Panic Disorder: Heart Risks and Management Strategies

Autonomic nervous system dysfunction (severe panic disorder) raises concerns about its impact on the heart?

Hello Doctor, I experienced my first panic attack at the age of 20 while studying in Hualien, which led to an ambulance ride to Tzu Chi Hospital.
After a series of tests, three doctors informed me that I had "hyperventilation syndrome." I didn't understand it at the time, being from Taipei, so I returned to Taipei and went to the psychiatric department at Shou Bei Hospital with the report.
After evaluation, I was diagnosed with anxiety disorder, and that's when I learned that anxiety disorder is a broad term with subcategories, one of which includes panic disorder.
Over the past 18 years, I have accumulated about two volumes of medical records, with over 30 emergency visits.
After completing my master's degree and entering the workforce, I now run my own company.
This panic disorder has troubled me for a long time.
I have a family history of hypertension and take medication regularly, keeping my blood pressure around 140/90, which I consider normal.
However, during panic attacks, my systolic blood pressure can spike to 160-200, and my diastolic pressure has reached as high as 110-130, with a heart rate of about 150, although these occurrences are rare.
I usually take Xanax 0.5mg (4 tablets a day) and Lisinopril, but for over a decade, I've only taken Xanax because it is the only medication that works for me.
Now that I am older, I am concerned about heart-related issues.
In the past two years, I have undergone cardiac evaluations at Tzu Chi Hospital, including EKG, echocardiogram, 24-hour urine collection for kidney function, and blood tests, all of which were normal.
The cardiologist mentioned that my right ventricle is slightly enlarged and suggested that I might be experiencing autonomic nervous system dysregulation, indicating a return to the psychiatric department.
They prescribed BOKEY 100mg for long-term use (to prevent embolism), but my doctor later discontinued it.
For the past ten years, I have consistently taken Prazosin 0.5mg, Xinfeng, and BOKEY, which I insisted on for the last three years.
I would like to ask the doctor, when I experience sudden panic symptoms, with rapid heartbeat and elevated blood pressure, what dangers could arise for my heart? When I consult my doctor, he always says these are typical panic symptoms, and the more I worry, the worse the symptoms become.
He attributes the high blood pressure to emotional factors.
Indeed, my blood pressure can drop from 150 to 128 within about 15 minutes after taking Xanax.
After reviewing my blood pressure records, the doctor can only suggest that I coexist peacefully with my condition, stating that it is not a heart problem.
However, during my recent emergency visit, I noticed some elevated cardiac markers, but the doctor said they were unreliable due to emotional stress, indicating that changes in sympathetic nervous system activity could affect heart values.
My test results included: 1.
Cardiac Troponin I (0.067 - normal range is 0-0.018) 2.
Creatine Kinase (213 - normal range is 25-175) 3.
Lactate Dehydrogenase normal, Creatine Kinase (MB) normal, and all other tests were normal.
Previously, these markers were within the standard range during health checks.
I am worried about potential myocardial infarction, although I usually do not feel discomfort in my heart and have no family history of heart disease.
Each time I follow up, the doctor reassures me that it is just autonomic nervous system dysregulation and not to overthink it.
He states that the Cardiac Troponin I level is not a reliable indicator, as all my other tests are normal.
I feel I need to consult a specialist for peace of mind.
I want to know if acute panic attacks can influence the levels of Cardiac Troponin I due to stress.
I am considering paying out of pocket for a CT scan, but I can confirm that after taking a sedative, my levels return to normal quickly.
Recently, I also had an EKG, which was normal, indicating that the rapid heartbeat is merely due to panic.
What should I do next? I am now so anxious that I am afraid to travel far or exercise.
I would like to ask the cardiologist if there are any further tests I should undergo, as it seems the only one left is a cardiac CT scan.
Or is it truly as my doctor says, that it is just autonomic nervous system dysregulation causing panic attacks, and the more I think about it, the worse it gets? I feel really lost.
In 2017, I had a comprehensive health check, and my heart was fine, but I still feel something is wrong.
Can the elevated Cardiac Troponin I levels during panic attacks truly be influenced by emotional stress? What further recommendations do you have for me?

