Chest Pain: Is It Anxiety, a Heart Attack, or COVID-19?

Panic disorder – whether you’ve lived with it for years or have developed it due to the pandemic – can cause chest pain, but cardiac and other physiological issues need to be ruled out before treatment can begin. And remember, any kind of chest pain requires medical attention.

Chest pain or tightness could be a symptom of the increased anxiety that is now prevalent in every facet of life as the COVID-19 pandemic continues to develop. Then again, it might not.

Chest pain also can be the result of a cardiac issue or due to a non-cardiac cause, such as gastroesophageal reflux disease, or GERD1, a muscle or skeletal problem in the chest,2 or even a symptom of COVID-19.3

When associated with a panic attack, chest pain is a common symptom, but how do we know what’s causing chest pain when we feel it? The only way to know for sure is  by seeking medical attention.

Heightened levels of anxiety can cause chest pain to develop. (Image: iStock)

When Anxiety Attacks the Body: Physical Symptoms

In some cases, heightened levels of anxiety can cause chest pain to develop. Anxiety is the body’s reaction to a perceived threat, explains Richa Bhatia, MD, FAPA, of the Anxiety and Depression Association of America.

“When people are anxious, their blood supply to different parts of the body can be decreased because the body is in a fight-or-flight response and more blood is directed to the muscles,” she says. Dr. Bhatia adds that people in a state of heightened anxiety often hyperventilate and breathe in a shallow manner, which can cause dizziness or chest tightness. 

What a Panic Attack Feels Like

Experiencing chest pain because of anxiety can be one of the symptoms of a panic attack, which is defined as a feeling of sudden, intense fear and the severe onset of four or more of these symptoms:4

  • chest pain
  • palpitations
  • sweating
  • trembling
  • feeling short of breath
  • feelings of choking
  • nausea
  • chills
  • feeling dizzy or lightheaded
  • numbness and tingling
  • fear of going crazy or of losing control.

A panic attack can happen when a person is feeling anxious, or it can occur out of the blue. The symptoms described above tend to last for roughly 10 minutes before fading. It is possible to have several panic attacks within a number of hours, which can feel like the attacks are coming in waves. Some people experience panic attacks daily or weekly. A milder variation of panic attacks, known as limited-symptom attacks, feature three or fewer of the symptoms listed above.5

Sometimes, a state of heightened anxiety can cause people to experience chest pain. “Chest pain is more common in a panic attack, but at times, people may also experience chest pain/pressure from high anxiety without having a full-blown panic attack,” says Dr. Bhatia.

 

Panic Attack or Heart Attack?

The symptoms of a panic attack can overlap the symptoms of a heart attack, clinically termed myocardial infarction (MI), making it difficult for a person to know which one may be occurring.6 People often go to the emergency room (ER) with chest pain believing they have a heart issue, but research shows that roughly 60% to 90% of ER patients with chest pain do not have a cardiac cause of the pain.7

How does a panic attack feel different from a heart attack?

Unfortunately, says Una McCann, MD, professor of psychiatry and director of the Anxiety Disorders Program at Johns Hopkins School of Medicine, “They can feel identical. People often are short of breath, feel dizzy, and can feel crushing chest pain. Somebody who is perfectly healthy, with great lungs, undergoing a panic attack can feel really, really short of breath. And then, of course, those symptoms feed on the panic so it builds exponentially to this enormous crescendo.”

Dr. McCann explains that because of the many different ways that people experience symptoms of  heart attacks and panic attacks, there’s no way to know the cause of those symptoms on your own.

“There are a variety of symptoms that people who are having myocardial infarctions  experience or don’t experience, so certainly if someone came in with a panic attack to an emergency room, they would undergo a full workup for an MI, no question,” she says.

Dr. Bhatia stresses that people should not self-diagnose their chest pain or assume that it is a panic attack, especially if they have never had chest pain before nor been diagnosed with panic disorder before. “Because anxiety disorders and panic disorder are diagnoses of exclusion, they can only be diagnosed once a physician has done a full medical check-up and ruled out underlying cardiac or other medical causes of chest pain,” she says. “Also, it is worth noting that even people [who experience] panic attacks can have chest pain of cardiac origin.”

