by Carolyn Thomas ♥ @HeartSisters
Perhaps you’ve heard the term “silent” heart attack. If you’ve experienced this cardiac event, you might recall having only mild cardiac symptoms at the time, or symptoms that didn’t feel like they were heart-related – or even no symptoms. In fact, you may be unaware that this has happened to you at all until later medical tests reveal evidence of heart muscle damage in the past.
Yet silent heart attacks might be surprisingly common, according to Cleveland Clinic cardiologists.
And the worst part about a silent heart attack is that if you’re not even aware it’s happening, you won’t seek immediate medical care that can help to limit the dangerous damage to those heart muscle cells.
Silent vs. NON-silent heart attacks:
Coronary artery disease typically causes both silent and non-silent heart attacks. Deposits of plaque that contain cholesterol and other waxy substances can build up in your coronary arteries, limiting the blood flow to your heart muscle cells. Similarly, you may experience non-obstructive coronary artery disease in which that oxygen-rich blood is prevented from getting through to the heart muscle – not because of a blockage, but due to a coronary artery spasm – or a condition like Spontaneous Coronary Artery Dissection (SCAD).
In the worst case scenario of coronary artery disease, a blocked artery caused by a plaque blockage, spasm or SCAD in one or more arteries can cause heart muscle cells to die. That’s what a heart attack is. And damaged heart muscle cannot heal like an injured arm or leg muscle can. After heart muscle cells die, they’re replaced with scar tissue. Which is not good.
How could you have a heart attack without knowing it?
According to Cleveland Clinic, the symptoms during a silent heart attack may feel like:
- the flu
- a pulled muscle in your chest or upper back
- an ache in your jaw, arms or upper back
- severe fatigue
- indigestion
We know from years of academic studies on what researchers call treatment-seeking delay behaviour that women are especially prone to minimizing or dismissing symptoms compared to our male counterparts – yes, even severe and obvious cardiac symptoms – including denying that anything is wrong and refusing help (as I did for two whole weeks after being misdiagnosed in mid-heart attack and sent home by the Emergency Department physician who had confidently proclaimed to me:
“You are in the right demographic for acid reflux!”
If women excel at treatment-seeking delay behaviour despite textbook Hollywood heart attack symptoms, imagine how reluctant we would be when experiencing silent heart attack symptoms that we don’t interpret as heart-related.
Your healthcare professional can assess your cardiac risk factors and treat those that are treatable in order to help lower your chance of having a silent heart attack.
The risk factors for having a silent heart attack are the same as heart attacks accompanied by those textbook cardiac symptoms. These include:
- age
- diabetes
- obesity
- pregnancy complications
- family history of heart disease
- high blood pressure
- high cholesterol
- lack of exercise
- smoking
So far, imaging tests (e.g. electrocardiogram or echocardiogram) are the only ways to detect heart muscle damage in someone who has had a silent heart attack in the past. A research review published in the Annals of Translational Medicine journal, however, reported that ECGs can detect previous silent heart attacks less than 50 per cent of the time – so the prevalence of silent heart attacks might actually be far higher than we know. Researchers have suggested that ultimately, ECGs tend to be more helpful in determining if someone has NOT had a previous heart attack.
Dr. Leslie Cho, director of the Women’s Cardiovascular Center at Cleveland Clinic, described a common scenario during silent heart attacks to an American Heart Association interviewer:
“Many times, people believe that it is something else. Much later, when they end up getting diagnosed with a heart attack that they didn’t even know they were having, they may recall there was a past episode where they were feeling short of breath or tired, but thought at the time they were just working too hard.”
Damage from a silent heart attack to the heart muscle itself can vary, Dr. Cho explained. For some fortunate people, their silent heart attacks may have activated what are called collateral arteries to provide what she calls “the body’s own natural bypass”.
About 1/4 of people with normal coronary arteries also have these small extra arteries called collaterals, which can reroute blood flow around a blockage in times of dire need (like a blocked coronary artery, for example). See also: Bypassing bypass surgery by growing new arteries. This amazing process is officially called arteriogenesis, defined as “the transformation of pre-existing collateral artery pathways into conducting vessels.”
