New onset panic attack in patient w/new, possibly malfunctioning defibrillator

nancysinatra · Feb 5, 2009

I was in the ER today, and we had (what seemed to me anyway) a really interesting patient. The patient was a 48 year old man with a history of an MI ten years ago followed by CHF. He had a defibrillator/pacemaker placed three years ago following sudden cardiac failure from which he had been luckily revived. (He was revived with induced hypothermia and coma--another interesting feature!) Over the holidays, this defibrillator (which had never fired before) fired repeatedly and he was brought to the ER. He developed heart failure and pulmonary edema. Those were treated, and he was discharged. I'm not sure why exactly, but he received a new, fancy defibrillator/pacemaker last week. Apparently, this thing is the Porsche of defib/pacemakers, because all the attendings were drooling over how many wires it has and what a nice rhythm it makes.

In the last month, he has also developed a new onset (or so he says) complaint of anxiety. For the past month he had been very worried about his health, and his PCP had recently referred him to a psychiatrist, and in the meantime prescribed Ativan.

When he came in today he was sweating, lightheaded, short of breath, trembling and said he felt palpitations and a "weird" feeling in his chest similar to when his defibrillator went off last time. What he THOUGHT was happening was that his new defibrillator was firing. The attending was worried about real heart problems, including tamponade as a result of one of the new wires having punctured the heart. He got a pretty big cardiac workup, including of course EKG, but also ultrasound, and interrogation of his new defib/pacemaker, which turned out to be ok. In the end the conclusion was that this was anxiety, not cardiac. This being the medical ER it wasn't the most in-depth psych work up but it was still pretty interesting.

I know EKG is common for patients who ultimately turn out to have panic attack. But how often do such patients get more involved cardiac workups and an urgent visit by the cardiologist? I wonder if this patient is going to have similar scenarios in the future, where the differential is panic disorder vs defibrillator issue. How often is panic disorder obscured by a very serious medical problem being in the differential like this, one that requires a big time workup? Is this the typical deal, where a specialist comes in? If so, panic disorder must be a major problem for emergency doctors!

Another thing this got me thinking about is, well, this poor guy has very good reason to be anxious. Is panic disorder more common among people with real things to panic about (I know stress can cause anxiety, but I'm talking about where there's a real prospect of death looming)? Yeah, I could probably look this up...

And meanwhile, we had another patient today who had RLQ abdominal pain, but due to the nature of her situation we didn't want to mask her pain and so gave her little by way of pain meds. Now are there ever situations in anxiety (as opposed to pain) where you are concerned with masking the anxiety, or where you just realize that the patient has a really good reason for their anxiety, and so choose not to treat it too aggressively? Or is severe anxiety always pathological, regardless of the patient's situation? Theoretically speaking, is there ever a situation where you'd be concerned about interfering too much with the fight-or-flight response? Kind of a strange question, I suppose, but I was just wondering!

masterofmonkeys · Feb 5, 2009

I think we are still scratching the surface of the link between mind and body. It's a loop. Body can affect the mind and mind can affect the body.

Panic symptomatology and its relationship with the heart is still being fleshed out. But there is a lot of interesting work being done on Mitral Valve Prolapse Syndrome, which is recognized to be a dysautonomia. A couple of years ago we recognized that mitral valve prolapse has a link with panic attacks/disorder. Where things get interesting is in the complexity of this relationship. People with MVP are predisposed to panic attacks. Panic attacks are associated with SVT/palpitations. MVP is associated with SVT/palpitations. Some patients with MVP report palpitations/SVT but not panic.

Could he have had a run of SVT inducing a panic attack with a normal EKG and no firing from the pacemaker/defibrillator? Absolutely depending on what the settings and parameters were on the pacer/defib, and if the EKG was actually done during the episode of palpitations.

Furthermore, baseline anxiety lowers your threshold for both SVT (I believe, can't cite sources offhand) and panic attacks.

And anxiety in the cardiac patient population as a comorbidity is off the charts. I believe that this is both cardiogenic and psychogenic in nature.

