A heart attack is when a fatty plaque in the wall of a coronary artery ruptures and a subsequent clot forms over the rupture blocking the artery. When most people think of a heart attack, the usual thought that is conjured in the mind is that of the typical “Hollywood heart attack”, where someone clutches their chest with pain radiating to the throat and down the left arm requiring an urgent emergency call and admission to hospital for acute management.

So, can a heart attack present without these typical findings and symptoms? The answer to this is, “Absolutely!”

1) You will find it quite bizarre to hear that the most common symptom of a heart attack is probably no symptoms at all. A recent study from the US has suggested that up to 45% of heart attacks are silent, although, I suspect it’s probably closer to around 10%. This is especially the case for diabetics. Long-standing diabetics not only have macrovascular disease which refers to blockages in the larger blood vessels such as the coronary and carotid arteries but also microvascular disease that can affect the eyes, the kidneys and the nerves throughout the body. This may reduce the pain sensation experienced with a heart attack and explain why silent heart attack is quite common in a diabetic.

Also, in some cases, a person may go to sleep and have a heart attack whilst asleep, wake up the next morning feeling rather seedy and clearly are not aware they had suffered a heart attack overnight.

Finally, there is no doubt that a significant proportion of silent heart attacks are purely that — silent.

image source: livewellrehab.com.au

2) Another common presentation is pain in the arm, shoulder, neck, back or even in the solar plexus region. The solar plexus, also known as the epigastrium, is commonly the area where discomfort is experienced with heart attacks that affect the under surface of the heart, otherwise known as inferior wall myocardial infarctions. Basically, any discomfort experienced from the tip of your nose to your bellybutton, which does not have an obvious explanation should be viewed with some suspicion and assessed by a doctor. Dr Google is not always the answer.

Also, another important point here is that it doesn’t always have to be pain. Many people complain of a discomfort, a niggle and often typically describe the symptoms as tight or gripping rather than the aching pain seen with many other conditions.

3) Unexplained nausea, especially when acute may be another unusual presentation for heart attack. Again, this is more common in inferior wall heart attacks that affect the undersurface of the heart.

4) Unexplained and marked fatigue may occasionally be the only presenting symptom for heart attack. Although there are many causes for fatigue and heart attack is certainly not up there at the top of the list, it is commonly an associated symptom that occurs when somebody does experience the classical heart attack, such as described above. But, in my career I have seen the occasional patient whose only symptom for a heart attack was significant and severe fatigue.

5) Finally, and not particularly surprising, is unexplained shortness of breath without significant chest pain. This is especially so if the person is complaining of relatively sudden onset shortness of breath. It is important to realise that this may be due to any form of cardiac disease, intrinsic lung disease such as pneumonia, a pneumothorax, a pulmonary embolus, which is where a clot travels from the veins below the heart into the lungs, or even a systemic problem such as anaemia or a thyroid disorder. A heart attack should be considered in this situation as well.

In conclusion, heart attack is the commonest cause of death in our society and in anyone who presents with acute symptoms, this should be put at the top of the list of conditions that need to be excluded.

Symptoms are nature’s tickets into the system; ignore them at your peril.