This can happen when these collateral arteries “wake up” and form a kind of detour around the blockage, thus providing an alternate route of blood supply to feed the oxygen-starved heart muscle. It’s like Do-It-Yourself bypass surgery!
We also know that one of the strongest predictors of a heart attack is having already had one. About one in every five people who have survived a heart attack will be readmitted to the hospital for a second one within five years, according to the American Heart Association. Having one silent heart attack also increases your risk of having another not-so-silent heart attack, which could actually be worse than the first, as well as your risk of severe complications, such as heart failure.
And it’s also why addressing that list of known cardiac risk factors is so important if you’re one of those survivors. Some risk factors (like your age or family history) are ones you cannot of course control. So your only job now is to make decisions to manage the risk factors you can.
Q: Have you or somebody you know experienced a silent heart attack?
♥
Teacup image: GrumpyBeere, Pixabay
NOTE FROM CAROLYN: I wrote more about women’s cardiac risk factors in my book A Woman’s Guide to Living With Heart Disease (Johns Hopkins University Press). You can ask for it at bookstores (please support your local independent bookseller) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Heart Sisters 
Thank you for this, Carolyn. An important topic of which we all need to be aware.
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This IS an important topic, Helen – thanks for taking the time to share your response! ❤️
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Thank you for writing about SCAD! Your article is very relevant to me. I had a silent heart attack, and then some 10 or so years later had a SCAD.
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Hello Tobe – everything is connected, right? It’s not surprising that a disruption in one cardiovascular area affects other areas of the body. For a long time I didn’t know, for example, that a pregnancy complication (in my case, preeclampsia) meant a 3-4 times higher risk of heart attack – years down the road.
I hope your heart is now doing much better.
Take care. . . ♥
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Hi Carolyn,
My cardiologist said that I truly suffered a silent heart attack and I was seeing a doctor very regularly. I’ve had a number of abnormal medical problems all my life. I was born with respiratory problems and bronchial asthma.
The only risk factor would be my age, I was 55 years when I was diagnosed with having a ‘silent’ AMI/STEMI widowmaker with massive irreversible progressive damage. Not a diabetic, never been pregnant, no family history, uncontrollable high BP(bad temper), no cholesterol problems, very active, and light smoker. Because of my asthma I’ve never been able to inhale a cigarette.
My INS Specialist tested me each time I had severe breathing problems and severe bronchial spasms and the very first test was an ECG and it showed no signs of cardiac issues. My cardiologist got all my records from my INS and said that with all my other tests coming back as being in excellent health, no one would have any reason to do any further invasive testing on me. I am 5’4″ tall and at the time weighed 108 pounds which places my BMI as under weight.
I have orders that if I don’t feel right or feel funny that I’m to call ME and have them transport me to the hospital. I hate the ER as I have a 48-72 hour hold on me so that they can do the proper cardiac testing to make sure I’m not having another heart attack. My AMI was caused by a spasmodic artery disease. I have a condition called “Coronary artery disease involving native coronary artery of native heart without angina pectoris “, I feel absolutely nothing happening in my chest and can be in the middle of a cardiac arrest with all of the meds I weigh 103.4 fully dressed.
I had scar tissue from at least a dozen untreated heart attacks that had taken place over a years that were un-treated. I showed up in the ER for what I thought was an uncontrollable asthma attack and my medication wasn’t working.
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Hi again Robin,
When your INS specialist told you your symptoms were “not cardiac” because your ECG showed “no signs of cardiac issues”, it could have been because (although the ECG is apparently the most commonly-used tool to identify silent heart attacks) as this article suggests, its accuracy hovers around just 50%.
Another interesting issue with ECGs is that – as Yale cardiologist Dr. Harlan Krumholz wrote in the New England Journal of Medicine about a study on how accurate doctors were in correctly interpreting ECG tests:
“This sobering study reports LOW ACCURACY in the interpretation of electrocardiograms across a wide range of clinicians. Cardiologists did best, but still had a high prevalence of errors.”
So yet another reminder that diagnostic errors are common and predictable in medicine. In your case, especially without chest pain symptoms, you were very lucky that other doctors were able to correctly read your later ECGs.