It is absolutely essential to do a thorough cardiac workup in a patient like this. In a healthy young patient with a clean EKG and no mid-systolic click or murmurs appreciated, you can probably forego an extended cardiac workup. But if a mid-systolic click is appreciated, I would get an echo and consider treatment with a beta blocker if it reveals MVP. But cardiogenic anxiety/panic attacks secondary to SVT have NOT been ruled out in your patient. Defibrillator issues have though.

Oh I'm an MS4 and have no idea wat the actual practice guidelines are, this is just my personal opinion.

Eagerly awaiting Doc samson's take.

edit: wherever I said go ahead and insert 'or sinus tachycardia' as well.

masterofmonkeys · Feb 5, 2009

nancysinatra said:
And meanwhile, we had another patient today who had RLQ abdominal pain, but due to the nature of her situation we didn't want to mask her pain and so gave her little by way of pain meds. Now are there ever situations in anxiety (as opposed to pain) where you are concerned with masking the anxiety, or where you just realize that the patient has a really good reason for their anxiety, and so choose not to treat it too aggressively? Or is severe anxiety always pathological, regardless of the patient's situation? Theoretically speaking, is there ever a situation where you'd be concerned about interfering too much with the fight-or-flight response? Kind of a strange question, I suppose, but I was just wondering!

two situations where I'd be worried about concealing anxiety symptoms are diabetics and heart disease. I have personally seen several cases of patient complaint of anxiety being the only presenting symptom of both hypoglycemia and heart attack. I will never forget the colon cancer patient who a day after his surgery just looked at me and said 'when are you gonna tell me the truth?" "sir, we got all the cancer." "No, that I'm gonna die." He proceeded to have a heart attack...and then died after being on pressors for a month.

Patients on long-acting hypoglycemics (like chlorpropamide for instance), insulin, intermittent tachycardia, or at high risk of heart attack would all thus freak me out about going overboard on treating their anxiety. The thing is they might not actually have ST elevations, TnI/TnT bumps, or low FSBG when you see them. If your diabetic patient has lost a significant amount of weight or significantly improved their diet but remains on the same dosage of his/her sulfonylurea or other oral hypoglycemic, they might be having transient hypoglycemic attacks. If your patient has an intermittent arrhythmia, they might not have anything visible on echo or EKG. etc etc etc. No good answer on when to treat or not to treat their anxiety symptomatology though. My focus would instead be on ruling out and investigating other sources of anxiety symptoms.

I think the underlying thingy for me with regard to anxiety is that it is so wrapped up with autonomic activation/dysregulation, that I am very concerned about whether it is somatogenic or psychogenic in origin.

OldPsychDoc · Feb 5, 2009

nancysinatra said:
... Now are there ever situations in anxiety (as opposed to pain) where you are concerned with masking the anxiety, or where you just realize that the patient has a really good reason for their anxiety, and so choose not to treat it too aggressively? Or is severe anxiety always pathological, regardless of the patient's situation? Theoretically speaking, is there ever a situation where you'd be concerned about interfering too much with the fight-or-flight response? Kind of a strange question, I suppose, but I was just wondering!

I think that for CBT to be effective in treating anxiety, "not masking it" is EXACTLY the way to go. It takes more time to educate a patient about their fight/flight response and help them to realize that even though they FEEL like they are dying, they are not and will not and that this awful feeling will pass. This is why benzos are such a problem--they take away that awful feeling, and for a patient who just wants to feel better they'll do the trick, over and over again. That said, you can't do good CBT if a patient is terrified and paralyzed, so treating acute anxiety is still a good thing to do.

whopper · Feb 5, 2009

This case you mentioned is a classic reason why psychiatrist & IM docs shouldn't just dump out the knowledge they obtained in medical school about the other field. Reminds me of a case where someone I had was compliant on their psyche meds, but noncompliant on their asthma meds. Then they'd having a respiratory problem, their doctor prescribed steroids, and the person then went into mania and never associated the 2 because his PCP & psychiatrist weren't working together on this case.

http://www.psychosomaticmedicine.org/cgi/content/abstract/63/2/231
http://www.mayoclinicproceedings.com/content/80/2/232.refs
The above articles, in addition to several others have noted that those with defibrillators may be at risk of panic attack or other anxiety disorders. Some of it from articles I read were from a cognitive perception that the person had no control over when the next shock would occur--> giving a feeling of helplessness which in turn turned into anxiety.

