Panic or the heart? What to check with a doctor before starting therapy

“I know what you’re going to say. That it’s panic. The A&E doctor said it, my mother said it, and Google said it at three in the morning. But I feel it in my chest. What if all seven people who told me that are wrong, and I die because everyone assumed I was just anxious?”

That sentence seems entirely reasonable to me. I do not try to argue it away. When something clamps down on your chest, your heart goes to a hundred and sixty, your breath deserts you and your arms turn cold, “is this my heart?” is a sensible question. Any doctor will tell you it is better to come in and hear that it is nothing than not to come.

So this piece is a practical one. I am not explaining here why a panic attack is not dangerous — I wrote about that separately. This is something more down to earth: what a doctor should actually check before we start therapy, why it matters that we do this once and thoroughly, and why doing it fifteen times does not help but harms.

The question is not stupid, and it is not a lack of faith

The first thing I want to say: anxiety and physical illness do not exclude one another. Someone with panic attacks can also have a thyroid disorder. Someone with an arrhythmia can also have panic — and often has it precisely because of the arrhythmia. “Just panic” is a phrase I do not use in my room, because hiding behind it is the assumption that the body has already been checked. Often it has not been.

Emergency department data are telling here. Among people who come in with chest pain and whose tests show no cardiac cause, a large share — typically between a quarter and a third in the research — have panic disorder, which most often goes unrecognised and unreferred. The reverse also holds: for people who have it, panic disorder is frequently the only explanation for chest pain, but that can only be said after an examination, not before.

What a doctor actually does

People often imagine that “every test” would have to be run. In fact, for a typical panic picture the basic set is short, and a GP can complete it in one or two consultations.

That is the core. Everything else depends on what the examination shows, and that is decided by a doctor — not by you, and not by me.

The ECG: what it says and what it does not

A resting ECG is a ten-second recording of the heart’s electrical activity. It reliably shows conduction problems, signs of a past heart attack, prolonged intervals, signs of strain on the heart muscle. In a young person with no risk factors, a normal ECG together with a normal clinical examination is a very strong argument.

What it does not say: it will not catch an arrhythmia that happened yesterday and is absent today. That is why, where there is suspicion, a doctor orders a Holter monitor — a recording of the rhythm over twenty-four hours or longer. It is worth doing if your attacks begin with a sudden, fast, perfectly regular pounding that ends just as abruptly. That pattern points more towards supraventricular tachycardia than panic, and it deserves to be recorded.

The thyroid: panic’s most common physical double

An overactive thyroid is the best impersonator of anxiety we have. Trembling hands, a pounding heart, sweating, feeling hot, restlessness, insomnia, weight loss despite appetite, irritability. People with untreated hyperthyroidism often spend months believing their mind has broken.

So TSH belongs in this set without discussion. It is a single tube of blood, and if the value is normal, the thyroid question is closed — not “let’s check again in three months”, but closed.

Anaemia and what follows it

Iron deficiency and anaemia are common in women of reproductive age and produce exactly the symptoms people attribute to anxiety: tiring quickly, breathlessness on the stairs, a pounding heart, dizziness on standing, poorer concentration. Low ferritin can cause fatigue even before haemoglobin has fallen.

Same section: hypoglycaemia. A drop in blood sugar gives trembling, sweating, hunger and anxiety — in someone who eats nothing all day and drinks coffee, it is a fairly common trigger for attacks that get blamed on the mind. It is neither rare nor shameful; it is something worth checking and correcting before we explain anything further.

What people search for at three in the morning

Let me name three things people find online and then carry around for months.

Phaeochromocytoma — an adrenal tumour that secretes adrenaline. It really does produce attacks that resemble panic. But it is extremely rare: a few cases per million people per year. If your doctor does not mention it, that is not an oversight but a reasonable judgement about probability. Suspicion is raised mainly by very high, paroxysmal spikes in blood pressure.

Mitral valve prolapse — once a very popular explanation for panic. More recent research has largely failed to confirm the link; it is a common and generally harmless anatomical variant. If it was ever mentioned to you, that on its own does not explain the attacks.

Pulmonary embolism — this is the one not to speculate about. Sudden breathlessness, sharp pain on deep inhalation, swelling in one leg, coughing up blood, or a recent long immobilisation, operation or long flight are reasons for immediate examination, not for an article.

