Q&A 028 : Heart Attack Warning Signs

⏱ 10 min read

Dr. Hayes Q&A · No. 028

By Eleanor Hayes, M.D. · Hospitalist

Most men picture the same scene: a hand clutched to the chest, a collapse, a crushing pain no one could miss. Real heart attack warning signs are often quieter than that, and the quiet ones are the ones people talk themselves out of.

The Question

“Everything I read about heart attacks talks about crushing chest pain. I don’t have that. What I have is heartburn for the last couple of weeks, mostly after lunch, and it gets worse when I take the stairs up to my office. I’ve been living on antacids. What are the warning signs I should actually be watching for?”

— Name withheld

The Short Answer

The warning signs of a heart attack are not limited to crushing chest pain. Pressure, tightness, or burning in the chest, shoulders, arms, neck, back, jaw, or upper abdomen can all come from the heart, and so can shortness of breath and unusual fatigue. The feature that matters most in this reader’s story is not where it burns but when: “heartburn” that shows up with exertion and does not answer to antacids should be treated as the heart until proven otherwise. With diabetes in the picture, the threshold for getting checked should be low. Today, not after the next flight of stairs.

Heart Attack Warning Signs Men Over 50 Tend to Miss

Chest pain means more than pain in the chest. The 2021 U.S. chest pain guideline made this point on purpose. Patients often do not use the word “pain.” They describe pressure, tightness, squeezing, heaviness, or burning, and they may feel it in the shoulder, arm, neck, back, upper abdomen, or jaw rather than the chest. The guideline also dropped the word “atypical,” because it was too often used to wave off symptoms that were in fact coming from the heart. (2021 AHA/ACC guideline for the evaluation of chest pain) Shortness of breath and fatigue are counted as possible equivalents too. (AHA summary of the chest pain guideline)

Heartburn that climbs stairs. Ordinary reflux tends to follow meals and lying down. It does not usually get worse because you walked up three flights. Discomfort that is brought on by effort and eases with rest is the classic pattern of a heart muscle that is not getting enough blood when it works harder. The reader’s lunch is a distraction. The stairs are the clue. And the antacids he keeps reaching for without relief are part of the story too: when a treatment for the stomach does not fix a “stomach” problem, the stomach may not be the source.

Diabetes can muffle the alarm. Diabetes can change the way heart pain is felt, sometimes dulling it, sometimes shifting it into vaguer signals like fatigue, breathlessness, or discomfort that is hard to place. That is why a man with diabetes cannot wait for the textbook version. The signal he gets may be the only one. If blood sugar numbers themselves are unfamiliar ground, the question on A1C and fasting glucose covers them.

Warnings often come before the worst event. A community-based study from Cedars-Sinai looked at sudden cardiac arrest, which is related to a heart attack but not the same thing. Half of the people who had a witnessed cardiac arrest had at least one warning symptom in the 24 hours before, and in men the most prominent one was chest pain. (Cedars-Sinai study on warning symptoms before cardiac arrest) The lesson carries over. The body often knocks before it breaks down the door. The question is whether anyone answers.

What I See in the Hospital

The pattern I see most often in men is the explanation that arrives before the diagnosis. It is indigestion. It is a pulled muscle from the weekend. It is stress, or bad sleep, or getting older. Each explanation is reasonable on its own, which is exactly why it works so well at keeping someone home. By the time the explanation runs out, days have often passed.

The other pattern runs the opposite way. Someone does come in, the first tests are reassuring, and he walks out believing the question is closed, when what the ER actually answered was narrower: not a heart attack right now. That gap is the subject of the case of chest pain with negative ER tests. A clean night in the ER is good news. It is not always the end of the workup.

Plain-Language Reference

What to Actually Do

· Notice when symptoms come, not just where. Discomfort brought on by effort deserves a same-day call to a physician, and an ER visit if it is new or getting worse.
· If you have diabetes, lower your threshold. Unexplained fatigue or breathlessness with effort counts.
· If antacids are not working, stop treating it as the stomach on your own and get it evaluated.
· If any of the 911 signs appear, call. Do not drive, and do not wait to see if it passes.
· Learn hands-only CPR and where the nearest AED is at work. It is the one skill in this article you use for someone else.

This article is for general information only and does not constitute medical advice, diagnosis, or treatment. Reading it creates no provider-patient relationship. The reader’s situation is a composite and does not represent any specific person. Heart attack symptoms vary widely, and no article can tell you whether your own symptoms are coming from the heart. If you have chest discomfort, shortness of breath, or any of the warning signs described here, call 911 or go to the nearest emergency room without delay. Do not drive yourself, and do not wait to see whether symptoms pass. If you see someone collapse and stop breathing normally, call 911 and begin chest compressions.

Take care of yourself. Nobody else will do it for you.
— Eleanor Hayes, M.D.