Heart disease is a very common ailment in the United States. In general, heart disease may be divided into two categories: congenital and acquired. The following discussion centers predominately on acquired heart disease. Coronary heart disease is the most common form of heart disease [11]. Cardiovascular diseases altogether are the leading cause of mortality in the United States [11]. Atherosclerosis of the coronary arteries is ultimately responsible for myocardial infarction, congestive heart failure, cardiac arrhythmia, and angina pectoris. These conditions, collectively, affect over 20 million adults. Symptoms of heart disease include the following [12]: ? Shortness of breath ? Chest pain ? Palpitations ? Syncope or presyncope ? Fatigue Many of the symptoms of heart disease are not specific and may overlap with many other diseases. Heart disease symptoms are also closely similar to the symptoms of an anxiety disorder. The practitioner should also be aware that patients with heart disease may also suffer from a coexistent anxiety disorder. Patients with congestive heart failure (CHF) may suffer from anxiety disorders (18%) and depression (29%) [13]. These disorders have been studied in CHF patients. Although anxiety is common in CHF patients, it is not associated with poor outcomes. On the other hand, depression in CHF patients has been associated with a worse prognosis [14]. Patients recently discharged from the hospital for CHF treatment have demonstrated higher levels of anxiety and depression [15]. The recognition of anxiety and depression in patients with heart disease and CHF is important and must be addressed. Since the symptoms of heart disease and anxiety may overlap, it may be difficult for the practitioner to distinguish them. The following points may be helpful to the practitioner in the evaluation of patients with the common symptoms of both heart disease and anxiety: ? Palpitations: Palpitations are common patient complaints. Palpitations may be characterized as rapid or irregular heart beat, fluttering, or thumping sensations in the chest. Heart disease and anxiety are the two most common causes of palpitations [16]. When palpitations are associated with syncope, the likelihood of a serious cause is increased. Some medications and substances with stimulant properties may produce palpitations. Supraventricular and ventricular arrhythmias may occur with variable frequency [12]. Holter monitoring and event recording may be of great help in discovering the cause of palpitations. No etiology is discovered in 16% of patients with palpitations. ? Chest pain: Chest pain is a subjective term for the discomfort associated with acute coronary insufficiency. Chest pain may come from a variety of causes including coronary heart disease and ventricular ischemia, pulmonary embolus, aortic dissection, costochondritis, esophagitis, gallbladder disease, pneumothorax, myocarditis, mitral valve prolapse, and pulmonary hypertension [12]. The chest pain symptom of acute coronary ischemia may occur as an isolated event, but is often associated with dyspnea, weakness, diaphoresis, and decreased ventricular output. Chest pain may also occur as a result of an anxiety disorder. The associated symptoms of decreased cardiac output are usually absent. ? Shortness of breath: Shortness of breath may occur frequently in patients with heart disease, especially in those affected by congestive heart failure. Patients with panic disorder may also experience shortness of breath as a result of hyperventilation. The dyspnea of CHF is usually worse when lying down and may be associated with jugular venous distention, hepatomegaly, peripheral edema, and cyanosis. The shortness of breath commonly seen in panic disorder is described as an inability to achieve a full, deep breath. There may also be a choking feeling as if something is lodged in the throat. Typically there is no cyanosis in panic disorder. Physical examination may be beneficial in determining the difference between heart disease and an anxiety disorder. Patients with CHF may have rales on chest auscultation. The presence of wheezing or pleural effusion also supports the diagnosis of CHF. The presence of a third or fourth heart sound would indicate ventricular dysfunction. While the above findings may help establish the diagnosis of CHF, the existence of an anxiety disorder is not necessarily discounted. However, the practitioner may prefer to address the CHF treatment with a greater priority. The treatment of anxiety disorders in patients suffering from heart disease may include short-acting benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs). Much has been written regarding the safety of SSRI and TCA medications in patients with coronary heart disease. Some reports indicate an increased risk to heart disease patients from the use of TCA or SSRI therapy [17]. Other studies indicate the relative safety of antidepressant therapy, especially the SSRI group [18]. Some research indicates the possibility of antiplatelet activity of SSRIs and a potential benefit from their use in coronary heart disease patients [19]. The practitioner may wish to consider the risk versus benefit of treatment with antidepressant medications in patients with heart disease. The patient who suffers from an anxiety disorder with coexistent heart disease carries a significant health burden. The practitioner must recognize this fact and consider offering medical therapy, when appropriate, for both illnesses.