What is not typical of panic

Even an anxious person benefits from knowing which signs do not fit the picture and deserve a fresh examination, even if the first was normal.

Pain that comes on with exertion and goes with rest is not typical of panic — panic more often arrives at rest. Pain that radiates to the jaw, neck or left arm accompanied by cold sweating and nausea. Fainting with genuine loss of consciousness — in panic people believe they will faint but rarely do, because blood pressure rises during an attack rather than falling. Attacks that begin after the age of fifty in someone who never had them before. And any attack that stays at the same high level for more than an hour — a panic wave peaks within minutes and then falls.

Why once and not fifteen times

Now the part that is hardest to accept, though every person with panic recognises it from their own experience.

The reassurance you get from a normal result works. But briefly. Research on reassurance after normal tests in people with a low probability of serious disease shows the same picture: anxiety drops immediately after the result, then returns to baseline within weeks. Each further check reassures for less time and fades faster. Eventually the checking itself becomes part of the illness — not of panic, but of health anxiety.

So in practice I suggest a simple agreement you make with yourself, and where possible with your doctor: we do the basic set once, thoroughly, we write it down — and then we do not repeat it for a year, unless something new appears from the list above. Without that agreement it is impossible to work, because every therapy hour ends at the same question.

What to do with a result that says everything is fine

The most common reaction to a normal result is not relief but disappointment. “So it’s all in my head.” It is not. The symptoms are in the body, real and measurable — the heart really does beat faster, the muscles really are tight, the breath really is shallow. A normal result only says that no organ damage is required to produce them. I wrote about why that is not the same as “there’s nothing wrong” in the piece on physical symptoms when the tests come back clear.

The second common reaction is mistrust: maybe they missed something. Here it helps to take the result as data rather than as a promise. A test does not promise that nothing will ever happen to you. It says that today, in this place, no cause was found. That is all tests can ever say, and also all we need in order to begin work. Moving from “what if” to “what now” is exactly what the piece on catastrophising is about.

How to get this done in Slovenia

Practically: start with your registered GP, not at A&E. At A&E they will assess you for an acute condition and send you home — that is their job and they do it well, but it is not the place for planned exclusion.

Go to the appointment prepared. Write down when the attacks started, how often they come, how long they last, what triggers them, which symptom comes first, which medicines and supplements you take, how much coffee and how many energy drinks you have in a day, whether you smoke cannabis, when you last slept eight hours. This saves the doctor half the consultation and gets you better care. I recommend something similar before a first therapy session too — that is the piece on preparing for a first visit.

If a referral stalls and the waiting time becomes an obstacle, see the piece on routes to help in Slovenia. And if it turns out that psychiatric care makes sense before therapy, that is not a step backwards — I described when the doctor comes first rather than last in the piece on when to see a psychiatrist first.

Where this advice does not apply

Now I have to argue against myself, because otherwise this would be dishonest.

The “once is enough” rule does not apply if you have known heart disease, diabetes, a thyroid disorder, take medication that affects heart rhythm, or have had a recent procedure. Then regular monitoring is part of treatment and has nothing to do with checking out of fear.

It also does not apply if the picture has changed. A new symptom, a different course, attacks in different circumstances — that is not rechecking, that is new information and it deserves a new examination. The line between sensible caution and compulsive checking is not in the number of visits but in whether you are led by new information or by old fear.

And third: for some people, ruling out a cause never brings peace, however complete it is. If fear is unchanged after five normal results, the problem is not too few tests — it is that the tests are answering the wrong question. That is the point at which it makes sense to stop looking for proof of health and start working with the fear itself.

What to remember

The question “is it my heart?” deserves an answer, not reassurance. The basic set is short: history and clinical examination, ECG, TSH, blood count with iron, glucose and electrolytes. Anything else is added if a reason for it appears.

Do it once and thoroughly, ideally with the same doctor, and keep the results in one place. A fifteenth examination does not bring fifteen times more safety — it brings less peace than the first.

Some signs are not typical of panic and deserve a fresh visit: pain on exertion, radiation to the jaw or arm, genuine fainting, first attacks after fifty, sudden breathlessness with pain on inhaling.

And once the exclusion is done, move the question. Not “what is wrong with my body”, but “what is my body trying to do, and why now”. From there the work is different — and possible.