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Ruling Out Mitral Valve Prolapse for Panic Attacks

Permission graciously given by the author to reproduce this paper
 
  Ruling Out Mitral Valve Prolapse for Panic Attacks

Joel Prather

Introduction

Mitral Valve Prolapse is a defect of the valve in the heart that separates the atrium from the ventricle.  The defect prevents the valve from closing properly.  Panic attacks and sudden feelings of intense anxiety or impending doom, may actually be a symptom of Mitral Valve Prolapse (MVP).  Panic attacks can cause at least four of the following symptoms to occur: dyspnea, palpitations, chest pain, a feeling of being choked, dizziness, paresthesias, sweating, trembling, and a fear of dying or uncontrollable behavior (Goldstein & Smith, 2005).  It is worthwhile to determine whether or not the symptoms are due to MVP or to a psychological disorder, such as a panic attack or Generalized Anxiety Disorder (American Psychiatric Association, 2000).  Evidence suggests a possible connection between MVP and panic attacks.  This paper is an extension of an earlier paper, discussing the connection of MVP and panic attacks as well as testing methods that may identify the difference.

MVP and Panic Attacks

Although the connection between MVP and panic attacks is recognized, the reason remains a mystery.  Some researchers believe that the connection is a dysfunction in the Autonomic Nervous System (ANS).  Since the ANS controls the involuntary systems within the body, the balance of the sympathetic and parasympathetic systems may be interrupted, causing dysautonomia.  Mitral Valve Prolapse is one of these types of dysautonomia.  In addition to MVP, this condition can cause anxiety, panic attacks, depression, mood swings, chest pain, palpitations, dizziness, fainting or feeling faint, pallor of the extremities, malaise, weakness and fatigue, inability to tolerate heat or sun for long, gastrointestinal problems, headaches, and numbness or tingling in the extremities.  

Anxiety disorder, panic attacks, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder are caused by the Amygdala, the part of the brain that controls anxiety.  The amygdala is the organ that triggers anxiety, causing the reactions listed above.  In essence, the amygdala’s stress reaction can become activated and not “switch off”, causing these symptoms to occur.  If the amygdala is “reset” at a higher level, chronic symptoms may occur.  In essence, problems with the Amygdala can cause a person to be unable to cope with normal situations because the reactions occur inappropriately. 

First, it is appropriate to get the necessary historical and medical information from the patient.  According to the Medical Evaluation Field Manual (Koran, 1991), essential information should include identifying information about the patient, active physical diseases and problems as conformed by the physician, current suspected physical diseases, medications, prescribed or not prescribed, which the patient is taking, alcohol, illicit drug, tobacco and caffeine use, past substance abuse, the use of over-the-counter medications, past physical diseases or physical injuries, and information on former health care providers.  Changes in the above should be recorded as they occur.  

It is also important to ensure that symptoms of panic attacks may also occur.  Symptoms include sweating, trembling or shaking, sensations of shortness of breath, or smothering, feeling of chocking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, derealization, depersonalization, fear of losing control or going crazy, fear of dying, paresthesias, chills or hot flashes (American Psychiatric Association, 2000).  Agoraphobia may or may not necessarily be a factor in determining whether or not the patient has panic disorder, but would not likely be a factor for ruling our MVP.  

It is important to know that symptoms of MVP and irregular heartbeat and palpitations are often caused by other factors as well.  Other problems include congestive heart failure, pericarditis, hyperthyroidism, vasovagal syncope, and hypoglycemia must also be ruled out.  Palpitations also can result from stimulant drugs, and over-the-counter and prescription medications (Abbott, 2005).  Furthermore, there has been some indication that Brain-derived neurotrophic factor (BDNF) (Lam, Cheng, Huaong, & Tsai, 2004) may be due to a genetic disorder.  

The following tests may be appropriate for determining and/or eliminating MVP as the problematic condition, whether the disorder is actually anxiety and panic attacks.  It is important to keep in mind that these tests may not be part of the normal regimen that a physician may prescribe, and medical insurance may not always consider these tests necessary or even pay for them to be conducted.  Some of these tests were chosen using the screening process as part of the SB929 screening algorithm in the Medical Evaluation Field Manual (Koran, 1991) and some were determined using Mosby’s Manual of Diagnostic and Laboratory Tests (Pagana & Pagana, 2002).  

(1) Atrial Natriuetic Factor.  This is used to identify patients who have chronically increased end-diastolic heart pressures indicating ongoing or imminent congestive heart failure.  While this may not necessarily indicate problems with MVP, it can indicate a distended atrium (Pagana & Pagana, 2002).  The test is performed by drawing blood.  Normal findings should be 22-77 pb/ml or 20-77 ng/L (Pagana & Pagana).  Abnormally increased levels indicate possible congestive heart failure, increased risk for CHF, and mitral valvular disease.  It should be noted that these levels increase with age.  Cardiovascular drugs can interfere with the results.  If necessary, Cardiac Catheterization may be necessary.

