symptoms for both sexes include breaking out in a cold sweat,
general weakness, nausea, shortness of breath, dizziness and/or
lightheadedness, and/or discomfort or pain between the shoulder
Women are more likely than men to complain of the less common
symptoms listed above, as well as jaw and back pain, unusual
fatigue, and trouble sleeping due to the pain. They may also have
a sense that something is terribly wrong or feel an impending
sense of doom. Because these are not necessarily the typical
symptoms, and women still often perceive themselves as being less
likely to experience a heart attack than men, they are slower to
seek medical attention and therefore are at greater
risk of dying from a heart attack than men.
Brief episodes of chest pain or breathlessness and/or discomfort
or pain between the shoulder blades may occur weeks before a heart
attack, especially upon exertion. You may first notice symptoms
while exercising or walking up a flight of steps, or even during
sex, if that's the most demanding physical activity you engage in.
These symptoms could be angina, brief periods when the blood flow
is temporarily cut off from a portion of the heart.
If you have any of the symptoms described above, especially if
you've never experienced them before, and even if they come and
go, call the doctor and then take one 325-milligram, preferably
uncoated, aspirin. An aspirin can help break up the blood clot
that is causing the heart attack. (If you are allergic to aspirin
or think you're having a stroke, don't take it.)
How do you know whether it's indigestion,
angina, or a heart attack?
Many people get
chest pains, the great majority of which do not signal the
presence of a heart problem. My standard advice is, if you
have a symptom that is new and does not represent an
established pattern, call immediately for an ambulance and
have someone call your doctor. The modern, well-equipped
ambulance is a bit like the emergency room
brought to your doorstep, and the emergency medical services
(EMS) team can perform CPR or use a defibrillator to restore
normal heart rhythm if need be. Calling 911 is certainly safer
than taking yourself to the ER (if you must, have someone else
drive you or go with you). Even if you and your doctor have
agreed ahead of time that a certain hospital's ER is best, if
you're having a heart attack and the EMS team advises you to
to the nearest hospital in order to save your life, go
When you arrive in the ER, immediately communicate your
concern that you are having a heart attack and describe your
symptoms. This is not the time to be shy about asserting
yourself. At the hospital, you will be given an
electrocardiogram (EKG or ECG), a noninvasive test used to
check for any sign of injury to the heart muscle and to detect
an irregular heartbeat. If, based on the EKG and your
symptoms, the doctor judges that you are having an acute
coronary syndrome (a heart attack or unstable angina), he or
she will treat you immediately. If the EKG is inconclusive, a
blood test that identifies certain heart enzymes will confirm
whether or not you are having a heart attack. These enzymes
are substances that perform vital functions in the heart
muscle; they leak out of
dying cells into the bloodstream during a heart attack.
If you are having a heart attack, you will most likely be sent
for an invasive angiogram or given a clot-busting drug
intravenously. There are also times when these approaches may
not be appropriate and medical therapy may be the best
treatment. Do whatever your doctor tells you to do. Now is not
the time to talk about aggressive prevention, demand a
noninvasive heart scan, or get a second opinion. Now is the
time for aggressive intervention. In the event of a heart
attack, angioplasty, bypass surgery, and clot busters can be
Women, take note: Many studies indicate that women are more
likely to sustain a heart attack without the classic symptoms,
such as chest pain, described on the preceding pages. This
raises the possibility of misdiagnosis by both the patient and
the physician. Women may only experience the less typical
symptoms, such as shortness of breath, weakness, or dizziness.
As a woman, you have to be extra vigilant to make sure that an
EKG and heart enzyme test are performed if you are
experiencing symptoms that are new and that concern you.
Whether you're a man or woman, once you've had a heart attack,
you have a 20 percent chance of dying within 10 years of the
first attack, unless you have significantly altered the risk
factors that caused the heart attack in the first place.
That's why, as soon as you begin recovering from a first heart
attack, it's time to begin an aggressive prevention
program to make sure that it never happens again.
Heart attack victims, take note: According to a Mayo Clinic
study, for the first month after having a heart attack, your
risk of having a stroke is 44 times higher than normal. The
risk for stroke declines rapidly after the first month;
nevertheless, anyone who has just had a heart attack should be
familiar with the symptoms of stroke.
When Chest Pain Isn't a Heart Attack
Almost all of us will experience chest pain from time
to time. In my experience, the most common cause of chest pain is
reflux of stomach acid into the esophagus, widely known as GERD (gastroesophageal
reflux disease). If the esophagus goes into spasm, it can cause
severe chest pain that closely mimics the symptoms of a heart
Muscle spasm can also cause chest pain, and women may
experience chest discomfort under the left breast due to muscle
strain. Transient sharp pains or "sticks in the chest" lasting for
only seconds are frequent complaints that are also
uncharacteristic of limited coronary blood flow.
However, if you
experience any chest discomfort, especially if you have risk
factors for heart disease, do not self-diagnose. Let your doctor
make the diagnosis.
The first sign of chronic angina typically occurs when you
are under unusual physical or emotional stress. In such
situations, your heart beats faster and your blood
pressure increases, and blood flow through your coronary
arteries must increase in response.
If one or more of
your arteries is substantially blocked, you may be unable
to supply the required increase in blood flow and your
heart muscle will, in a sense, cry out for more blood. This "cry" is manifested as chest pain. When the
stress is removed (you stop running or reach the top of the
stairs, for example), your heart rate and blood pressure return
toward normal, your heart muscle requires less blood, and the
chest pain goes away.