 

Could My Chest Pain Be Because of the Coronavirus?

Chest pain is a rare symptom of COVID-19 and usually does not occur as the sole symptom. For instance, if your chest pain was due to COVID-19, you would most likely have accompanying signs of upper respiratory infection such as coughing and phlegm. And, the pain would not be due to a panic attack, says Dr. McCann. But again, because of the wide range of symptoms that people experience with COVID-19, there’s no way to know without getting checked by a healthcare provider. 

The CDC lists common COVID-19 symptoms as: fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell.3

 

When It is Panic Disorder: Treatment Options

When the cause of chest pain has been determined to be psychiatric (ie, anxiety) rather than cardiac in nature, patients and their doctors can discuss treatment. It is important to know that panic attacks can occur with any type of anxiety disorder--there are 5 in all:8

  1. generalized anxiety disorder
  2. obsessive-compulsive disorder
  3. post-traumatic stress disorder, or PTSD
  4. social anxiety disorder
  5. panic disorder.

A person must have recurring panic attacks and be fearful of having another to the point where it interferes with their everyday life in order to be diagnosed with panic disorder. According to the American Psychiatric Association, 2% to 3% of US adults are diagnosed with panic disorder in a given year. Anxiety disorders affect women more than men.8

Dr. McCann says that it is possible for a person with no history of anxiety to develop panic disorder because of the stress of the coronavirus pandemic.

“A person can develop panic disorder (PD) for the first time in the setting of COVID-19,” she explains. “However, there are specific ‘criteria’ that must be met for it to be characterized as PD. In particular, symptoms need to be present for at least 1 month. People need to change their behaviors in maladaptive ways (or have a month of persistent fears about having another panic attack).”

She notes that sleep problems can play a huge role in the development of panic disorder. “Poor sleep increases the risk of recurrent panic attack. Anxiety related to panic often leads to poor sleep, resulting in a self-perpetuating negative cycle,” she says. Cognitive behavioral therapy (CBT) can be an effective treatment for panic disorder. Dr. McCann describes CBT as a way to recognize abnormal, irrational thought patterns and the behaviors that one engages in when these thoughts occur. A CBT therapist helps patients practice helpful behaviors that can reduce panic symptoms. Techniques like breathing retraining, meditation, and yoga can help patients identify and reduce the tension in their bodies when they are anxious. (Learn how to practice CBT at home.)

Both Dr. McCann and Dr. Bhatia emphasize that, even with a diagnosis of panic disorder, it’s possible for a patient to have cardiac or medical chest pain that should not be ignored.

 

How to Hang On: Coping During a Pandemic

A poll conducted in mid-April 2020 by the Kaiser Family Foundation (KFF) found that 56% of adults reported that worry and stress because of the pandemic has had a negative effect on their mental health.

Respondents reported adverse effects such as trouble sleeping, poor appetite or overeating, frequent headaches or stomachaches, difficulty in controlling their temper, or increasing alcohol/drug use, and worsening chronic conditions like diabetes or high blood pressure. This is up from 45% reporting that stress over coronavirus had negatively affected their mental health in a KFF poll conducted in late March 2020.9

“Right now everybody has increased anxiety, whether you’re healthy as a horse, whether you have a psychiatric illness, or not,” says Dr. McCann.

Telemedicine can help by connecting people with their doctors, and video meeting apps provide a means to keep up a social life as we remain in our homes. More on how to access telemedicine.

Dr. McCann also suggests exercising together with friends via video chat to support social interaction, while Dr. Bhatia recommends practicing mindfulness to ease stress.

Symptoms that are related to anxiety/panic can improve with mindfulness-based breathing exercises,” says Dr. Bhatia.10 More on this technique from Dr. Bhatia. 

 

More Resources

The following pages contain additional recommendations on how to cope with heightened stress and anxiety during the COVID-19 pandemic.

And remember, if you experience any type of chest pain, it is important to seek immediate medical care.

Updated on: 05/11/20
Continue Reading:
How to Deal with Heightened Anxiety During COVID-19
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