(2) Echocardiography:  This is performed most commonly to evaluate heart wall motion and to detect valvular disease, evaluate the heart during stress testing, and identify and quantify pericardial fluid (Pagana & Pagana, 2002).  In this case, echocardiography can be used to identify or rule out mitral valve prolapse.  This test is painless.  The test is performed by coating a sonogram sensor with a gel and moving the sensor over the chest area.  Normal findings include normal position, size and movement of the cardiac valves and heart muscle wall, as well as normal directional flow of blood (Pagana & Pagana).  Difficulty may arise in conducting this test if the patient has chronic obstructive pulmonary disease (COPD) due to the inability of air to conduct ultrasound waves.  The results may indicate valvular heart disease, pericardial effusion, ventricular or atrial mural thrombi, moximas, poor ventricular muscle motion, ventricular hypertrophy, endocarditis, and septal defects.  In this case, the absence of mitral valve deficiency may rule out MVP as the cause of the panic attack symptoms.  There are no particular cautions when viewing the test results other than they must be read and interpreted by a qualified specialist.

(3) Holter Device:  Holter monitoring allows the monitoring of the electrical activity of the heart over a period of time.  It may be that, during normal testing, the patient is not experiencing panic attacks or MVP symptoms.  The Holter Device is placed on the patient, using electrodes placed at strategic points, recording the patient’s heart activity for at least 24 hours.  During that time, if the patient has a panic attack or MVP, the information will be recorded for future evaluation (Pagana & Pagana, 2004).  Normal findings include normal sinus rhythm during the entire recording phase of the Holter device.  Syncope, palpitations, atypical chest pains, or unexplained dyspnea can be recorded and explained (Pagana & Pagana).  Difficulties and precautions include uncooperative patients, patients having difficulty maintaining lead placement, patients unable to maintain an accurate diary of activities, and the interruption of electrode contact to the skin. 

(4) Though this is not suggested currently, genotyping using genomic DNA can be determined by extracting ETDA-containing venous blood samples.  To date this is not confirmed, but is worth mentioning as a possible method to rule out physical or behavioral reasons for panic disorder.  It may also prove the genetic possibility of cardiovascular disease.  The method of testing can be either by drawing blood, using a cotton swab in the mouth, testing chorionic villis sampling, or the use of body tissue.  The method depends on the testing laboratory.  If the angiotensinogen (AGT) has one mutation, the risk of CVD is moderately elevated.  If the AGT has two mutations, the risk of CVD is nearly triple that of the general population (Pagana & Pagana, 2004).  There are no particular cautions in testing other than the fact that patients may not be able to deal with the results.

(5) Chest radiograph: This can rule out a pulmonary embolism, which has symptoms similar to a panic attack.  This test is a simple chest x-ray.  Results demonstrate any wedge-shaped abnormally that may be identified, revealing a possible embolism) Pagana & Pagana, 2004).   A simple chest radiograph cannot be used on those who are pregnant.  They are also distorted if the patient has pneumonia, emphysema, or other pulmonary problems.

(6) Urinalysis (UA):  Although this test may not be effective in determining problems specific to MVP, other illnesses can be ruled out.  The UA is generally given as part of a health screening or for drug screening.  The UA reveals several factors relating to the body, but increased levels of protein in the urine can be an indication of congestive heart failure.  A high occurrence of hyaline casts observed when viewing dried urine, can also indicate congestive heart failure.  Normal protein levels should be 0-8 mg/dl.  Few or no hyaline casts should be observed.  Several drugs may affect the UA results, so it is important to screen the patient for any medication taken (Pagana & Pagana, 2002).  Negative observations indicate the need for further tests.

(7) Hematocrit: Blood can be drawn to test for abnormalties in RBC values.  Normal findings in males are 42% to 52% or volume fraction units.  For females normal ranges are 37% to 47 %.  Values may be slightly decreased in the elderly.  Increased levels can reveal congenital heart disease and a host of other deficiencies.  Abnormally large RBCs are associated with higher blood count levels (Hct), boosting the percentage.  Extremely elevated white blood cell counts (WBC) may falsely indicate anemia.  Hemodilution and dehydration affect the values.  Pregnancy causes slightly decreased levels.  High altitudes cause high Hct levels.  Recent hemorrhaging may cause unreliable values.  Chloramphenicol and penicillin may cause decreased levels.  