I remember hearing anectdotally (so someone correct me if I'm wrong) that when an implantable defibrillator goes off---> its was the equivalent of pain to getting punched in the abdomen by a golden gloves boxer.

Well anectdotal, but the idea of getting shocked at any moment certainly isn't a positive thought.

Current Psychiatry had I believe a good article a few years ago on defribrillators & anxiety disorders.

In such a case, doctors from both fields should be working together & in cooperation.

How often is panic disorder obscured by a very serious medical problem being in the differential like this,

Don't have any hard data, but about once every 2 months I'd see a case where I detected a non-psychiatric medical issue being mixed with the psychiatric issue. Often times the patient had a situation where the 2 issues were not being worked upon in a cooperative manner by the psychiatrist & other medical doctor working on the case. I don't know if it was just an honest mistake, a trend I've noticed where several get locked into a mental box of thinking only within their own field, or simply the doctors not taking the time & effort to communicate with each other.
Some other cases I remember, patient was labelled as psychotic, who had a known history of bipolar. When she started acting funny, her psychiatrist (who I knew and he is a good psychiatrist) had her committed to inpatient. Her calcium levels were high. She was also "sundowning". Antipsychotics weren't getting her any better. The sundowning was a tip to me that this was delirium, and therefore not a psychosis as a result of her bipolar disorder. Her elevated calcium was the only thing that tipped me off that something was wrong. PTH labs were ordered, and they were abnormal, indicating she had hyperparathyroidism. She got better after that calcium levels were brought back to normal. Her psychiatrist was surprised since she had been psychotic in the past, and never had any parathyroid problems in her history.
Had another patient with hypercalcemia who was depressed. She was on Zoloft and presented with several symptoms of hypercalcemia. I ordered a lab workup to check the calcium levels and they were above normal. I unfortunately didn't have her long enough to see if the depression was caused by the hypercalcemia. We scheduled a meeting with an endocrinologist to treat her, but by the time that happened I was on another rotation.

OldPsychDoc · Feb 5, 2009

whopper said:
This case you mentioned is a classic reason why psychiatrist & IM docs shouldn't just dump out the knowledge they obtained in medical school about the other field. Reminds me of a case where someone I had was compliant on their psyche meds, but noncompliant on their asthma meds. Then they'd having a respiratory problem, their doctor prescribed steroids, and the person then went into mania and never associated the 2 because his PCP & psychiatrist weren't working together on this case..

I work in a system with a common EMR shared between all disciplines in our network, and we STILL have problems working together. What's killing me is how many of my colleagues have forgotten that TCAs are ANTIDEPRESSANTS! I get these patients admitted to me on amitriptylline ("for my sleep and fibro, doc") and Cymbalta ("my 'regular doctor' said it would help my pain and my depression") and, of course, klonopin or valium and an opiate for "breakthrough" pain. <sigh>

billypilgrim37 · Feb 6, 2009

OldPsychDoc said:
("my 'regular doctor' said it would help my pain and my depression")

Does that mean you are his "92 octane doctor," then?

Doc Samson · Feb 6, 2009

I've seen several of these cases. Anticipatory anxiety is the key here, which is why it so closely follows the clinical course of classic panic. Just as a panic DO patient's worry about repeat panic attack is what often triggers a panic attack, these folks worry about AICD malfunction - also precipitating a panic attack. Whether the initial source of anxiety is "real" ir somewhat irrelevant. I'd go SSRI + BZD (klonopin not xanax) + Clonidine (if he can tolerate it from a cardio standpoint), with plan to taper the BZD over time.

nancysinatra · Feb 6, 2009

Thanks for these interesting responses everyone! Whopper, I just got home but am looking forward to reading those articles you found. Thanks!

masterofmonkeys said:
I think we are still scratching the surface of the link between mind and body.

You're not convinced it's the neck?

masterofmonkeys said:
A couple of years ago we recognized that mitral valve prolapse has a link with panic attacks/disorder.

That's really interesting--I had never heard of that.

masterofmonkeys said:
Could he have had a run of SVT inducing a panic attack with a normal EKG and no firing from the pacemaker/defibrillator? Absolutely depending on what the settings and parameters were on the pacer/defib, and if the EKG was actually done during the episode of palpitations.

