What is the best approach for patient education and management of a patient experiencing panic-related chest pain?

Patient Education for Panic-Related Chest Pain

After cardiac causes have been ruled out through appropriate testing, patients with panic-related chest pain should be referred to cognitive-behavioral therapy, which has demonstrated a 32% reduction in chest pain frequency and represents the most effective evidence-based treatment for this condition. 1, 2

Critical First Step: Rule Out Cardiac Disease

Before attributing chest pain to panic or anxiety, cardiac evaluation is mandatory:

• Obtain a 12-lead ECG immediately upon presentation, recognizing that its sensitivity for ischemia may be as low as 50%, and 2-4% of patients with evolving myocardial infarction may have normal ECG findings 1, 2, 3
• Assess vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 2
• Evaluate for cardiac-specific symptoms: diaphoresis, pallor, cool skin, nausea, vomiting, and dyspnea 1, 2
• Consider cardiac biomarkers (troponin) to exclude myocardial infarction 1, 3
• Perform a focused cardiovascular examination to identify life-threatening causes including acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture 4

Common Pitfall: Premature attribution of chest pain to anxiety before completing appropriate cardiac testing can lead to missed diagnoses of serious conditions, particularly in younger patients and diverse populations who may not fit typical cardiac profiles 1, 2, 3

Understanding the Mechanism of Panic-Related Chest Pain

Once cardiac causes are excluded, educate patients about how anxiety produces physical chest symptoms:

• Anxiety triggers the sympathetic nervous system, causing increased heart rate, blood pressure elevation, and muscle tension in the chest wall, creating genuine sensations of tightness or pressure 1, 2
• Hyperventilation during panic attacks causes chest muscle spasms, contributing to chest tightness 1, 2
• The mechanism involves central nervous system-visceral interactions, heightened body vigilance, lowered pain thresholds, and sympathetic activation causing cardiovascular changes 1, 2
• Patients misinterpret normal chest sensations as signs of serious illness (impending heart attack), which generates more anxiety, creating a vicious cycle that amplifies both chest pain and anxiety 5

Key Educational Messages for Patients

Explain the anxiety-chest pain cycle clearly:

• Anxiety produces real physical sensations in the chest—these are not "imaginary" or "all in your head" 5
• Worried patients focus more on bodily reactions and check their functioning repeatedly, increasing the likelihood of detecting changes and perpetuating the cycle 5
• Seeking repeated medical evaluation or reassurance can paradoxically increase worry and misinterpretation 5
• Each anxious reaction increases the perception of chest pain, creating a self-reinforcing cycle 5

Distinguish panic-related chest pain characteristics:

• Often presents as squeezing or tightness in the chest 2
• May last minutes to hours (unlike cardiac pain which typically follows exertion patterns) 2
• Worsens with stress rather than physical exertion 2
• Accompanied by other panic symptoms: shortness of breath, palpitations, sweating, trembling, feeling of choking, fear of losing control, or fear of dying 6, 7, 8

Evidence-Based Treatment Approach

Cognitive-behavioral therapy is the first-line treatment:

• CBT has demonstrated a 32% reduction in chest pain frequency in patients with non-cardiac chest pain 1, 2
• Seven sessions of CBT delivered by psychologists showed significant reductions in panic disorder severity, frequency of panic attacks, and depressive symptoms 9, 10
• Treatment focuses on identifying specific fears, educating about anxiety's role in producing physical sensations, and demonstrating processes that produce and maintain symptoms 5
• Patients are encouraged to take actions to disconfirm their worst fears rather than receiving passive reassurance 5

Pharmacological options as adjuncts:

• Selective serotonin reuptake inhibitors (SSRIs) are FDA-approved for panic disorder and effectively reduce symptoms 6, 7, 8, 11
• Paroxetine 20-40 mg daily or sertraline 50-200 mg daily are established treatments for panic disorder with chest pain symptoms 6, 7, 9, 10
• Short-term benzodiazepines may provide acute symptom relief while initiating CBT, with preliminary studies showing reduction in both chest pain and anxiety 8
• Evidence for antidepressants and anxiolytics in treating non-cardiac chest pain is mixed, making CBT the preferred primary intervention 1

When to Seek Emergency Care

Educate patients to call 9-1-1 for:

• New-onset chest pain that differs from their typical panic-related pattern 4, 1, 2
• Chest pain accompanied by diaphoresis, pallor, or radiation to arms, neck, or jaw 2
• Any chest pain in the context of new or worsening cardiovascular risk factors 3

Important caveat: Even patients with known panic disorder and anxiety-related chest pain require appropriate cardiac evaluation when presenting with chest pain, as having panic disorder does not exclude cardiac disease 2, 3

Follow-Up and Monitoring

• Schedule regular follow-up appointments to monitor symptoms and response to therapy 1
• Periodically reassess the need for continued treatment, as panic disorder is a chronic condition that may require long-term management 6, 7
• Document all patient education in the clinical record to facilitate consistent messaging from other healthcare providers 4
• Provide written information tailored to the individual patient, including an action plan for symptom recurrence 4

Addressing Healthcare Disparities

• Be aware that patients with non-cardiac chest pain often undergo extensive and repetitive cardiac testing with low referral rates to mental health services (less than 10%) 1, 2
• Cultural competency is essential, as there may be differences in the description and perception of chest pain among various diverse patient groups 4
• Women may describe chest pain differently than men, using terms like "tearing" more frequently and experiencing pain more often in the back, neck, and jaw 1, 2