Shisan Ye, 30~39 year old female. Ask Date: 2020/07/14

Dr. He Dongjin reply Cardiology

Hello, it is normal for panic to cause high blood pressure.
If multiple heart examinations show no issues, there is theoretically no need for concern.
The computer can produce false positives easily, and not every red flag indicates an abnormality.
Doctors also fear serious conditions; they won't insist you're fine just to send you home.
It's not that easy to dismiss concerns about myocardial ischemia.
You can take a sedative to quickly return to normal.
If you still feel uneasy, consider paying out of pocket for a CT scan for peace of mind.
Changhua Hospital cares about you.

Reply Date: 2020/07/14

More Info

Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic attacks, which are sudden periods of intense fear or discomfort that peak within minutes. Symptoms can include palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, dizziness, chills, or hot flashes, and a fear of losing control or dying. Given your history of panic attacks and the physiological responses you've described, it's understandable to be concerned about the potential heart risks associated with these episodes.

From a medical standpoint, panic attacks can indeed lead to temporary increases in heart rate and blood pressure due to the body's fight-or-flight response. This response is mediated by the sympathetic nervous system, which releases stress hormones like adrenaline. In your case, you mentioned that during panic episodes, your systolic blood pressure can spike to 160-200 mmHg, and your heart rate can reach around 150 beats per minute. While these numbers are concerning, they are typically transient and return to baseline once the panic attack subsides.

The heart risks associated with panic disorder primarily stem from the stress and anxiety that accompany the attacks rather than from any underlying heart disease. In individuals without pre-existing heart conditions, the heart is generally capable of handling these temporary spikes in heart rate and blood pressure. However, chronic stress and anxiety can contribute to long-term cardiovascular issues, including hypertension and potentially increased risk for heart disease over time.

Your recent tests, including EKG and echocardiograms, have shown normal results, which is reassuring. The elevated levels of cardiac biomarkers like troponin I and creatine kinase (CK) during a panic attack can occur due to the stress response, but they do not necessarily indicate permanent heart damage. These markers can be influenced by various factors, including muscle strain and anxiety, and should be interpreted in the context of your overall clinical picture.

Given your concerns, here are some management strategies you might consider:
1. Regular Monitoring: Continue regular check-ups with your cardiologist to monitor your heart health. If you experience any new symptoms, report them immediately.

2. Medication Management: It seems that you have found some relief with medications like Xanax (alprazolam). Discuss with your doctor the possibility of adjusting your medication regimen or exploring other options, such as SSRIs or SNRIs, which are often effective for anxiety disorders.

3. Therapy: Cognitive-behavioral therapy (CBT) is particularly effective for panic disorder. It can help you understand and manage your anxiety, reduce the frequency of panic attacks, and improve your overall quality of life.

4. Lifestyle Modifications: Incorporate regular physical activity, which can help reduce anxiety and improve cardiovascular health. Mindfulness and relaxation techniques, such as yoga or meditation, can also be beneficial.

5. Avoidance of Triggers: Identify and avoid situations that trigger your panic attacks when possible. Gradual exposure to these situations, under the guidance of a therapist, can also help desensitize you to anxiety-provoking stimuli.

6. Education: Understanding panic disorder and its physiological effects can help reduce fear. Knowing that your symptoms are a result of anxiety and not a heart problem can be empowering.

7. Emergency Plan: Have a plan in place for when you feel a panic attack coming on. This might include breathing exercises, grounding techniques, or having a trusted person to call.

In conclusion, while panic disorder can lead to temporary increases in heart rate and blood pressure, it does not inherently cause heart disease in individuals without pre-existing conditions. Your medical evaluations have been largely normal, which is a positive sign. Focus on managing your anxiety through therapy, medication, and lifestyle changes, and maintain open communication with your healthcare providers about your concerns. If you continue to experience distressing symptoms, consider seeking a second opinion or further evaluation to ensure your peace of mind.

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