Synopsis: Heart attacks that produce few if any symptoms may be mistaken for indigestion or simple malaise, but they can be more serious than heart attacks that bring crushing pain because they often don’t bring a victim to the hospital for lifesaving help. Experts discuss.

Host: Reed Pence. Guests: Dr. Martha Gulati, cardiologist, Universisty of Arizona and Editor-in-Chief, American College of Cardiology patient education initiative, Cardiosmart. org; Dr. Robert Vogel, Professor of Medicine and Cardiology, University of Colorado and co-author, The Pritikin Edge.

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Silent Heart Attack

Reed Pence: More than a million people have heart attacks in the United States each year. We usually picture someone having crushing pain in their chest, and maybe falling to the floor. But a surprising number of heart attacks can occur without a person even realizing it’s happening to them. They’re called “silent heart attacks.”

Dr. Martha Gulati:  Silent, in general, means that at least it wasn’t the standard heart attack, meaning you always hear about an elephant standing on your chest or a rubber band across your chest or chest pressure or tightness that we classically see depicted in movies, and actually can be the symptom people will have when they have a heart attack. But not everyone has symptoms. In fact, about a third of people will not have symptoms of a typical nature when they are having a heart attack.

Pence: That’s Dr. Martha Gulati, a cardiologist at the University of Arizona and Editor-in-chief of the American College of Cardiology’s Patient Education Initiative,

Gulati:   It is true that sometimes you can have absolutely no symptoms, but sometimes it can also mean the symptoms were so subtle that people didn’t notice them. Or that they had symptoms, but they didn’t know they were having a heart attack at the time. An example of that would be someone who had a severe bout of indigestion. And then, somehow in the next month or so, get sent to a cardiologist and the cardiologist realizes actually they might have had a heart attack, and it might have been at the time that they had indigestion. Sometimes it can also be when people have flu like symptoms. They think they’re just run down having the flu, when in fact they’re actually having a heart attack.

Dr. Robert Vogel: Usually patients are quite surprised to hear that they’ve had a heart attack. Silent heart attacks are about 20-30, maybe a little bit more, percent of the time. So they’re not at all unusual. And when we tell people, Oh, you’ve had a heart attack, they say, I had no chest pain going down my arm, or something that they associate with a heart attack. Sometimes the symptoms can be very mild or even not existing.

Pence: Dr. Robert Vogel is professor of medicine and cardiology at the University of Colorado, Denver, co-author of the book, The Pritikin Edge and an active advocate for Pritikin ICR.

Vogel: It’s not exactly like the tree following in the forest nobody hears, because if you have a heart attack, something is going to happen. Hundreds of thousands of people die every year due to sudden cardiac death, which is a rhythm problem where the heart goes so fast it can’t pump any more. That is a consequence early on in the first few hours of a heart attack. That, if you’re sitting at home, taking an antacid is a disaster because you’re not going to expect it, and your family around you is not going to expect it. So, silent heart attacks with regard to that complication are really a disaster because you’re preventing yourself from prompt medical attention, which can save your life.

Pence: Taking antacids in response to what’s really a silent heart attack isn’t unusual, because often it feels like indigestion.

Vogel: Indigestion is common and it’s often confused. Even we have trouble as cardiologists sometimes differentiating indigestion or heartburn from the symptoms of a heart attack. That’s why whenever we see a patient in the emergency room or if the office, they say, Oh, I’m having some sort of heartburn, we as cardiologists are always saying, well was that heartburn, or was that cardiac pain? The advice to anybody is unless you’ve seen some physician and have definitely characterized it as heartburn, we are very concerned about new heartburn in individuals who are at risk for heart attack. So, if you have anything you just can’t assume that it is heartburn as much as it may feel to you like some sort of indigestion that you had after last year’s Thanksgiving.

Pence: However, that’s far from the only symptom among people who are actually having a silent heart attack… Or who’ve had one in the past and haven’t felt good ever since. Emergency room doctors usually have heart attacks prominently on their radar… But Vogel says sometimes even they miss the diagnosis.

Vogel: Heart attack can really be quite unusual. It’s more unusual in older folk, more unusual in women and more unusual in silent and diabetics. So, for example, a woman may experience some fatigue or just not feeling right. She’s tired, she’s a little short of breath. She comes in and sees a doctor and gets an electrocardiogram and there was a heart attack. The symptoms can be very transient, very mild, very similar to other common things like fatigue that occur in daily life.

Gulati:  Women particularly will get told oh maybe it’s anxiety, maybe you’re stressed out. It’s well documented in medical literature that we don’t treat women as aggressively as men, and women — it’s much harder for them to even get an EKG, even when they come to the emergency room with these subtle symptoms. Same with diabetics. It’s surprising to me particularly about diabetics because when you have diabetes in my mind you have heart disease until proven otherwise. We know diabetics can have atypical symptoms or no symptoms at all. These groups really do often get missed. They might come in and they know something’s wrong, but they don’t say those classic symptoms of crushing chest pain, tightness, neck pain, jaw pain, left arm pain, left shoulder pain. When the doctors don’t hear those key words, they don’t always look at the heart as being at risk.     

