Can early warning symptoms predict a heart attack?

18 Mar

by Carolyn Thomas  @HeartSisters  March 18, 2018

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%

Dr. O’Keefe-McCarthy cited a number of previous studies that have suggested women tend to 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.”

She did conclude that early recognition of these prodromal symptoms is “imperative for effective targeting, screening, and diagnosis and timely treatment to identify those at risk for future coronary heart disease-related events.”
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In other words, next time you present yourself to the Emergency Department with what you believe could be cardiac symptoms, don’t forget to also mention to Emergency staff if you’ve also noticed if any of your current symptoms had happened earlier during the weeks or months prior to this visit.
.

*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

 

  1. Jean C. McSweeney. “Women’s Early Warning Symptoms of Acute Myocardial Infarction”. Circulation; 108: 2619-2623 November 3, 203, 2003.
  2. 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

Q: Did you experience early warning (prodromal) symptoms in the weeks/months before similar cardiac symptoms later on?

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17 Responses to “Can early warning symptoms predict a heart attack?”

  1. Franklin Cardiovascular Associates March 28, 2018 at 10:03 am #

    You are right Carolyn, lots of patients start to get the signals and the best way is not to ignore them but to get a thorough checkup and take preventive measures to prevent its occurrence.

    Liked by 1 person

    • Carolyn Thomas April 1, 2018 at 5:29 am #

      I agree – yet part of the problem remains that very few of us are going to even suspect that our prodromal symptoms mean anything. It’s why I like to stress: if that symptom feels unusual for you – that’s the time to mention it to your doctor.

      Like

  2. Heart Currents March 19, 2018 at 3:55 pm #

    Thanks Carolyn, always informative… Interesting that while anxiety is listed in 100% percent of the prodromal symptoms, it is not one of the five that Dr. McSweeney uses as predictive… I wonder if that has to do with the discounting of anxiety and “psychological” symptoms in general, or our own lack of being able to distinguish or verbalize different types of anxiety (there is just one word for it, but many kinds and levels of anxiety)…

    Anxiously awaiting your response…
    Steve

    Liked by 1 person

    • Carolyn Thomas March 19, 2018 at 10:43 pm #

      You can relax now, Dr. Steve… 😉 I can’t speak for Dr. McSweeney’s findings, but I noticed too that all of her Top 5 symptoms are indeed physical ones. Odd that psychosocial symptoms aren’t included – and I’m leaning towards voting for this: patients (including those studied in her research) likely do not verbalize: “I’m feeling quite anxious!” to the ER doc – maybe we figure it goes without saying at that time!!

      The other thing I noticed was that one’s prodromal symptoms *might* feel exactly like those that are later repeated during a subsequent cardiac event, but that’s not a given e.g. I had two episodes of severe shortness of breath two days in a row the week before my actual full-blown heart attack signs began – but none of my heart attack symptoms included shortness of breath at all after those two days). Are they still considered advance warning signs if they only happen in “advance” of the actual cardiac event? YES, I think so!

      Like

  3. Meghan March 18, 2018 at 10:52 pm #

    I had symptoms for months before ending up in the cath lab where I received my first stent in the LAD, which was 99% blocked — shortness of breath, tightness across the chest, awful fatigue. Had not considered that I could be having heart symptoms, just chalked it up to stress and the fatigue and my type 2 diabetes.

    I remember going to a gym for the first time with my daughter, going around with a trainer and trying to do what he wanted us to, and not being able to but not wanting anyone to see the struggle I was having. Collapsed in the car almost in tears unable to breathe and hating myself for being so out of shape. Felt the same way following less than 3 minutes on the treadmill during the stress echocardiogram the cardiologist wanted me to do.

    When she couldn’t be sure of what the images were showing, she recommended the cath. Total shock at first to think I could be having heart issues, but when I finally did the cath and they told me they needed to put in a stent and there was a blockage, I wasn’t surprised because by then I had put all the pieces together of the symptoms I’d been having for months.