Well, ok, I'm not very knowledgeable about pacemakers and paced rhythms, but his rhythm was paced the entire time. He never was tachycardic. His own sinus node sets the rate and rhythm about 80% of the time--if it did not the pacemaker would take over--but 100% of the time, the pacemaker takes up his rhythm and causes the ventricles to contract together. Also, he continued to endorse the funny feeling even while we were watching his normal EKG.

masterofmonkeys said:
It is absolutely essential to do a thorough cardiac workup in a patient like this. In a healthy young patient with a clean EKG and no mid-systolic click or murmurs appreciated, you can probably forego an extended cardiac workup. But if a mid-systolic click is appreciated, I would get an echo and consider treatment with a beta blocker if it reveals MVP. But cardiogenic anxiety/panic attacks secondary to SVT have NOT been ruled out in your patient. Defibrillator issues have though.

He got a thorough workup. I wasn't in the room the entire time the cardiologist was there so I don't know everything that happened. He had just had the pacemaker placed and the cardiologist who saw him in the ER spoke with the cardiologist who had placed it. I can't imagine he hasn't had a recent echo. In fact I know he did--he reported that his most recent EF was 10%.

I guess my question is just whether this poor patient is going to have to have his pacemaker interrogated and perhaps even be worked up for tamponade every time he has a panic attack for the rest of his life. He does have a referral to a psychiatrist and hopefully this will not happen again, but I'm just saying, I feel sorry for him if it does, because it surely can't be therapeutic for a panic disorder patient with such bad heart disease to be worked up multiple times for tamponade, arrhythmias, etc. (Though tamponade seems to be a danger more of recently placed pacemakers). Think of a person who gets panic attacks on airplanes--how much worse their panic attacks would start to get if EVERY time they had a panic attack it coincided with a delay of the flight due to mechanical failure of the plane that required urgent inspection. (For example say they were only able to fly on one airline, and it was a very, very crappy airline). This person would never get to experience a normal flight. How could that possibly help their panic disorder?

About not concealing too much of a person's anxiety, for therapeutic purposes--I can definitely understand how if a patient is leaning on benzos to quell their anxiety, you'd want to teach them some skills to deal with the anxiety instead, by facing some of it and realizing they will live through it.

What I was thinking of here was more along the lines of the fight or flight response at times when it is needed. For example, what about that pilot who flew the plane that landed in the Hudson? What if he had been receiving CBT for anxiety? When your plane is going down--that is NOT the time to tell yourself "You'll live through this, so just relax." (hee hee.) Or what if he were taking beta blockers for stage fright? (I would say benzos here but obviously, a pilot couldn't take benzos, and obviously, a benzo would interfere with his ability to react to anything). Anyway, something like that. Would his ability to react quickly and precisely and NOT panic, but at the same time NOT remain blase either have been effected if he were being "treated" for anxiety in some way? What I'm asking is, can you interfere with the sympathetic fight or flight response through anxiety treatment? Please forgive me if the scenario I'm proposing has holes in it in the real world. I'm not even sure that pathological anxiety even works through that system. So most of the treatments don't go through that system either. But beta blockers are used for stage fright. And people with panic disorder get autonomic symptoms. Aside from the obvious problem of other side effects, could you provide so much sympathetic blockade to a person that if a tiger entered the room, the person would just sit there and let themselves be eaten?

Now I am trying to learn why beta blockers are not used more broadly for anxiety since they are effective in certain situations. It's one of those subjects I guess, where the answer is probably so well known that it's common medical knowledge and there isn't an easily searchable article I can find. Sorry if I'm sounding foolish, I've just never heard why this is.

Oh, and another thing, once I've seen a few more interesting patients like this, I think I will start a thread along the lines of "Crazy Differentials." This one is crazy because at the top was basically Tamponade vs Panic Attack, and how often do those two things go together?

Abram Hoffer · Feb 6, 2009

There will come a day when this patient will be covered by a cardiopsychiatrist -- one who knows the in's and out's of cardio, psychiatry, and their crossover. Psych issues are a contraindication to AICD's, but the funny thing is... most people develop psych issues after they get shocked. How about the prosthetic heart valve that clicks 24/7? Depression and cardio issues go hand in hand.

whopper · Feb 6, 2009

I just got home but am looking forward to reading those articles you found. Thanks!

good to see the passion in your words. This to me is REAL psychiatry. Its understanding something to a level that transcends mere diagnosis & prescribing a pill.

