Commentary: When heart attack symptoms are a false alarm - more awareness needed on panic attacks
Panic attack patients experience frightening symptoms that make them rush to the hospital, where they may not get a proper diagnosis, say Sharon Sung and Marcus Ong of Duke-NUS Medical School.

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SINGAPORE: Elizabeth (not her real name) was a top performer at her job and regular gym attender. One night she woke up with sudden chest pain and felt her heart racing. Gasping for breath, she tried desperately to understand what was happening to her.
She woke her husband who tried to calm her down, but she soon started feeling dizzy and was worried she might faint. They rushed to the nearest emergency department (ED) where Elizabeth was evaluated for signs of a heart attack. Tests, however, were negative and she was discharged with a follow-up appointment to see a cardiologist.
Over the next few weeks, she continued to experience almost daily episodes of chest pain and breathlessness. She became fearful of going out without her husband, took multiple medical certificates (MCs), and stopped exercising as a precaution. But her cardiology evaluation also found no physical cause for her symptoms.
What Elizabeth experienced was a panic attack. Panic attacks are not rare - world mental health surveys suggest that between 13 and 30 per cent of people will experience panic attacks at some point in their lives. Many of them will visit EDs at the onset of a panic attack, but it often results in extensive, repeated and unnecessary investigations without a proper diagnosis.
AN UNDER-DIAGNOSED CONDITION
Patients like Elizabeth come to the ED for good reason. They experience symptoms such as chest pain, shortness of breath, heart palpitations and dizziness, which can be very frightening, as these can be signs of a heart attack, stroke, or other life-threatening conditions. There is much less public awareness that these symptoms can also be related to stress or anxiety.
From 2013 to 2018, a team from Singapore General Hospital and Duke-NUS Medical School conducted studies at local hospitals to screen patients visiting an ED for panic attacks and a more severe condition called panic disorder.
We found that 24 per cent of ED patients with symptoms like chest pain, giddiness, shortness of breath, or heart palpitations met the diagnostic criteria for a panic attack and another 23 per cent met the criteria for panic disorder.
However, fewer than 1 per cent of them were discharged from ED with a diagnosis of panic-related anxiety or referral for treatment. Our local findings were nearly identical to studies conducted overseas that consistently show a lack of detection and early intervention for panic attacks at EDs.
After ruling out heart attack, stroke and other life-threatening conditions, most patients who present at ED with panic attack symptoms are discharged with a symptom-based diagnosis like “chest pain”, “palpitations”, or “dizziness and giddiness” and are referred to cardiologists or other specialists for additional tests.
Without appropriate mental health help, we have seen otherwise healthy adults like Elizabeth exit the workforce or significantly limit their usual activities due to panic disorder. Many also develop depression or suicidal thoughts.
Undiagnosed panic-related anxiety exerts a burden on the healthcare system. A recent local study by members of our team found that depression and anxiety disorders like panic disorder are associated with over S$600 million in healthcare costs, including medication, in-person visits and diagnostic tests.
Nearly half of the participants who reported anxiety symptoms had never been formally diagnosed. Over the previous year, 13 per cent had at least one visit to the ED, 9 per cent had at least one hospital admission, 7 per cent underwent an electrocardiogram (ECG) test and 6 per cent underwent a magnetic resonance imaging (MRI) scan.
PANIC ATTACKS ARE TREATABLE
Panic attacks are part of the body’s natural alarm system that goes off when we are in danger. When our alarm system is working well, it prompts us to react and get out of harm’s way immediately.
But sometimes our alarm system is overly sensitive and it gets triggered even when we are not in danger. These false alarms are what we call a panic attack, which is not life-threatening and very treatable. Early identification and treatment are very important to prevent occasional panic attacks from progressing to panic disorder, which is more severe.
The first step for someone who suspects they or their loved ones have panic attacks, after ruling out serious conditions like stroke and heart attack, is to request a comprehensive evaluation to determine if the symptoms are consistent with panic attacks or panic disorder.
Singapore has a network of more than 400 general practitioners (GP) who are trained to provide mental health services, which are also available at 17 of the existing 24 polyclinics. These numbers will be increased as part of the new national mental health and well-being strategy.
As part of a clinical trial, our team at Duke-NUS developed a quick and easy-to-use checklist for EDs to screen patients for panic attacks. We have used this tool to identify patients like Elizabeth in the ED and prescribed cognitive behavioural therapy (CBT), which involves patients learning how to respond differently to panic attack symptoms. Preliminary results suggest this treatment significantly reduces the impact of panic-related anxiety on patient’s lives.
Medications like selective serotonin reuptake inhibitors, commonly known as antidepressants, are very effective either alone or in combination. Patients can request a GP referral to see a psychologist for therapy or a psychiatrist for medication, depending on their preference.
After six CBT sessions, Elizabeth is back at work and exercising regularly. Recognising the problem and seeking help early is something everyone can do to help themselves or their loved ones.
Sharon Sung is Assistant Professor, Health Services and Systems Research Programme at Duke-NUS Medical School, and Supervising Clinical Psychologist, Department of Psychological Medicine at KK Women’s and Children’s Hospital. Professor Marcus Ong is Senior Consultant, Department of Emergency Medicine at Singapore General Hospital, and Director, Health Services and Systems Research Programme at Duke-NUS Medical School.