    Had more symptoms a year and a half later and it was worse the second time. I knew what was happening though and was not surprised when I had to have a second cath and stent, again in the LAD but in a different location (the first stent was holding). I’ve never experienced any misdiagnosis and my doctors have all been great so I guess I’ve been lucky.

    However, just wanted to share this since you mentioned dentists and jaw pain — I had just read your very helpful book so everything in it was fresh in my mind on March 3rd when I was lying in bed around 9:30pm and my heart suddenly started thudding and leaping all over the place. That was concerning enough but what really scared me was the dull, achy discomfort in my neck and jaw. I popped a nitro pill under my tongue and the jaw pain went away, but we ended up calling 911 for the very first time ever. The ambulance guy came in, very polite, and the first thing he said was, “Are you having any stress or anxiety at this time?” I wondered how to take that. Was he implying that he thought my symptoms were emotional?

    I let his comment go by and explained clearly that I was a heart patient with 2 stents and I knew it was my heart, and he didn’t mention anxiety again. In the ambulance, I told him I lead a support group for cardiac patients and know a lot about heart disease. I was not surprised to learn that my heart had gone into a-fib, although it was a brand new diagnosis for me, because my husband has a-fib and I know a lot about it.

    The ambulance guy later came into my ER room on his way out and told me that I did the right thing to call 911. He ended up being really nice! But it also helped that I knew what was going on and was clear about what I knew. Knowledge really is power.

    My care at the hospital was excellent. I never realized that calling 911 has a secondary benefit of validating your diagnosis before you reach the hospital because you’re already on a monitor. They told me it was a “classic a-fib” pattern on the EKG. I spent the night in the ER and ICCU; they slowed the rate down with a diltiazem IV and my heart popped back into rhythm at about 5am. I went home later that day and will be having an echocardiogram this week for follow-up. Haven’t had any more episodes, everything has been fine.

    But, speaking of dentists, I saw my dental hygienist a couple days after my night in ICCU. I was noticing that my gums hurt right around the area where I had placed the nitro pill under my tongue, which was a brand-new prescription and burned a lot. I asked her if she thought it had actually burned the tissue and she said yes, nitro can do that. I had no idea!

    And while a-fib doesn’t cause preliminary symptoms like a blockage does, when I look back on it now, I realized last month that my prescription for nitro was getting old, and even though I hadn’t needed it in a very long time I had the feeling I should get a fresh refill. So maybe I had a premonition without knowing it?

    Liked by 1 person

    • Carolyn Thomas March 19, 2018 at 5:47 am #

      So many interesting points in your story, Meghan. First, of course – that odd question from the paramedic about your stress/anxiety. (I’ve often said that there are few things in life more anxiety-producing than being in the middle of a frickety-frackin’ cardiac event!! – so no paramedic/doc/nurse should be remotely surprised if YES is the answer to that irrelevant question).

      Thank goodness you were already (A) an experienced heart patient, and (B) a cardiac support group leader. Imagine if you had not had those two pieces of credible background. And yes it does seem surreal that a month earlier, you’d been suddenly thinking of getting new nitro… Hope you’re doing well and that AFib episode was a ‘one-off’. Best of luck!

      Like

  4. Eileen March 18, 2018 at 3:27 pm #

    I experienced the extreme fatigue, dizziness, shortness of breath despite working out in a gym 3 days a week, alternating with yoga the other days. I recall being “too tired” to go on our 3 week cruise but went anyway, and experienced extreme SOB walking up and down the ship’s stairways on the way to meals.

    A week after my cruise I could not walk up the hill to my job without stopping. Went to my GP who told me I did not meet the criteria for having heart problems and that it was probably the stress of my work as a social worker in a chronic health program. 5 days later I had a stabbing pain in my mid back which exacerbated to the point that my nurse drove me to hospital.

    Later that night I was told I had a heart attack and would be kept overnight for observation. Next morning I experienced increasing chest pain and Troponins were elevated, and eventually taken to Victoria General for angiogram which revealed I had an 80% block in the LAD. I was 67.

