the two, or even between angina and an actual MI, and there are a number of tests that can be run to check your heart condition (like checking your EKG or doing a test for troponin, a chemical released into the blood when cardiac muscle is damaged). Before then, you really just don’t know. So if you have chest pains, play it safe!


Your chest wall has various muscles e.g intercostals that contract & tighten during a panic attack, mimicking an heart attack Heart attacks occur due to lack of blood, and hence oxygen supply to the cardiac muscle resulting in harm and possible death. This is why certain tests e.g. EKG, heart enzymes (troponins) are done in at-risk populations e.g. older males, comorbidities even if we suspect a panic attack


Anxiety causes your sympathetic nervous system (flight or flight) to go into over drive. You body then releases adrenaline and cortisol from your adrenal glands. Adrenaline causes your heart rate to increase (tachcardia) and your blood vessels to narrow to increase blood pressure (vasoconstriction). This can give rise to chest pain amongst other symptoms such as increased sweating, loss of appetite etc. This would have been great when we needed to.run from predators, not so useful when have an exam to take. Long term sufferer and an RN. It will pass. I promise you.