If you’re having chest pain now and you don’t know what it is, call emergency services. Nothing on this page is a substitute for that, and no article can assess you. Read the rest afterwards.
The typical differences
These are tendencies rather than rules, and any one of them can be wrong in an individual case.
Onset. Panic peaks within about ten minutes and then declines. Cardiac pain often builds more gradually and persists or worsens over time.
Character of the pain. Panic chest discomfort is often sharp, localised, and worse when you press on it or change position. Cardiac pain is more typically pressure, heaviness or squeezing, and is unaffected by position.
Radiation. Pain spreading to the jaw, the left arm, the back or the shoulder is more characteristic of cardiac events.
Exertion. Cardiac symptoms are classically brought on or worsened by physical effort and relieved by rest. Panic often arrives at rest and out of nowhere.
Accompanying symptoms. Tingling in the hands and around the mouth, and derealisation, point toward over-breathing and panic. Cold sweat with nausea and a sense of impending doom appears in both, which is precisely why this is difficult.
Why the first one gets investigated
Because a first episode of chest pain warrants a medical opinion, full stop. An ECG and basic bloods are quick and rule out a great deal. Get it done once, properly, and get the result in writing.
Two groups get failed by pattern-matching, and both deserve saying. Women more often present with atypical cardiac symptoms — fatigue, nausea, jaw or back discomfort, breathlessness without classic chest pain — and are more likely to be told it’s anxiety when it isn’t. And people with a known anxiety diagnosis get their cardiac symptoms attributed to it. If something feels different from your usual panic, say exactly that, in those words.
After you’ve been cleared
This is where the advice reverses, and the reversal is the important part.
Once you’ve had an adequate cardiac assessment, repeated presentations for the same symptoms become reassurance seeking, and reassurance seeking maintains anxiety. The relief lasts an afternoon, and the next episode arrives with a new question about whether the test could have been wrong.
The way clinicians handle this is with a rule agreed in advance, ideally with your doctor: what constitutes a genuinely new symptom warranting review, what the routine follow-up schedule is, and what is out of bounds. Set once, when calm, and not renegotiated mid-episode.
The treatment
Interoceptive exposure — deliberately producing the sensations you fear — is the core treatment for panic, and it’s unusually effective. It sounds alarming to someone convinced their heart is the problem, which is why it’s done after the medical question has been properly settled, and never before.