Although the plaque rupture leading to the obstruction may have
occurred months or even years ago, it will not become apparent
until you do an activity that requires a substantial increase in
coronary blood flow.
Many of us who do not regularly do vigorous exercise will remain
oblivious to a new obstruction. If we rush for a plane, shovel
snow, move furniture, or experience unusual emotional stress,
suddenly the heart muscle will require more blood flow than can be
supplied through the obstructed coronary artery, and chest pain
will result. At rest or with mild exertion, the blood flow will be
adequate and chest pain will not be experienced.
In patients with the exertional symptoms or with a chest pain
pattern that is atypical for angina, I perform a stress test to
first establish whether the symptoms are due to a limitation of
blood flow. If that is the case, I then determine how much of the
heart muscle is compromised and at what level of exercise capacity
the symptoms and limitation of blood flow occur. The earlier
symptoms occur and the greater the amount of
heart muscle affected, the more likely I am to proceed with an
invasive approach. When exercise capacity is good and compromise
of blood flow is limited, the more likely I am to treat with
medications and lifestyle interventions alone. For many people,
this type of medical therapy can relieve angina and reverse the
abnormalities seen on the stress test.
Is It a Stroke?
Many of us fear a stroke more than a heart attack
because if we survive, we may be left with paralysis and a
severely reduced quality of life.
Each year, approximately 700,000 Americans suffer a stroke and
273,000 people die from one. Today more than 1 million American
adults have long-term disabilities as the result of a stroke.
You don't have to be one of those people. As with treating heart
disease, aggressive risk-factor intervention can prevent stroke.
The same medications and lifestyle therapies that can reduce the
risk of having a heart attack can do the same for stroke.
There are two different types of stroke: hemorrhagic
stroke and ischemic stroke. Hemorrhagic stroke is
caused by the rupture of an artery and the release of
blood into the brain. The major risk factor for
hemorrhagic stroke is high blood pressure.
stroke is caused by a sudden blockage of one of the arteries
leading to the brain due to the rupture of a soft plaque and the
resulting blood clot. Or it may be caused by a clot or
atherosclerotic debris that has traveled to the brain from the
heart or the vessels leading to the brain. Almost 90 percent of
strokes are ischemic.
An ischemic stroke is very similar to a heart attack, which is why
some people refer to this type of stroke as a "brain attack."
Therapies that reduce the risk of soft plaque rupture in the
coronary arteries also reduce the risk of soft plaque rupture in
the arteries leading to the brain.
If the clot blocks a small artery leading to the brain, the stroke
may be so minor that the person is not aware of having had one.
This is called a silent stroke. Silent strokes are quite common in
older people and are believed to cause problems with memory and
the ability to think.
In a study of 5,000 people 65 years of age and older, brain scans
showed that 31 percent had some stroke-related brain damage.
Another 28 percent had clear evidence of brain damage, even though
they were not aware of having had a stroke or any stroke symptoms.
It's critical to know the symptoms of stroke so you can recognize
when it's happening to you and get help. Stroke symptoms in both
men and women include:
Sudden weakness or numbness in the face, arm, or leg on one side
of the body
A severe headache worse than anything you have ever experienced
(this is most characteristic of a bleed into the brain)
Slurred speech, loss of speech, and/or sudden blurring or loss
Dizziness, drowsiness, or falls
You may experience one or more of these symptoms briefly and then
go back to feeling normal. This is called a transient ischemic
attack (TIA). It is common to have several TIAs prior to having a
stroke. If you think you have experienced a TIA, seek immediate
For the most part, the same risk factors for heart disease apply
to stroke. Women, take note: If you take estrogen either in the
form of oral contraceptives, the Patch, or hormone replacement
therapy, you are at greater risk for stroke. Women who smoke and
take birth control pills have a considerably greater risk of
stroke (and heart attack) because
each predisposes you to abnormal blood clot formation.
If you suspect that you are having a stroke, get medical attention
immediately. Call 911 for an ambulance to take you to the
hospital, and have someone call your doctor. If you are in the
midst of having a stroke, the ER physician may administer a drug
to break up the clot to restore normal blood flow to your brain.
Drug therapy works best during the first 3 hours of a stroke and
can make a real difference in terms of outcome. However, treatment
once a stroke has occurred is quite limited. The best strategy is
Fortunately, the simple, painless, noninvasive carotid ultrasound
test we discussed in Step 3 can be performed to detect the buildup
of plaque in the carotid arteries, which carry blood to your
brain. Plaque buildup in the carotids generally occurs later than
it does in the coronary arteries; however, atherosclerosis in the
carotids can still be seen
years before it could lead to a stroke. If you have cardiac risk
factors and a family history of heart disease or stroke, then a
screening carotid ultrasound can be very helpful. If
atherosclerosis is detected, its response to therapy and lifestyle
changes can be monitored. Discuss your risk of stroke and the
potential benefits of a carotid ultrasound with your doctor. With
the information obtained from the ultrasound, your doctor can
decide if you need to make any changes in your lifestyle or take
medications such as a statin drug, a blood pressure lowering drug,
or a blood thinner to prevent a stroke.
by Arthur Agaston, M.D.