Joey Wahler (Host): Their signs can be quite similar, but they're actually very different conditions. So, we're discussing the differences between a panic attack and a heart attack. Our guest, Dr. Robert Frankel. He's a cardiologist and Director of Interventional Cardiology at Maimonides Medical Center. This is Maimo Med Talk, a podcast from Maimonides Medical Center. Thanks for listening. I'm Joey Wahler. Hi, Dr. Frankel. Thanks for joining us.

Robert Frankel, MD: Good afternoon, Joey. My pleasure.

Host: So first, what are some of those symptoms that panic attacks and heart attacks share?

Robert Frankel, MD: Well, most of the time, people are having some sort of symptoms related to their chest. It could be a chest pain, a pressure, a tightness. Sometimes patients experience shortness of breath, palpitations or rapid breathing. And distinguishing between a panic attack and a heart attack is at times difficult. But we'll try to get through some of the differences between panic attack and heart attack. And these are the questions that cardiologists face every day when patients come into the hospital or come into the emergency room or come into a doctor's office. With chest pain, we try to determine is it cardiac in origin or is it not cardiac and due to some other reason.

Host: Sure. So, that begs the question, what are the main differences between the two and how does someone in your position establish that?

Robert Frankel, MD: So, the most common complaint that most patients have is some sort of a chest pain or chest discomfort. Distinguishing between whether it's cardiac or not can be done by a couple of several steps. So, the first thing we try to do is assess when does the pain happen? Pain that comes from the heart is usually a discomfort because of an imbalance of supply of blood versus the demand. So, most patients who have chest pain from the heart or angina usually experience that pain at high workloads, meaning so that if somebody is walking fast briskly up the street, walking up a hill, running to catch a bus, then the demand on the heart is higher because you're exercising more and, therefore, you need more blood flow to the heart. If you have a blockage, then you can't increase the blood flow because the blockage is preventing additional blood from going through the arteries. And so, patients that have that symptom on high workloads, it's more suspicious or more consistent with pain from the heart.

Pain that comes from just pressing on the chest area, the center of the chest or the left of the chest where most people feel their heart is, if you press on it and it causes you discomfort and that's the discomfort that you're experiencing, then most of the time that is not pain from the heart or a heart attack. The heart is deep inside the chest. It's below the skin, the muscles, and the ribs, and deep within the chest cavity. For most people, you really can't press on the heart to cause any kind of discomfort. So if you press on it and it's causing the symptoms for you, then it's less likely to be from the heart and more likely to be from other causes, such as musculoskeletal or some sort of strain, muscle strain or arthritic conditions.

When you have pain from the heart and you think you're having a heart attack, it's pain that usually comes on and stays with you. It's not a fleeting pain. It's usually a pain that stays with you for a period of time. It could be from, minutes to hours, if you're truly having a heart attack. And oftentimes, it can be associated with nausea, vomiting, shortness of breath, difficulty breathing, and sweating. So if you have those concomitant symptoms while you're experiencing the chest pain, then it is quite possible that you may be having a heart attack and should certainly seek care. Pain that comes and lasts only for a few seconds, a fleeting type of pain, that comes on suddenly like a stabbing or a sticking or a needle type of pain and then immediately goes away in a few seconds, is unlikely to be due to the heart.

And different people sometimes feel different symptoms. So patients who are diabetic, they have issues sometimes with sensation because the diabetes can affect the nerves and sometimes they don't feel chest pain like other people do. They may just get an annoyance feeling in the chest or some people feel it as a burning situation. Some feel it as a pressing situation, a squeezing situation. Many women don't get chest pain either. What they do get though is acute shortness of breath. And so, the symptoms can vary from person to person. But if they're associated with nausea, vomiting, associated with palpitations or becoming sweaty or diaphoretic, that would be a reason for concern and certainly one should seek medical care at that point.

I think the most important thing to understand that sometimes there's a blur and it's not so easy to distinguish between the two. And if you have to err on the side of conservatism, I would say that if you're not sure and the pain is not going away in a few minutes, then it pays to seek medical care, just to be certain. You know, if you should wind up in an urgent care or a doctor's office, or even a hospital, and it's not from your heart, then you just say, "Okay, I checked it out and everything is great." But if you sit home and you don't seek care, then you suffer some permanent damage or even death from a heart attack.

So, I can tell you a story that when I was a medical student, my own mom sat home and drank an entire bottle of Maalox. She felt that she had some sort of indigestion, epigastric pain, and completely finished a bottle of Maalox before she called her son, the medical student, that she was having these symptoms. Of course, I sent her to the hospital and she was having a heart attack, but did very well. So, it hits close to home, heart issues.

Host: Wow. So, I would imagine that's a story you shared with patients as a warning over the years, yes?