(8) White blood cell count (WBC):  This blood test measures neutrophils, lymphocytes, monocytes, eosinophils, and basophils.  Normal findings are 5000-1000/mm3.  Critical values help to determine infection, Leukemic neoplaisa and other cancers, traumas, stress, hemorrhaging, tissue necrosis, inflammation, dehydration, thyroid problems, and steroid use.  Decreased levels indicate drug toxicity, bone marrow failure, dietary deficiency, congenital marrow aplasia, myelofibrosis, autoimmune disease, and hyperspleism.  While many of these conditions have no bearing on panic disorder, infections, autoimmune disorders and other conditions may affect the patient’s well being and the root of some panic (Pagana & Pagana, 2002).

(9) Aspartate Aminotransferase (AST):  This test is collected using a venous sample of blood.  It is used to evaluate patients with suspected coronary artery occlusive disease or suspected hepatocellular diseases.  High levels detected helps to detect the presence of injury to the heart muscle, among other things.   Lower levels may reveal diabetes and other renal disease.  The normal range in adults is 0-35 U/L.  Pregnancy, exercise, antihypertensive drugs, cholinergic agents, certain antibiotics, and several other medications may cause increased AST levels.

(10) Serum T4 and free T4:  This test is used to measure thyroid function.  The test is administered by drawing blood through venipuncture.  Normal adult index levels are 1.5 to 4.5 units.  Increased levels indicate hyperthyroidism, and decreased levels indicate hypothyroidism. Hyperthyroidism has been known to cause symptoms of heart problems as well as panic disorder.  No conditions interfering with the results were indicated (Pagana & Pagana, 2002).

Allergy testing may also be considered.  Symptoms of food intolerance, such as rapid breathing, sweating, palpitations, nervousness, and tightness across the chest are similar to those consistent with MVP and panic attacks.  The patient should be questioned as to when the attacks occur, particularly in relation to a reaction after consuming food.  The elimination diet test, RAST test, and other allergy tests may be conducted to determine if allergies are the cause.  Possible complications include severe reactions to exposure to particular allergens.  Anaphylactic shock is possible, and it can be lethal (Braly, no date). 

Hair analysis is also an option.  Mineral deficiencies found through hair analysis can reveal an historic accounting of possible abnormalities.  For example, hair analysis can determine iodine deficiency, resulting in thyroid insufficiency.  A selenium deficiency could be responsible for increased lipid peroxidation and cardiac muscle abnormalities (Brand, 1984).  While these tests may not be conclusive for determining MVP, they may be used to determine trends due to historic findings.  There are no particular precautions or dangers concerning hair analysis, it must be understood that mineral levels are different depending on hair color.  Also, washing with certain chemicals may alter or eliminate trace minerals (Brand).

Summary

There appears to be a broad range of tests that can assist in ruling out medical causes for a mental disorder.  Many of the tests do no provide adequate results and must be combined with others.  In some cases, theses tests are redundant.  The inclusion of tests for this purpose is not to identify them as all being necessary, but rather to identify them as possible tests to identify and narrow the presenting problem.  Testing is generally expensive and insurance often does not pay for tests that are not deemed medically necessary.  More obvious, less expensive testing and techniques can be used to minimize the use of excessive testing.  Testing can also be traumatic to the patient.  The least amount of testing is probably the most effective. 
 
References

Abbott, A. (2005).  Diagnostics Approach to Palpitations.  American Family Physician, 71(4), 743-752.  Retreived on February 13, 2006, from the ProQuest database.  

American Psychiatric Association (2000).  Diagnostic and Statistical Manual, 2nd Ed., Text Revised.  Washington, D.C.

Bland, J. (1984).  Air Tissue Mineral Analysis.  Northwest Diagnostic Services, Bellvue, WA.  Retrieved on February 13, 2006 from www.centeronbehavioralmedine.com.

Braly, J (2004). Allergy Testing.  Retrieved on February 17, 2006, from http://www.centeronbehavioralmedicine.com and http://www.drbralyallergyrelief.com/

Goldstein, D., and Smith, L. (2005).  Handbook for Patients with Dysautonomias.  Retrieved on July 15, 2005, from www.ndrf.org.  

Koran, L (1991).  Medical Evaluation Field Manual.  Retrieved from www.centeronbehavioralmedicine.com on February 13, 2006.

Lam, P., Cheng, C., Hong, C., and Tsai, S. (2004).  Association Study of a Brain-Derived Neurotrophic Factor Genetic Polymorphism and Panic Disorder.  Neuropsychobiology, 49(4).  Retrieved on February 1, 2005, from the ProQuest database.  

Pagana, K., & Pagana, T. (2002).  Mosby’s Manual of Diagnostic and Laboratory Tests, 2nd ed.  Mosby, Inc.  St. Louis, MO.

<>Wallace TL; Stellitano KE; Neve RL; Duman RS.  Effects of cyclic adenosine monophosphate response element binding protein overexpression in the basolateral amygdala on behavioral models of depression and anxiety. Biological Psychiatry 2004 Aug 1;56(3):151-60.  Retrieved from the ProQuest database on July 15, 2005.