A 40-year-old man woke up with a pounding heartbeat. He had been sleeping poorly, his activity had slowed down, and he had been struggling with underlying depression. That morning, along with the palpitations, he experienced a sudden sense of impending doom and broke into a cold sweat. He became increasingly frightened that something was seriously wrong with his heart and rushed to our hospital.His initial investigations were reassuring. Cardiac markers were normal, and doctors found no evidence of an acute heart attack. He went home, but the fear did not disappear. Three days later, the symptoms returned and he came back to the emergency department. Again, the investigations did not show a heart attack. He eventually underwent CT coronary angiography, which was also normal. Yet the symptoms felt very real.This is a situation emergency room physicians increasingly encounter: a person arrives with intense palpitations, sweating, fear and a feeling that death is imminent, convinced that something is wrong with the heart. Sometimes, the person may make multiple emergency visits because reassurance from one visit does not prevent the next episode. In many such cases, the underlying problem may be anxiety or panic attacks. But distinguishing a panic attack from a heart attack is important because the symptoms can overlap—and a potentially serious cardiac problem should never be dismissed as anxiety without appropriate medical evaluation.Also read | ‘Very different’: Cardiologist explains heart attack vs cardiac arrest vs heart failurePanic often begins with a surge of anxietyDuring a panic attack, a sudden wave of anxiety, fear or impending danger is often the dominant initial experience. The person may feel as though something terrible is about to happen, even when there is no obvious external threat. The physical symptoms then become increasingly prominent.The heart begins to race or pound. Breathing may become rapid. The person may sweat, tremble, feel dizzy or experience cold hands and feet. There may be a feeling of choking or tightness in the chest. Some people describe it as suddenly feeling as though they are sitting in an examination hall, with the body reacting as if it is facing an immediate threat.The frightening part is that the physical sensations reinforce the anxiety. A person feels the heart racing and thinks, “Something is wrong with my heart.” That thought increases fear, which releases more adrenaline, which makes the heart beat faster. The cycle continues. A panic attack can therefore feel overwhelmingly physical even though the underlying trigger is psychological.A heart attack is differentA heart attack occurs when blood flow to part of the heart muscle becomes blocked. The classic symptom is pressure, heaviness, squeezing or discomfort in the centre of the chest, although symptoms can vary. The discomfort may spread to the arm, shoulder, back, neck or jaw. Breathlessness, nausea, sweating, weakness or light-headedness may accompany it. Not everyone experiences the textbook pattern, which is why it is dangerous to rely on symptoms alone.Story continues below this adAn ECG and blood tests, including cardiac troponin, are important tools doctors use when evaluating someone for a heart attack. Depending on the clinical situation, additional testing—including coronary imaging—may be required. This is why someone experiencing new or unexplained chest symptoms should not simply assume they are having a panic attack.Also read | 4 heart attacks in 5 years and 8 stents: My patient is now fit; his biggest lesson wasn’t about surgeryThe age factor can be misleadingHeart attacks are more common as people get older, but age does not provide complete protection. Conversely, panic attacks are reported by people in their 20s and 30s.The emotional impact can be considerable. After one frightening episode, people may become hyper-alert to every heartbeat. A normal increase in heart rate after climbing stairs can suddenly feel threatening. They may repeatedly check their pulse, avoid exercise, stop going out alone or keep returning to hospital for reassurance.Panic attacks can follow a trigger—or appear unexpectedlyPanic attacks may occur after a stressful event, prolonged anxiety, lack of sleep or emotional upheaval. In other cases, there may be no obvious trigger.Story continues below this adWhen episodes recur, the person can begin changing their life around the fear of another attack. Sleep becomes disturbed. Work suffers. Social activities decline. Someone who once enjoyed watching a movie, meeting friends or going out may lose interest because anxiety has taken over. This can become particularly complicated when anxiety coexists with depression.Also read | Diabetologist shares case of 35-year-old who collapsed suddenly, had high BP, chest pain, obesity: ‘Don’t take your life so lightly’Don’t ignore recurrent panicOnce a doctor has appropriately ruled out an acute cardiac problem, recurrent panic symptoms should not simply be brushed aside.Repeated episodes can place a person under considerable psychological and physiological stress. Chronic stress and anxiety can affect sleep, blood pressure, activity levels and overall cardiovascular health. The answer is not to keep visiting emergency departments indefinitely, but neither is it to simply tolerate the symptoms.The next step should be appropriate treatment for anxiety and any underlying depression.Story continues below this adFive simple measures can form part of recovery1. Exercise: Regular, appropriately paced physical activity can improve mood, sleep and cardiovascular fitness.2. Meditation and relaxation: Mindfulness, controlled breathing and relaxation exercises can help a person recognise the beginning of an anxiety surge and prevent it from escalating.3. Take breaks from work: Constant work-related stress without adequate recovery can worsen anxiety. Regular breaks and boundaries are important.4. Maintain good sleep hygiene: Going to bed and waking at consistent times, reducing late-night stimulation and addressing persistent sleep problems can make a significant difference.Story continues below this ad5. Seek professional treatment: Panic attacks are treatable. Cognitive behavioural therapy and other psychological approaches can be highly useful. Medication may sometimes be prescribed by a doctor. Medicines such as Petril MD (clonazepam) should not be self-medicated or used routinely without medical supervision because benzodiazepines can cause drowsiness and dependence.When in doubt, get the heart checkedDo not try to diagnose a heart attack or panic attack at home. New or severe chest pain or pressure, particularly when accompanied by breathlessness, fainting, sweating, weakness, nausea or pain spreading to the arm, jaw or back, requires urgent medical evaluation. An ECG and appropriate blood tests can help doctors determine whether the heart is in danger. If the evaluation is reassuring and similar episodes continue, anxiety and panic should then be taken seriously as medical conditions in their own right.(Dr Shetty is lead cardiologist and medical director, Sparsh Hospital, Bengaluru)