Oh, by the way, I found the Current Psychiatry article I mentioned.
http://www.currentpsychiatry.com/article_pages.asp?AID=5305&UID=

Don't know if you'll be able to see it without being a CR member.

nancysinatra · Feb 6, 2009

whopper said:
good to see the passion in your words. This to me is REAL psychiatry. Its understanding something to a level that transcends mere diagnosis & prescribing a pill.

Don't give me too much credit. The main reason I have been posting so much lately and thinking about psychiatry is because I am supposed to be studying for Step 2. But thanks for the links!

OldPsychDoc · Feb 6, 2009

Abram Hoffer said:
There will come a day when this patient will be covered by a cardiopsychiatrist -- one who knows the in's and out's of cardio, psychiatry, and their crossover. Psych issues are a contraindication to AICD's, but the funny thing is... most people develop psych issues after they get shocked. How about the prosthetic heart valve that clicks 24/7? Depression and cardio issues go hand in hand.

We did ECT on a pt with an AICD--anesthesia had to turn it off with the magnet thing before each procedure...

Abram Hoffer · Feb 7, 2009

OldPsychDoc said:
We did ECT on a pt with an AICD--anesthesia had to turn it off with the magnet thing before each procedure...

Wow! Impressive that you were willing to take the risk(s). Most would run the other way. ECT is the only option (thank God it's available) for some. Thanks for the info.

masterofmonkeys · Feb 7, 2009

Meh. For an ICD, the risk is minimal. What are the odds of someone going into an arrythmia right there, right then? Pretty low. Besides, just shut off hte equipment and pull off the magnet. AICDs are implanted for a reason *shrug*

Even for a pacer, it still shouldn't be a huge deal.

Now an end-stage CHF patient with an EF of 5-10% with complete heart block on Bi-V pacing, yeah I'd freak a little bit. Then again, I tend to freak out even looking at those patients.

masterofmonkeys · Feb 7, 2009

nancysinatra said:
What I was thinking of here was more along the lines of the fight or flight response at times when it is needed. For example, what about that pilot who flew the plane that landed in the Hudson? What if he had been receiving CBT for anxiety? When your plane is going down--that is NOT the time[ to tell yourself "You'll live through this, so just relax."

Actually it is a pretty good time to do so. Remember, CBT works ABOVE the hypothalamus. His fight or flight response will still be intact. However his emotional centers' response to it (and consequent inhibition of frontal areas) will be diminished. I think that's absolutely a good thing.

Or what if he were taking beta blockers for stage fright? (I would say benzos here but obviously, a pilot couldn't take benzos, and obviously, a benzo would interfere with his ability to react to anything). Anyway, something like that. Would his ability to react quickly and precisely and NOT panic, but at the same time NOT remain blase either have been effected if he were being "treated" for anxiety in some way? What I'm asking is, can you interfere with the sympathetic fight or flight response through anxiety treatment?

Absolutely you can. That's why I'm not the biggest fan of long-term pharmacologic treatment for anxiety.

Please forgive me if the scenario I'm proposing has holes in it in the real world. I'm not even sure that pathological anxiety even works through that system. So most of the treatments don't go through that system either.

Pathological anxiety absolutely DOES work through that system. It's a complex issue because pathological anxiety is partially an overblown cognitive and emotional RESPONSE to normal sympathetic activation (i.e. fight or flight), but is also an INDUCER of pathologic sympathetic activation and tone. I think the research is far from conclusive on this, but based on my own readings in this area, I believe that anxiety starts with the abnormal frontal and limbic response to fight-or-flight, which leads to potentiation of fight-or-flight.

But beta blockers are used for stage fright. And people with panic disorder get autonomic symptoms. Aside from the obvious problem of other side effects, could you provide so much sympathetic blockade to a person that if a tiger entered the room, the person would just sit there and let themselves be eaten?

Unlikely. Sympathetic neurons are pretty simple. The frontal brain is not. If a tiger enters the room, any individual with intact cognitive processes is going to say"oh crap there's a tiger coming to eat me". What will be affected are all the ways the SNS helps you respond effectively. (i.e. subjective time dilation, heightening of visual attention systems, changes in blood flow and muscle tone). In other words, while you'll respond to the dangerous stimulus in both cases, inhibited SNS will mean your response will be suboptimal.

