“I keep getting breathless and tingly — I think it’s panic, but what if it’s my heart?”

Attributing breathlessness to ANXIETY/PANIC or HYPERVENTILATION must be a POSITIVE diagnosis made AFTER excluding organic causes — it is a diagnosis of EXCLUSION, never a lazy first label — and, even when the story sounds typically panic-like, genuine exclusion is both safer and more therapeutic, because a confident "I’ve checked and these are clear" reassures far better than a dismissive "it’s just anxiety". In a young adult, take a careful history and examination and exclude the relevant causes: ASTHMA (episodic/nocturnal/exertional wheeze, triggers, atopy — peak flow/spirometry ± FeNO), ARRHYTHMIA (palpitations, syncope/pre-syncope, exertional symptoms, family history of sudden cardiac death — ECG), ANAEMIA (FBC), HYPERTHYROIDISM (weight loss, tremor, heat intolerance — TFTs), PE (only if risk factors), and rarer cardiorespiratory disease, with focused examination arranged face to face (obs, sats, heart, chest, thyroid/anaemia signs — none of which can be done on video). Recognise the features that POSITIVELY fit hyperventilation/panic — situational/stress onset, peri-oral and peripheral tingling, carpopedal spasm, a sense of doom, light-headedness, rapid full recovery and a normal examination — without using them to skip exclusion. Then make a positive diagnosis and EXPLAIN the physiology in a destigmatising way: over-breathing lowers CO2, producing tingling, light-headedness and chest tightness, which feel frightening and drive more over-breathing — a self-perpetuating cycle, not a heart attack — because understanding the mechanism is itself therapeutic. Manage positively: controlled/diaphragmatic breathing techniques (not paper-bag), psychoeducation, CBT, an SSRI licensed for panic disorder or CBT-based self-help according to preference (NICE CG113; self-referral to NHS Talking Therapies), with no benzodiazepines, sedating antihistamines or antipsychotics, addressing triggers/stressors and lifestyle (caffeine, sleep), screening mood and severity. Take the fear seriously, land reassurance on real exclusion, validate and treat the anxiety, and safety-net for new/atypical features.