Robert Frankel, MD: Yes, it is. Yes, it is. You know, and some people don't want to call 911. There's a lot of phobia to do that. You know, they feel funny. Paramedics are going to come in. They're going to make a whole scene, or the ambulance may pull up with the flashing lights, and everybody's looking who's going into the ambulance. And so, some patients don't seek medical care because they don't want to stigmatize themselves or their families. And they choose not to seek medical care. And it's unfortunate because today what we are able to do when patients are in the early phase of a heart attack is to stop the heart attack.

Most of the time as an interventional cardiologist, we do an angiogram and take a look and see what artery is blocked. And then we pass a very fine, soft wire through the blockage, put a balloon in it, and usually put a stent in and open up the artery, restoring the blood flow, and, therefore stopping the heart attack.

So, if you seek medical care in a timely manner, we can stop the heart attack and hopefully limit the amount of heart damage that one would get. If you stay at home with the pain, one is you risk your life. But the second thing also is that the heart attack will go to completion, and so where we might be able to stop it at 50% of the damage If you stay at home and don't seek care and, you know, stay until the next day and then you go see your doctor in the office when his office opens, it's too late and the heart attack is already complete and whatever damage was going to be done is already done. So when the signs and symptoms speak of a heart attack, it really makes sense to go get professional opinion and seek care, get an EKG done. That's the safest thing and the most conservative thing to do.

Host: Gotcha. Well, you just mentioned how, from an interventional standpoint, a heart attack can be addressed. How about a panic attack?

Robert Frankel, MD: That's a great question. So, panic attacks, usually something clicks off the panic attack, there's some inciting event that would make one have a panic episode. And then, it's sort of a circular motion, so to speak, that you stay in this panic mode. And then, it plays upon itself and it gets worse and worse and the breathing gets shorter and shorter and one can find themselves breathing at a rapid rate. And so if that's the case, we generally tell people to inspire into a bag, usually a paper bag is best, and try to calm down. But most panic attacks will be alleviated with just reassurance. And if you're breathing rapidly, just breathe into a bag so you don't get lightheaded. Quite different from a heart attack. I think if one really feels this pressure, heaviness, tightness, constriction, weight on the chest, don't mess with that. Get it checked out.

Host: Can a panic attack ever lead to or even help cause a heart attack?

Robert Frankel, MD: Certainly. You know, so I mentioned that when you increase the demand on the heart if you have narrowings, then you will get chest pain because there's an imbalance of supply and demand. And so, anything that causes an increase in demand can certainly cause real chest pain and real strain on the heart and it could possibly lead to a heart attack. And so, I mentioned earlier about physical strain, walking in the street, running for a bus, going up a flight of stairs, but there's also mental strain that we all undergo. If you having a panic attack where your heart rate goes up, and your blood pressure can go up, that also increases the demand on the heart and it can lead to a heart attack, especially if you have underlying blockages that you don't know about. And so, I've seen people come in with a heart attack who got into an argument with somebody and had a heated argument and discussion, you know, that kind of strain actually led to a heart attack. But if you have normal arteries, it's unlikely that that would happen. But many people do have blockages and don't know about it until they have an excess strain placed upon them, either a mental strain or a physical strain.

Host: And then in summary here, better safe than sorry here is the simple rule of thumb, but don't some heart attacks have very subtle symptoms? So, maybe just make people aware, doctor, of how when you're erring on the side of caution, you need to keep in mind that heart attack symptoms may not be extremely obvious, right?

Robert Frankel, MD: That's true, that's true. May not be extremely obvious and we'd love to see patients prior to them having a heart attack. So, if you're walking in the street or walking rapidly, and you start to experience some chest discomfort, you slow down and rest and it goes away. These are signs and symptoms of not enough blood flow or an imbalance. And it's important for you to go to your physician to have it checked out. And if you find out that you have blockages, we can do things prior to having a severe episode such as a heart attack. So if you feel like you're having symptoms, it really pays to see your doctor, have your cholesterol checked and perhaps even get a stress test down the road and, therefore, avoid the heart attack. If you can prevent the event, that is the most important thing because once you have a heart attack you lose heart muscle. When you have a heart attack a portion of the heart muscle dies. And it never grows back. So if you lose heart muscle, it's permanent. So, the best thing to do is to seek medical care, get your cholesterol under control, see your physician, control your risk factors. If you're smoking, stop, obviously. Eat a heart healthy diet and get out there and exercise.

Host: Interesting. I did not know that about losing heart muscle when a heart attack occurs. Yet another reason to try to head it off at the pass. Well, folks, we trust you're now more familiar with the differences between a panic attack and a heart attack. Dr. Robert Frankel, perhaps life-saving information. Thanks so much again.

Robert Frankel, MD: Always a pleasure. Thank you, Joey.

Host: Same here. And for more information, please do visit maimo.org. Again, that's maimo.org. For an appointment, please call 718-283-8578. Again, 718-283-8578. If you found this podcast helpful, please share it on your social media. Thanks again for listening to Maimo Med Talk, a podcast from Maimonides Medical Center. I'm Joey Wahler.