    I am now 71, still have heart and chest pain and my cardiologist has done many tests but cannot find a thing wrong with me. A few weeks ago I called 911 for chest pain, was admitted for 7 hours and told there is nothing there. It must be stress they say. The follow up of that has been another visit to cardiologist who states he does not see anything wrong with me, but will do one last test, a Cardio 3D to see if he can find anything.

    In the meantime I have been referred to the Cardiac Psychiatrist who prescribes medication for anxiety and depression.

    What’s a girl to do? It’s difficult because I feel invalidated and I feel strongly that MI number 2 is on its way. My fatigue levels are such that my legs are weak, and I am no longer working out in the gym. Admittedly, stress levels high as I look after my 92 year old demented father at home, and my husband has been diagnosed with prostate cancer.

    I often think to myself these two men of mine will outlive me, as sick as they are.

    Liked by 1 person

    • Carolyn Thomas March 18, 2018 at 5:29 pm #

      I’m so sorry to hear of your current issues, Eileen (on top of your other stressors with family) particularly as you are an identified heart patient now (compared to your first episode when your doctor said “you don’t fit the criteria”). Apparently, you did.

      I’m not a physician, of course, but I am hoping something definitive might show up in your next diagnostic test so that you’ll have some kind of treatment plan put into place to address your symptoms.

      The trouble is, of course, that if your diagnostics are “normal”, then you’re far more likely to have your symptoms dismissed as being non-cardiac. But if these symptoms aren’t cardiac, what is causing them? Perhaps it’s worth a try to give the psych meds a shot – especially given the great stress you describe at home with your Dad and your husband.

      Read this post about non-cardiac reasons for chest pain to see if anything there rings a bell. And best of luck to you in your next diagnostic appointment.

      Like

  5. Mary Kay Osborne March 18, 2018 at 11:36 am #

    I started experiencing symptoms almost 8 months before my heart issues. I remember in May exercising and it was like I hit a wall.

    After that everything changed. The fatigue and anxiety was terrible. And I began having trouble with my teeth. Had a couple of extractions that I don’t think I needed. The emotional stress was terrible. My poor husband. Doctors did not help.

    Then in February, I fell hard on my kitchen floor and the next day the pain in my arm started and pressure in my chest. I called my husband and told him I thought I was having a heart attack, he came home and took me to the ER. They sent me home saying I had acid reflux.

    Went to a doctor and he said he thought I pulled a muscle from the fall. Then I got in to my primary physician and he said that he didn’t like it and sent me for a stress test. Was on the treadmill maybe 1 minute and almost passed out. They did an echo and my cardiologist said I needed a catheterization.

    I had a 95% blockage. Took a whole week to get the correct diagnosis but finally did and I’m still here, Thank God!

    Liked by 1 person

    • Carolyn Thomas March 18, 2018 at 4:20 pm #

      Wow, eight months! That’s way too long to be suffering! I was thinking while reading your story that jaw/teeth pain is indeed a commonly reported symptom both during a heart attack and (as both Drs. McSweeney and O’Keefe-McCarthy reported during their respective studies) as an early warning symptom long before the eventual diagnosis. The trouble is, every time you saw a doctor, something else had recently happened in your life that seemed like a likely culprit to blame (instead of your heart!) I’m glad to see your comment here today, because I’m working on a new blog post about dentists being the first-line diagnostic team for certain heart disease symptoms like jaw/teeth discomfort. I’m glad you’re still here, too!

      Like

  6. Marilyn Smedberg-Gobbett March 18, 2018 at 9:35 am #

    Hi Carolyn:
    Your email today made me sit up and take notice of my symptoms. About 2 months prior to my emergency by-pass, I presented to my primary care physician with allergy/asthma symptoms. She prescribed additional antihistamines as well as Advair. I did not get any relief from these additional medications but never thought it could be related to my heart and blockages causing my shortness of breath.

