Is Your Chest Pain a Heart Attack or Anxiety?

Picture this: Your heart is racing. It feels like it’s not just beating in your chest but in your throat and neck. It’s beating so hard that it’s impossible to think of anything else.

You feel short of breath, but short of breath doesn’t quite describe it. It’s more like you’re smothering or choking. And when you think about it, swallowing is difficult, too.

On top of this, you’re sweating and shaking uncontrollably. And you are dizzy to the point of needing to throw up.

Your chest gets tighter and tighter. You feel a sense of impending doom. You’re worried that you may be having a heart attack. What else could it be?

Am I having a heart attack?

First, a disclaimer: If you feel badly enough to wonder if you’re having a heart attack, you should go to the emergency room.

That’s because there are no single defining characteristics that will tell you if you’re having a heart attack, says Gary Weeks, MD, a cardiologist at the UW Medicine Heart Institute.

It’s always better to be safe rather than sorry when your heart is involved. But chances are that your terrible feelings are not those of a heart attack, but of a panic attack instead.

Approximately one quarter of patients who go to the emergency room for treatment of chest pain have panic disorder, says Mark Sullivan, MD, a UW Medicine psychiatrist.

Panic disorder is a type of anxiety disorder that causes repeated, often unexpected, panic attacks and fear of having another panic attack. It is most often diagnosed in women but can happen to anyone.  

Can an anxiety attack really feel THAT bad?

During an anxiety attack, adrenaline courses through your body. Everyone experiences the effects of this adrenaline differently, but some symptoms are common, such as a racing heart, shortness of breath, tightness in your chest, dizziness, sweating, trembling, an upset stomach and a feeling like you might die.

Unfortunately, a panic attack has symptoms that closely resemble those of a heart attack, making it hard to tell the difference between the two, says April Stempien-Otero, MD, a cardiologist who practices at the UW Medicine Heart Institute.

“Your body is preparing you to either fight off a threat or flee to safety, and that’s serious stuff,” she says.

It is thought that panic attacks occur when the brain's fear circuity misfires, triggering the body's emergency fight or flight response. This reaction, in turn, heightens the brain's fear response, creating a fear-intensifying feedback loop. 

How do heart attack symptoms differ from anxiety symptoms?

The classic symptoms of a heart attack are a heavy central chest ache and squeezing and tightness that can radiate into the jaw or the left arm.  

Not everyone may have symptoms that are this noticeable, though. Women may experience similar symptoms not only in the chest area but in between the shoulder blades. They can also feel generalized upper back or neck discomfort, says Weeks.

Sometimes in women, the essential feeling from a heart attack can be shortness of breath and discomfort. Women are also more likely to experience overwhelming fatigue.

What should I expect at the emergency room?

You are seen quickly at the emergency room when you come in saying you have heart-related symptoms. You will receive a physical exam, a troponin blood test and an electrocardiogram along with questions about your immediate symptoms and your medical history.

The doctor will assess all of these factors to determine if you are experiencing a heart attack.

If an emergency room doctor determines that you are not experiencing a heart attack, it’s still a good idea to follow up with your own doctor afterwards, says Stempien-Otero. The tests in the emergency room determine only whether you’re in the midst of or just experienced an acute heart attack.

“It doesn’t necessarily mean that nothing happened, but it means that you are unlikely to progress to something serious right away,” says Stempien-Otero.

And, of course, if your symptoms are due to anxiety, that’s something you should discuss with your primary care provider. They can offer some treatment options, plus refer you to a therapist if needed.

What causes a heart attack?  

Heart attacks are typically caused by coronary artery disease, which is a buildup of plaque, called atherosclerosis, in the heart’s arteries that reduces blood flow and oxygen to the heart. Risk factors include age, high blood pressure, high cholesterol, diabetes, tobacco use and a family history of early-onset heart disease. 

“This means that if there is a 25-year-old woman with no risk factors, then the chances that she has coronary artery disease are very small,” says Weeks. “And because coronary artery disease is the most likely cause of a heart attack, her chances of having a heart attack are slim, too.”

The symptoms of coronary artery disease typically come on with exertion and tend to go away with rest. But there are rare syndromes that could cause a heart attack in a young person, says Weeks. These include spontaneous coronary artery dissection, coronary artery anomalies, and stress-induced cardiomyopathy, among others.  

“That’s why it’s important to go to the emergency room to get checked out if you experience relevant symptoms,” says Stempien-Otero.

How can I safely rule out a heart attack?

Stempien-Otero suggests that patients follow up with a treadmill echocardiogram test. During a treadmill echocardiogram, you exercise on a treadmill or stationary bike while your doctor monitors your blood pressure, heart rhythm and any discomfort you feel. An ultrasound picture of the heart is done to check heart function.

A treadmill echocardiogram is an easy, non-invasive test to rule out just about anything that could be wrong with your heart, says Stempien-Otero. It would pick up abnormal changes in your heart rate or blood pressure, heart rhythm, heart function or electrical activity.

If you have this test and the results are normal, it’s very reassuring, says Stempien-Otero. If you have symptoms again, you can be reassured that they are likely nothing to worry about.

And luckily, panic disorder is treatable, says Sullivan. Proven treatments include selective serotonin reuptake inhibitors such as Prozac and cognitive-behavioral therapy, he says. 

This article was originally published February 23, 2018. It has been reviewed and updated with new info. McKenna Princing contributed to this article.