Take care. . . ❤️
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Sometimes when I’m very fatigued and having chest or stomach pain, I myself wonder if I’m having a silent heart attack… I have all the risk factors (except smoking) and my mother had a silent heart attack sometime in her early 70s.
My mother’s heart attack was most likely hidden by the fact that she had Peptic Ulcer Disease. One time she was having what she thought were her “usual” stomach pains so she went to work anyway and collapsed in the elevator with a perforated ulcer!
Stoic women ignoring their symptoms, a disease in itself!!!
One day out of the blue, she called me and asked “What does it mean if my legs are swollen as big as tree trunks and I am so tired I can’t get out of bed?” I told her it could be heart failure and to call an ambulance and get to the emergency room.
Sure enough, without any known cardiac history, she was in Afib and heart failure. After all tests were completed, the cardiologist said “You must have had a heart attack at some point in the past and it weakened your heart muscle to the point it can no longer pump adequately.”
I imagine it occurred during what she thought was a “usual” ulcer attack years before.
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Hello Jill – your mother sounds like a classic example of how effortlessly we can blame all/most symptoms – even new symptoms! – on whatever chronic condition we are already used to.
And when she called you with a question about her new symptoms – and then most importantly followed your advice! – she was demonstrating the second of six most common reasons for what researchers call “treatment-seeking delay behaviour”, which is:
“-2. Knowing something is wrong and letting someone else take over (women told someone about their troubling cardiac symptoms and were willing to go along with recommendations to seek immediate medical care)”
The other most common reasons are covered here.
As you so correctly observed: “Stoic women ignoring their symptoms, a disease in itself!!!”
P.S. Jill, I almost forgot to share with you something my friend Liz in Vancouver told me during her recent visit. She subscribes to my blog and mentioned that she enjoys Sunday’s Heart Sisters articles here, but what she really likes is reading all the interesting comments from other readers!
When I agreed with her on how much I like these thoughtful, wise, funny comments too – she immediately said: “Jill C!!”
So your comments have their own fan base here Thanks for them all! ❤️
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About EKGs. . . Back in 2011 when I went to my PCP with vague symptoms of low level chest pain and weakness for several days, he immediately did an EKG and luckily it showed very visible changes and he sent me to the ER a block away.
A cardiac cath showed Takotsubo Syndrome.
Now EKGs are pretty much useless since I had surgery on my ventricular septum. The surgery resulted in a permanent Left Bundle Branch Block. This looks like the classic ST elevation of a heart attack on EKGs, rendering them useless for diagnosis.
So if I have troubling cardiac symptoms I have to undergo stress echo, or a nuclear med study, or a cardiac cath.
That, in itself, makes me think twice when trying to determine if a chest pain is my usual cardiomyopathy or microvascular chest pain, or something new that needs to be investigated. Do you have that issue when dealing with your own chest pain issues? Blessings!
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Hi again Jill – very interesting issue (unlike my early days/weeks/months when every “new” twinge meant another widow-maker heart attack to me, by now I’ve managed to figure out pretty quickly how bad this is going to get – or not) But it does remind me of something that former paramedic/EMS Battalion Chief Tom Bouthillet once told me about his stepdaughter’s unusual medical I.D. bracelet.
She has a history of brain tumors and seizures. Her medical alert I.D. now lets physicians/first responders know that hemianopsia (decreased vision or blindness in half the visual field of one or both eyes) is a NORMAL finding for her if she is unconscious or otherwise unable to speak for herself during a medical emergency.
I’m guessing that most patients don’t have what the medical problem ISN’T engraved on their medical I.D.s compared with what their medical problem IS.
But in your case, if you were unable to speak for yourself, I’m wondering if adding that “Ventricuar Septum Surgery/Left BBB” info on your med I.D. (so first responders/Emerg staff see that immediately) might be something to consider?
Thoughts? ❤️
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Thank You!
I read your blog every Sunday with my cup of coffee. I seem to have a plethora of cardiac experiences to draw from so I enjoy crafting responses. I am still on the verge of writing several books, so I practice my writing skills at the same time!
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Yes indeed, Jill – you do seem to have experienced more than your average lifetime quota of cardiac diagnoses! You can stop anytime now and just relax! 🙂
I hope you will one day soon write your 4 or 5 books. And I will be among the first in line to read them all!
❤️
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