What is the diagnosis and recommended workup for a 34-year-old female with a history of near accident while driving, presenting with chest discomfort, palpitations, tremors, chills, and near syncope, with normal electrocardiogram (ECG) and echocardiogram results, and experiencing recurrent symptoms of stress and anxiety when attempting to drive again, despite being diagnosed with gastroesophageal reflux disease (GERD) and tachycardia?

Diagnosis and Differential

This 34-year-old woman most likely experienced a panic attack triggered by the near-accident, and has now developed a specific phobia (driving phobia) with recurrent panic symptoms when attempting to drive. 1

Primary Diagnosis: Panic Disorder with Situational Trigger

The constellation of symptoms—chest discomfort, palpitations, tremor, chills, and near-syncope occurring abruptly and peaking rapidly—meets DSM-IV criteria for panic attacks, which require four or more of these specific symptoms developing abruptly within 10 minutes. 2, 3 The recurrence of identical symptoms specifically when attempting to drive after the initial traumatic event strongly suggests panic disorder with a conditioned fear response. 1

The normal cardiac workup (ECG, echocardiogram) combined with recurrent similar presentations makes noncardiac chest pain with psychological origin the most likely diagnosis. 1

Key Differential Diagnoses to Consider

1. Post-Traumatic Stress Disorder (PTSD)

• The near-accident constitutes a traumatic event involving threatened serious injury 2
• Symptoms include intense psychological distress and physiological reactivity when exposed to cues of the traumatic event (driving) 2
• However, full PTSD diagnosis requires additional criteria including intrusive thoughts, avoidance behaviors beyond the specific trigger, and symptoms lasting at least one month 2

2. Cardiac Arrhythmia (Lower Probability but Must Exclude)

• Tachycardia was documented in the ED 1
• However, normal ECG and echocardiogram make structural heart disease unlikely 1
• Paroxysmal arrhythmias could still occur between monitoring periods 1

3. GERD-Related Symptoms

• GERD was diagnosed in the ED 1
• Esophageal chest pain can mimic cardiac symptoms and worsen with stress 1
• However, GERD alone does not explain the acute episodic nature, tremor, chills, or near-syncope 1
• Some evidence suggests autonomic dysfunction may link GERD and tachycardia, though this is more relevant in chronic cases 4, 5

4. Neurally Mediated Syncope

• Near-syncope ("almost black out") was reported 1
• However, the patient did not actually lose consciousness, and symptoms are specifically triggered by psychological stress rather than postural changes or other typical vasovagal triggers 1

Recommended Workup

Immediate Assessment (Already Completed)

• ✓ ECG and echocardiogram are normal, effectively ruling out structural heart disease and acute coronary syndrome 1
• ✓ Emergency evaluation excluded life-threatening conditions 1

Additional Cardiac Evaluation (If Symptoms Persist or Worsen)

Extended cardiac monitoring is indicated only if there is high pre-test probability of arrhythmia. 1 Given the clear psychological trigger and normal initial cardiac workup, this is lower priority but consider:

• 24-48 hour Holter monitoring if palpitations occur frequently enough to capture during routine activities 1
• Event recorder or loop monitoring only if symptoms suggest arrhythmic syncope (sudden onset without warning, occurring during exertion, or with family history of sudden death) 1
• Tilt table testing is NOT indicated here—it's reserved for recurrent unexplained syncope without clear triggers, not for psychologically-triggered near-syncope 1

Psychiatric Assessment (HIGHEST PRIORITY)

For patients with frequent recurrent symptoms, multiple somatic complaints, and initial evaluation raising concerns for stress and anxiety, psychiatric assessment is recommended as a Class I indication. 1

Specific evaluation should include:

• Structured assessment for panic disorder using DSM-IV criteria (recurrent unexpected panic attacks with at least four characteristic symptoms) 2, 3
• PTSD screening given the traumatic precipitant 2
• Assessment for specific phobia (driving phobia) and anticipatory anxiety 2
• Screening for generalized anxiety disorder and depression, which commonly co-occur 6
• Brief screening tools such as the Generalized Anxiety Disorder-7 (GAD-7) can be administered in primary care (sensitivity 57.6-93.9%, specificity 61-97%) 6

GERD Evaluation (Lower Priority)

• Trial of empiric acid suppression therapy with proton pump inhibitors for 4-8 weeks if GERD symptoms are prominent 1
• Upper endoscopy only if alarm symptoms develop (dysphagia, odynophagia, GI bleeding, weight loss, recurrent vomiting) 1
• Important caveat: Long-term PPI use can cause mineral deficiencies (especially magnesium) that may worsen tachycardia—monitor if extended therapy is needed 7

Laboratory Tests

Basic laboratory tests are only indicated if syncope may be due to loss of circulating volume or metabolic causes. 1 Consider:

• Complete blood count (to exclude anemia as secondary cause of tachycardia) 1
• Thyroid function tests (hyperthyroidism can cause anxiety-like symptoms and tachycardia) 1
• Electrolytes including magnesium (especially if on PPIs) 7

Treatment Recommendations

First-Line Treatment: Cognitive Behavioral Therapy

For patients with recurrent, similar presentations for acute chest pain with no evidence of a physiological cause on prior diagnostic evaluation, referral to a cognitive-behavioral therapist is reasonable (Class 2a recommendation). 1

• Cognitive behavioral therapy has the highest level of evidence for anxiety disorders, with large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small-to-medium effects for panic disorder (Hedges g = 0.39) 6
• Specific exposure therapy for driving phobia should be incorporated 8, 6
• CBT has shown 32% reduction in chest pain frequency in patients with noncardiac chest pain 9

Pharmacotherapy Options

First-line medications are selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). 8, 6

• Sertraline (SSRI) is FDA-approved for panic disorder and PTSD, with demonstrated efficacy in maintaining response up to 28 weeks 2, 6

  • Starting dose: 25 mg daily, titrate to 50-200 mg daily 2
  • Effect size vs placebo: SMD -0.30 for panic disorder 6

• Venlafaxine extended-release (SNRI) is also first-line with similar efficacy 6

• Benzodiazepines (e.g., alprazolam) are NOT recommended for routine use despite FDA approval for panic disorder 3, 8

  • They provide rapid symptom relief but carry risks of dependence, tolerance, and withdrawal 8
  • May be considered for short-term use (4-10 weeks maximum) during acute crisis while initiating CBT or SSRIs 3, 8

• After remission, medications should be continued for 6-12 months before considering discontinuation 8

Combined Approach

The optimal strategy combines both pharmacotherapy and psychotherapy, as this addresses both the neurobiological and psychological components of panic disorder. 8, 6

Critical Pitfalls to Avoid

1. Do not dismiss cardiac causes prematurely in young women—they are at particular risk for underdiagnosis when presenting with chest pain 9

2. Do not use nitroglycerin response as a diagnostic criterion—esophageal spasm and other non-cardiac conditions also respond to nitroglycerin 10, 9

3. Do not perform extensive repetitive cardiac testing once initial workup is negative—this reinforces illness behavior and delays appropriate psychiatric treatment 1

4. Do not attribute symptoms to anxiety without completing appropriate cardiac evaluation first—this is a diagnosis of exclusion 9

5. Recognize that these patients have excellent cardiac prognosis—noncardiac chest pain is largely devoid of cardiac complications, which should be communicated to reduce health anxiety 1

6. Address the specific driving phobia explicitly—gradual exposure therapy is essential for functional recovery 8, 6