What is the differential diagnosis and initial management for a patient presenting with a panic attack, considering potential underlying conditions such as cardiac arrhythmias, pulmonary embolism, or acute asthma, and taking into account their demographic and medical history, including anxiety, trauma, or substance abuse?

Differential Diagnosis of Panic Attack

When a patient presents with suspected panic attack, immediately rule out life-threatening cardiovascular and pulmonary emergencies first—acute coronary syndrome, pulmonary embolism, cardiac arrhythmias, aortic dissection, and pneumothorax—before attributing symptoms to panic disorder. 1, 2

Life-Threatening Conditions to Exclude First

Cardiovascular Emergencies

• Acute coronary syndrome (ACS) presents with retrosternal chest discomfort, often with radiation to left arm, neck, or jaw, accompanied by diaphoresis and nausea 1, 2
• Obtain 12-lead ECG within 10 minutes of presentation and measure cardiac troponin immediately if ACS is suspected 2
• Cardiac arrhythmias, particularly supraventricular tachycardia, can mimic panic attacks with palpitations, chest pain, dizziness, and dyspnea—catheter ablation has cured patients previously diagnosed with panic disorder 3
• Aortic dissection manifests as sudden-onset tearing or ripping chest pain radiating to the back 2

Pulmonary Emergencies

• Pulmonary embolism presents with acute chest pain and dyspnea, causing severe pain from pulmonary artery occlusion 1, 2
• Tension pneumothorax causes acute chest pain with respiratory compromise 2
• Acute asthma presents with wheezing, shortness of breath, and chest tightness 1

Other Critical Conditions

• Anaphylaxis requires immediate recognition—look for urticaria, angioedema, hypotension with tachycardia, bronchospasm, and gastrointestinal symptoms (nausea, vomiting, diarrhea) 1
• Hypoglycemia can cause anxiety-like symptoms with altered mental status 1
• Acute poisoning and seizure disorder must be considered 1

Distinguishing Panic Attack from Medical Emergencies

Key Features Supporting Panic Attack Diagnosis

• Sudden onset building to peak within 10 minutes with at least 4 of the following: palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control, fear of dying, paresthesias, chills or hot flushes 1, 4, 5
• Accompanying psychiatric symptoms: trembling, dizziness, derealization, paresthesias, and chills or hot flushes are particularly suggestive 1
• Tachycardia is the rule in panic attacks (unlike vasovagal reactions which show bradycardia) 1

Critical Distinguishing Features from Other Conditions

Vasovagal Reaction:

• Bradycardia (not tachycardia), absence of urticaria, normal or elevated blood pressure, cool and pale skin 1

Anaphylaxis:

• Urticaria/angioedema present, exposure to known allergen, hypotension with potential hemodynamic collapse, bronchospasm 1

Acute Coronary Syndrome:

• Age-related risk (men 30-39: 67% probability increasing to 94% at 60-69; women 26% to 90%) 1
• Pain not affected by palpation, breathing, turning, twisting, or bending 1
• Associated with prior cardiovascular disease, male gender, specific radiation pattern 1

Critical Pitfalls to Avoid

• Never use nitroglycerin response as diagnostic for cardiac vs. non-cardiac chest pain—esophageal spasm also responds to nitroglycerin 2
• Do not assume "atypical" presentation excludes cardiac disease, especially in elderly women who present with jaw/neck pain, back pain, epigastric symptoms, or nausea rather than classic chest pain 2
• Do not attribute symptoms to anxiety until comprehensive cardiac workup is negative—misdiagnosis has devastating long-term clinical and financial consequences 2, 6, 7
• Recognize that documented tachycardia may be misinterpreted as secondary to panic when it actually represents primary arrhythmia 3

Demographic and Risk Factor Considerations

Age-Specific Approach

• Young adults: Musculoskeletal causes more common, but ACS cannot be excluded based on age alone 2
• Middle age: Increasing prevalence of ACS requires balanced evaluation 2
• Elderly (≥75 years): Age itself is a major ACS risk factor; consider cardiac causes when accompanying symptoms include dyspnea, syncope, acute delirium, or unexplained falls 2

Sex-Specific Considerations

• Women are at significant risk for underdiagnosis of cardiac causes and more commonly present with "atypical" symptoms including jaw/neck pain, back pain, epigastric symptoms, dyspnea, nausea, diaphoresis, and palpitations 2

Psychiatric History

• Prior panic disorder or anxiety increases likelihood but does not exclude medical emergency 1, 8
• Trauma history may predispose to panic disorder but requires same rigorous medical exclusion 1
• Substance abuse (particularly stimulants, alcohol withdrawal) can precipitate both panic-like symptoms and cardiac arrhythmias 1, 8

Initial Management Algorithm

Immediate Assessment (First 10 Minutes)

1. Obtain 12-lead ECG immediately if any chest pain, palpitations, or dyspnea present 2
2. Assess airway, breathing, circulation, and level of consciousness—altered mentation suggests hypoxia 1
3. Measure vital signs: tachycardia with normal/elevated BP suggests panic or anaphylaxis; hypotension suggests anaphylaxis, ACS, or PE 1, 2
4. Examine skin: urticaria/angioedema indicates anaphylaxis; cool/pale skin with bradycardia suggests vasovagal reaction 1
5. Cardiac biomarkers (troponin) as soon as possible if ACS suspected 2

If Life-Threatening Conditions Excluded

For Acute Panic Attack:

• Provide reassurance to patient and family—anxiety is a natural response; ensure calm environment and remove triggering stimuli 9
• Administer oxygen 2-4 L/min if patient is breathless or shows respiratory distress 9
• Consider benzodiazepine for acute symptom control: lorazepam 1 mg IV/SC (maximum 2 mg) or midazolam 2.5 mg IV/SC every 1 hour as needed (maximum 5 mg); use lower doses for elderly, frail, or COPD patients 9
• Caution: Benzodiazepines increase fall risk in elderly, may paradoxically cause agitation, and are contraindicated in severe pulmonary insufficiency, severe liver disease, and myasthenia gravis 9

Definitive Treatment Referral

First-Line Pharmacotherapy:

• SSRIs are first-line treatment for panic disorder: sertraline 25-50 mg daily or escitalopram 5-10 mg daily 10, 5, 8, 7
• Short-term benzodiazepine bridge (alprazolam 0.25-0.5 mg as needed) for first 2-4 weeks only while awaiting SSRI onset 10, 4
• Treatment duration: minimum 12-24 months after symptom remission with gradual taper over 2-4 weeks when discontinuing 10

Mandatory Cognitive Behavioral Therapy:

• Immediate referral for individual CBT (12-20 sessions) targeting panic-specific cognitions and exposure to feared situations 10
• CBT combined with SSRI is superior to either alone 10

Monitoring Requirements:

• Weekly monitoring for suicidal thinking (risk difference 0.7% vs. placebo) 10
• Monitor for serotonin syndrome: mental status changes, neuromuscular hyperactivity, autonomic instability 10

When to Call Emergency Services

• Severe prolonged chest pain of acute onset requires immediate ambulance transport regardless of suspected cause 1
• Within 1 hour of symptom onset when risk for ventricular fibrillation is greatest 1
• Any suspicion of ACS, PE, aortic dissection, or pneumothorax warrants immediate emergency transport 1, 2