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Aortic Aneurysm in the Differential for Panic Attacks

Key Words: Panic Disorder • Aneurysm

TO THE EDITOR: Panic Attacks have multiple cardiovascular etiologies including congestive heart failure, arrhythmias, angina, and mitral valve prolapse.¹ Studies suggest that one-third of patients with unexplained chest pain and normal coronary arteries may have panic disorder.² We present a case report of an enlarging aortic aneurysm rarely considered in the differential diagnosis of panic attacks.

Case Report

Mr. Z. is a 65-year-old White male with a long history of recurrent depression; historical diagnosis of alcohol dependence, which has been in remission for 20 years; and dependent personality disorder. For the last 14 months, the patient experienced anxiety symptoms, including shortness of breath, nonspecific chest pain (without radiation, left arm pain, nausea, or vomiting), diaphoresis, fear of dying, and palpitations that peaked in 15 to 20 minutes and resolved in 5 to 6 hours. Mr. Z. also experienced free-floating anxiety symptoms with much lower intensity that lasted for up to a day at a time. Mr. Z. did not endorse muscle tension, irritability, or feeling on edge. An increase in mental health contact over the past 14 months related to his recent worsening anxiety and panic symptoms.

Mr. Z.'s admission medications included albuterol (two puffs four times a day), amlodipine (5 mg every day), doxazosin (1 mg every night), ranitidine (150 mg every day), nitroglycerin (0.4 mg sublingual) as required for chest pain, enteric coated aspirin (325 mg every day), and isosorbide dinitrate (slow release 40 mg twice a day). There were no changes in his medication regimen that coincided with an increase in his anxiety symptoms. Repeat lab reviews over the 14 months showed normal complete blood count, chemistry panels, RPR, urinalysis, urine drug screen, liver function tests, thyroid screen, cardiac enzymes, oxygen saturation, and arterial blood gases. He had a normal heart catheterization within the past year. A chart review noted that a routine chest x-ray 1 year ago showed a widened mediastinum. This was followed up by a computed topography (CT) scan showing a thoracic aortic aneurysm of 6.3 cm. Aside from some mild hypertension necessitating an increase in amlodipine (10 mg once a day), Mr. Z. was medically stable. A current CT scan showed fusiform aneurysmal dilatations of the descending aorta from the aortic arch extending down to the celiac axis, 7 cm in diameter with a thrombus without dissection. Surgeons concurred that this expanding aneurysm could indeed be resulting in anxiety symptoms. Emergency surgery was scheduled, but Mr. Z. died before surgery.

DISCUSSION

A number of psychiatric and medical causes that can produce anxiety were stable during the 14-month period of worsening anxiety symptoms. Several CT scans showed an enlarging aneurysm that temporally coincided with Mr. Z.'s worsening anxiety symptoms. With numerous causes for anxiety symptoms, we recognize that his enlarging aneurysm was probably not the sole contributor to the anxiety symptoms.

The sympathetic nervous system has been implicated in the pathophysiology of panic attacks.³ Theoretically, an enlarging aneurysm may have a mass effect on the nearby sympathetic ganglion, which may result in panic-like symptoms. The symptoms of aortic aneurysms can vary widely with many being asymptomatic unless dissection is present. The natural progression of untreated aortic aneurysms is enlargement, rupture, and death. Enlarging thoracic aneurysms may compress the left recurrent laryngeal nerve producing hoarseness. Dissection of an aortic aneurysm is usually accompanied by pain; chest pain is most common (80% of patients) along with back pain (30%) and neck, epigastric, and arm and leg pain. Substernal or back pain, cough, dyspnea, and dysphagia may also be present. The dissecting aneurysm may produce ischemia of the brain, spinal cord, or peripheral nerves with syncope, stroke, or paraplegia. The risk of rupture is directly related to the diameter of the aneurysm. For example, the risk of rupture of a 6-cm abdominal aortic aneurysm is 25%–30% at 5 years, and for an 8-cm abdominal aortic aneurysm is 75 percent at 5 years. Therefore most vascular surgeons recommend elective repair of aortic aneurysms larger than 5–6 cm in diameter if the patient's condition warrants.⁴

It is impossible to quantify the contribution of the enlarging aneurysm to the panic symptoms.⁵ However, it is important that cardiovascular causes are ruled out because of the overlap of symptoms. We have not seen any reports in the psychiatric or medical literature that include an aortic aneurysm in the differential for anxiety or panic symptoms. We hope that this case report results in creating a broader differential for anxiety disorders. This in turn may result in more appropriate and possibly earlier interventions for what is a very serious medical and life-threatening condition.

REFERENCES

1. Practice Guidelines for the Treatment of Patients with Panic Disorder. Ann J Psychiatry 1998; 155:5
2. Beitman BD: Panic disorder in patients with angiographically normal coronary arteries. Am J Med 1992; 95(5A):335–405
3. Roy-Byrne PR, Cowley DS: Search for pathophysiology of panic disorder. Lancet 1998; 352:1646–1647
4. Galloway AC, Colvin SB, and Spencer FC: Diseases of the great vessels in Principles of Surgery, 6th Edition, edited by Schwartz SI. New York, McGraw-Hill, 1994, pp 903–924
5. Miniati M, Macri M, Dell'Osso L, et al: Panic-agoraphobia spectrum and cardiovascular disease. CNS Spectrums 1998; 3:58–62

This article has been cited by other articles:

				D. Katerndahl Panic & Plaques: Panic Disorder & Coronary Artery Disease in Patients with Chest Pain J Am Board Fam Med, March 1, 2004; 17(2): 114 - 126. [Abstract] [Full Text] [PDF]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Benjamin, A. B. Articles by Wright, J. Search for Related Content PubMed Citation Articles by Benjamin, A. B. Articles by Wright, J. Panic Disorder

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