Now I am trying to learn why beta blockers are not used more broadly for anxiety since they are effective in certain situations. It's one of those subjects I guess, where the answer is probably so well known that it's common medical knowledge and there isn't an easily searchable article I can find. Sorry if I'm sounding foolish, I've just never heard why this is.

To tell the truth, I have no idea. But I suspect it's the general tendency that since we view anxiety as a 'psych' issue, we should treat it through 'psych' methods. I personally feel that propranolol would be a much better drug for the management of anxiety, particularly in the individual undergoing either mindfulness or CBT therapy. The reason being that if we use a moderate dose, we control the SNS response, but don't eliminate it. That allows the patient to be less affected cognitively and emotionally, simply because the stimulus is smaller, not because they have been cognitively and emotionally desensitized (i.e. SSRIs and BZDs). Meaning that any additional response will be due directly to therapy. It also means that when we titrate the dose of propranolol down, we can safely say that maintenance of improvement vs. worsening has mostly to do with efficacy of therapy/mindfulness practice.

And as always, I'm an MS4, so I can't exactly speak with authority on this issue.

whopper · Feb 8, 2009

personally feel that propranolol would be a much better drug for the management of anxiety, particularly in the individual undergoing either mindfulness or CBT therapy

Although it would be useful in the use of anxiety, most psychiatrists I've seen would rather give a benzodiazapine. Why? Well I never asked a large forum as to why. My own personal opinion is that psychiatrists feel more comfortable giving benzodiazapines because they use them more often in clinical practice, patients tend to ask for them more often vs propranolol (IMHO patients ask for benzos too much), and a fear that the person may attempt suicide with them, or get hypotension--> causing them to possibly fall & hit their head.

I have seen psychiatrists prescribe it more often for social anxiety and the person had to do a 1 time project such as a grand rounds.

Regnvejr · Feb 8, 2009

Beta blockers are associated with depressed mood, though the association is weak. However, hypotension is real. Anxious patients get dizzy, and the last you need is induced postural hypotension.

With panic attacks, benzos do work. Panic attacks need to be shut down fast.

After that, anxiety needs to be managed. Are benzos the best? I use clonazepam quite a bit at night just for sleep, shutting down racing/ruminative thoughts and especially for nightmares with PTSD. I also use lorazepam (ativan) for breakthrough anxiety when it is to debilitating, but never do this without a foundation of a low dose clonazepam as well. The "roller coaster" of only a fast acting benzo getting in and out of a patient's system is a recepie for dependence.

And ultimately, we need these patients to develop their own self-soothing capabilities.

That's also why I send these patients to the therapists on my team, and do so WITHOUT the benzos for sessions. They don't take clonazepam on the days they have therapy and if they need a lorazepam, they are not allowed to take it until after the sessions. The therapy is for them to experience some stress and then practice calming themselves down without chemical sedation.

Benzos are very effective in the short run, but problematic in the long run; you're not exactly doing rocket science when your brain is slowed down.

And actually, plain old vistaril sometimes work better. Not really for PTSD or panic attacks, but for more level anxiety, it is great stuff

panicwithdefib · Mar 11, 2009

you have no idea how happy i felt when i read the post about the guy 48...defib he thinks might be firing... im also 48 Female going thru the exact same thing i'd doze off at night...think im waking up to a firing...but after the awakening i actually feel fine (unlike a real firing where it takes me 30 mins to get past the blast)...my doc has interogated my defib..and says its not firing and that most likely it mike be more a panic kinda feeling....but after reading your post...you made me feel much better just by you sharing your expereince

New onset panic attack in patient w/new, possibly malfunctioning defibrillator

nancysinatra

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masterofmonkeys

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masterofmonkeys

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OldPsychDoc

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whopper

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OldPsychDoc

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billypilgrim37

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Doc Samson

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nancysinatra

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Abram Hoffer

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whopper

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nancysinatra

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OldPsychDoc

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Abram Hoffer

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masterofmonkeys

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whopper

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Regnvejr

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panicwithdefib

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