    This raises a question to others… has anyone else been given medication for asthma/shortness of breath only to be diagnosed later with blocked arteries?
    Marilyn

    Liked by 1 person

    • Carolyn Thomas March 18, 2018 at 4:01 pm #

      Hello Marilyn – I haven’t personally experienced the asthma connection (but certainly did have unusual shortness of breath two days in a row the week before my severe cardiac symptoms), but have heard from many of my blog readers who have reported using their “puffer” when their first heart attack symptoms hit (e.g. Amy reported being told she had “exercise-induced asthma” during her cardiac event). I suspect that if a woman with a history of asthma or other breathing issues presents with any form of shortness of breath symptom, asthma may very well become the likely culprit to blame in the absence of very clear cardiac diagnostic test results…

      Like

    • Paul April 1, 2018 at 4:06 am #

      Regarding asthma type symptoms before being diagnosed with a blockage, I was diagnosed with mild asthma and medicated with inhaled steroids about 18 months before my heart attack.

      I had a NSTEMI in September 17, angiogram showed LAD 99% blocked and CIRC 80% blocked. I now have 5 stents in LAD, CIRC and OM, installed 4 days after my 51st birthday. I have had no asthma type symptoms since the stents were implanted, nor have I required the inhaled steroids to control it.

      In addition, for about a month before the attack I would wake every morning feeling extremely tired and with a “heavy, dragging” sensation in my chest. At the time I put it down to stress and exhaustion – we were going through the early stages with a new 8-week old Golden Retriever pup, who was causing some sleepless nights and stress integrating with the other dogs – but in retrospect it can only have been a warning sign. And even 6 months before the attack I consulted my GP because of episodes of extreme exhaustion – what I described as “falling-down tired” – which was pooh-poohed by the quack who told me I must be suffering from stress and could have the early stages of what she described as a “lifestyle related problem we refer to as Chronic Fatigue Syndrome “.

      Again, I now see all of this as warning signs for the heart attack. Pity nobody medically qualified put it all together before something went bang!

      Like

  7. Diana Hope March 18, 2018 at 8:35 am #

    I also was experiencing prodromal symtoms before my heart attack. I was 61, very fit, and shoveling snow, which was not uncommon for me. Suddenly my heart was pounding, I was dizzy and I thought my head was going to explode. I just thought, well I must be tired today and left it at that.

    This was January. After that I found I was continually fatigued and depressed. I went to the doctor several times but he put it off as age related and menopause. I finally took my husband with me to the doctors to confirm what I was experiencing. I was prescribed antidepressants.

    In May I collapsed in a Pilates class, taken to hospital, where it was discovered I had an 80% blockage in my LAD.

    Liked by 1 person

    • Carolyn Thomas March 18, 2018 at 9:02 am #

      Jeez Louise!!! Even taking a MAN with you to your doctor’s appointment couldn’t persuade your doc that your symptoms might actually mean something!

      The missing point in your case, Diana, was that these symptoms were very unusual FOR YOU! There’s a landmark study I wrote about in my book that showed when men and women with BOTH cardiac symptoms plus a history of a recently upsetting event sought medical help, all docs recommended further cardiac testing for the male patients, but chalked the women’s symptoms up to the recent emotional upset (Chiaramonte et al). It’s criminal….

      Like

  8. Lorraine Spinard March 18, 2018 at 7:41 am #

    Yes I did have prodromal symptoms before my attack. I became a grandmother that summer and my son got married a few months later. I was exhausted, could barely walk a few feet without stopping to catch my breath. I attributed it to caring for my new grandchild and wedding stress. I also had a lot of anxiety over the holidays.

    When I came home from visiting my daughter and new grandson at Christmas I was depressed and felt such a sense of doom. Again I thought it was because I was missing them so much. On New Year’s Day, I had my heart attack at a family gathering.

    It was only after that I could see where I had experienced many symptoms in the previous months. I think it is so important that woman know of these prodromal symptoms and act on them.

    Liked by 1 person

    • Carolyn Thomas March 18, 2018 at 7:52 am #

      Thanks for sharing your story, Lorraine. Those symptoms like exhaustion are tricky because it’s not surprising when we feel generally tired, and it’s easy to just dismiss those symptoms as “normal” fatigue. But your description is important: “I could barely walk a few feet without stopping to catch my breath”. That’s NOT normal for the average person. It’s only in hindsight that we can see how clearly abnormal such symptoms were.

      Liked by 1 person

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