Pence: So how do people find out they’ve had a silent heart attack? Often it’s luck.

Vogel: I’ve had patients sent to me by dentists because they’re complaining about a tooth pain, or by orthopedic surgeons because they were complaining about neck pain or back pain or abdominal pain. Or something that doesn’t trigger the usual suspicion for heart attack, but turns out to be that. So, it is a difficult area both for us and for patients to zero in on, unless we’re really thinking about it.

Gulati:  When people don’t know that they’ve had a heart attack, how do they know that they should even see a cardiologist let alone get on the right medications at the time of a heart attack? Because they don’t even know that it happened. Unless they are fortunate enough to have mentioned either subtle symptoms to their doctor and their doctor has the wherewithal to get an EKG or get some sort of imaging done of the heart and ultimately get them referred to a cardiologist, they may never even know anything happened. We know that those people who have a silent heart attack aren’t at any less of a risk of a second even. In fact, may be at a higher risk of a future heart attack for the reason that they’re not on the right medications.     

Pence: So while a lot of people might assume that a silent heart attack isn’t as serious as one with crushing pain, that’s not correct. A silent heart attack that goes on for a few hours may end up being fatal.

Vogel: A silent heart attack can be every bit as severe. And remember, if you think by any stretch of the imagination you’re having a heart attack or something unusual is going on call 911. Mistake number one, don’t drive yourself to the hospital or a physician’s office. Mistake number two, don’t have someone who’s living with you drive yourself there. Call 911. I can’t tell you how many patients I’ve had, even those who’ve previously had heart attacks who come in, I didn’t want to bother somebody or I’m afraid of the expense. But the problem is, early in a heart attack your heart can stop. We know that we can start therapy earlier when the ambulance arrives. They can alert the emergency room to what’s going on. They get a cardiogram and if anything bad happens they can treat it. It’s just a much safer way to go.     

Pence: Doctors want a head start because they want to treat heart attacks aggressively. Vogel says it’s better for both immediate survival and avoiding long-term damage due to scarring of the heart muscle.

Vogel: Today we treat heart attacks by opening up the artery. The longer you wait in opening up the artery, the less successful you are in getting that myocardium to revive. We know that after a heart attack, that which determines your future is how much muscle died. The earlier you can get into a hospital and the earlier that artery can be opened, then the greater chance you are to live through that event and to live happily thereafter.

Gulati:  That scarring in particular is at greater risk of arrhythmias, particularly dangerous arrhythmias that cause cardiac death or cardiac arrest. It’s that scarring makes the heart more irritable. It makes these dangerous rhythms more likely. That’s where we always hope that we can meet these people before that happens to see if they’re at a greater risk of such things happening. When someone actually has a heart attack and has symptoms, our hope is we can open up the artery that’s causing the problem where there’s a blockage and prevent scarring. The problem with silent heart attacks is it happens at home and we don’t get the chance necessarily to open the artery or get the blood flowing to the heart muscle, and therefore the risk of scarring is even greater.

Pence: That scarring means that people who’ve had silent heart attacks are at a much higher risk of a variety of other later problems as well.

Vogel: It makes it more likely that patients or individuals will get chest pain when they exercise. It makes it more likely that they will have heart failure. Heart failure is when the heart can’t pump enough blood and physically, heart attacks cost you heart muscle. As you use up your reserve then your heart can’t pump and shortness of breath and swelling and fatigue occur. So that’s a consequence. Heart attacks make it more likely to have another heart attack. In the weeks and months following a heart attack, if you don’t seek medical attention, you’re not getting the medicine and the lifestyle changes that can prevent another one, during this vulnerable period after the heart attack you are more likely to have another one, and perhaps not survive it.

Pence: Vogel says that 80 to 90 percent of heart disease can be prevented using both medicines and lifestyle changes to control factors such as high blood pressure, high cholesterol, and obesity. If you have those risk factors, Gulati says you’re just as much at risk of a silent heart attack as a regular one.

Gulati: If you have a lot of risk factors where it’s a family history of early heart disease or you have high blood pressure or high cholesterol, if you’re a smoker, if you’re a diabetic, if you don’t exercise on a regular basis, if you are obese, all of those things are risk factors, as is age actually. So as we get older we’re at a greater risk of having heart disease. As we get older sometimes the heart attacks do in fact tend to be silent. So knowing of you’re at risk is key. Seeing your doctor on an annual basis is also key, because that way you should be talking every year. What is my greatest risk right now? Am I at risk for any disease, and what should I be doing to prevent that? And also deciding whether you need a screening test, whether it’s an EKG or some imaging or a discussion of have you had any symptoms since I last saw you that might be related to your heart?

Pence: If Gulati sees a patient who’s recently been having trouble walking much where they could easily walk before, she suspects a heart problem until it’s specifically ruled out. That can be the kind of person who’s experienced a silent heart attack… And needs medical attention right away.

You can find out more about all our guests through links on our website,, where you can also find archives of our programs. You can also find them on iTunes and Stitcher.

I’m Reed Pence.


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