Did you know that you might experience early warning signs that mean you could be on your way to having a heart attack?
I would have answered NO to that question until I reflected (after the fact!) on the puzzling symptoms that I’d personally experienced two days in a row during the week before my first severe cardiac symptoms hit.
Many of these early warning heart attack symptoms do not feel earth-shakingly alarming.
We don’t drop what we’re doing to call 911 when they happen.
We typically ignore or dismiss them, much as we ignore or dismiss the countless other bubbles and squeaks our bodies can produce an any given day.
It’s only after we are appropriately diagnosed that we can actually reflect at our leisure on what doctors call these “prodromal” symptoms that sound a little warning message that something is not right.*
These warning signs can – if we are aware of them – indicate that the heart is in trouble. In fact, previous research by Dr. Jean McSweeney suggested that up to 95% of heart attack survivors report that they knew something was “very wrong” in the weeks or even months leading up to their ultimate cardiac event.(1)
Dr. Sheila O’Keefe-McCarthy is a Canadian researcher and professor at Brock University (in my old hometown of St. Catharines, coincidentally) whose studies have confirmed those earlier findings. In her paper published in the Journal of Cardiovascular Nursing, she found that women reporting one or more prodromal symptoms were more than four times more likely to have a subsequent major adverse cardiac event compared with women who had reported none.(2)
She also noted that the most commonly reported prodromal symptoms in both male and female heart patients are:
- unusual fatigue: 100%
- anxiety: 100%
- arm pain/discomfort: 86%
- shortness of breath: 86%
- nausea, vomiting, indigestion: 71%
- chest pain/discomfort: 57%
- jaw pain: 43%
- back/shoulder blade pain: 43%
- dizziness: 43%
- headache: 43%
- sleep disturbance: 29%
UPDATE: February 8, 2019: See Dr. O’Keefe-McCarthy’s new Prodromal Symptom Screening Scale, a new web app to help women identify symptoms before it’s too late.
Dr. O’Keefe-McCarthy cited a number of previous studies that have suggested women experience more warning symptoms compared with men. Women tend to experience less prodromal chest pain, but reported more episodes of fatigue, anxiety, and head-related symptoms such as headache or dizziness compared with their male counterparts.
Dr. O’Keefe-McCarthy, whose own mother, sister and father-in-law died of cardiovascular disease (each of whom had complained of pain, unusual fatigue or escalating anxiety well before their cardiac diagnoses) explained that this research is helping to raise awareness of how subjective and often ambiguous these reports of prodromal symptoms are when they occur before an actual diagnosable cardiac event.
Is there a woman alive who hasn’t had periods of fatigue? So before you stop reading this in favour of rushing immediately to your local Emergency Department because you’re feeling a bit tired today, remember that the key fact to remember is this: it’s when these symptoms feel unusual for you that you need to take particular notice. “Unusual” does not mean unbearable or even painful, by the way. Just distinctly unusual for YOU.
One of my blog readers told me that when her physician suggested antidepressants to address her debilitating symptoms of crushing fatigue, she replied: “Will they help me carry the laundry basket up the stairs? Because I’m unable to do that now.” She was subsequently correctly diagnosed with heart disease.
In my own case, early warning symptoms first happened very early on a beautiful spring morning as I was walking to work – one week before my severe cardiac symptoms struck in earnest.
I’d been walking briskly for about 25 minutes when I was suddenly struck by such extreme shortness of breath that I had to stop walking and lean on the front yard fence of the little house I was passing. This house sat at the end of a street on a slight incline. This shortness of breath was puzzling to me, mostly because I’d been walking to work via the exact same route every day, day after day, for a long time and had never felt any shortness of breath before then.
But that morning, I had to suck wind for several minutes leaning on that fence, gasping for breath until I was able to breathe a bit easier once again, at which time I turned the corner and walked the short rest of my way to work without further incident.
When the same thing happened on the following day too, in front of the same little house, I remember feeling more puzzled than alarmed. I recall thinking that this shortness of breath might just be some kind of sign that I needed to do more “hill work”, as my old running group used to call those days when we deliberately ran up and down the crazy-steep Quadra Street hill while in training for road races.
The reason that my symptoms happened at the top of that small hill, and in front of that same house two days in a row was probably because, like most episodes of angina (chest pain that comes on with exertion and goes away with rest), the symptoms hit after a certain length of time once my pulse became fast enough on exertion to stress my heart while my coronary arteries began having trouble delivering oxygenated blood to a struggling heart muscle.
In some patients studied in the Brock research, prodromal symptoms occurred from hours to days, weeks or even months before patients’ acute cardiac event. Other studies have also found reports of what researchers call non-specific symptoms like dizziness, visual disturbances, changes in cognition, heart palpitations, sweating, numbness and tingling in the hands and arms, or loss of appetite.
But can these early warning symptoms accurately predict a heart attack?
Dr. McSweeney and her colleagues identified the five specific prodromal symptoms that appear to be most predictive of future cardiac events:
- unusual fatigue
- discomfort in one or both arms
- generalized chest discomfort
- shortness of breath
- discomfort in the jaw/teeth
Specifically, she found that women who reported one or more of these five symptoms were four times more likely to experience an adverse cardiac event compared to women who had never reported prodromal symptoms.(3)
These adverse events happened from weeks to two years after the first early symptoms. That’s a long time to wait before being able to recall, “Hey, remember two years ago when my jaw felt sore?”.
What might also be happening when that cardiac event finally hits is that the most prominent heart attack symptoms reported are likely to be the same or very similar to the early warning ones experienced earlier.
For example, Dr. O’Keefe-McCarthy’s research suggested that the risks of experiencing chest-related symptoms (pain, discomfort, pressure, palpitations, etc.) in the acute stage of a heart attack were more than five times greater in women who had already experienced prodromal chest pain, and almost three times more likely in men.
As Dr. O’Keefe-McCarthy told a Brock News interviewer:
“Women need to know that, 50 per cent of the time, their warning signs of heart disease are different from those of men. The symptoms are often vague in nature, and may be felt days or even months before a heart attack.”
“Lack of knowledge can result in delays in seeking urgent medical attention.
“This means that women who are older, experiencing menopause, along with other conditions such as hypertension or diabetes when presenting with other unexplainable symptoms such as increasing fatigue or breathlessness are stuck in a cloud when it comes to diagnosis. Warning signs can be vague, unrecognizable and unusual, but they do not need to remain a mystery.”
*prodromal: “pertaining to early symptoms that may mark the onset of a disease”
Dr. Sheila O’Keefe-McCarthy works and studies in the Heart Innovation Research Program of Brock University. Her program focuses on three inter-related areas:
- 1. development and testing of innovative digital health technology interventions for both acute and palliative cardiovascular populations
- 2. examination of cardiac pain-related anxiety
- 3. detection, screening and examination of pre-hospital cardiac prodromal symptoms in men and women with coronary artery disease
Fun fact: This post was the #1 most-read Heart Sisters article in 2018.
Jean C. McSweeney. “Women’s Early Warning Symptoms of Acute Myocardial Infarction”. Circulation; 108: 2619-2623 November 3, 203, 2003.
O’Keefe-McCarthy S. and Ready L. “Impact of Prodromal Symptoms on Future Adverse Cardiac-Related Events: A Systematic Review”. Journal of Cardiovascular Nursing. 2014
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