Heart Attacks Without Chest Pain: The Danger Is Greater?

Most everyone is familiar with the "classic" description of a heart attack and its hallmark symptom of crushing chest pressure - pain that does not go away even when a nitroglycerin is slipped under the tongue. Patients might describe this chest discomfort as a tightness, a burning, or an ache. It often spreads to the shoulders, left arm, or jaw. Many individuals report shortness of breath, sweating, nausea, and a sense of impending doom as well.

Such symptoms should prompt people to immediately call their doctors and head to the nearest emergency room. When chest pain is due to a heart attack, prompt diagnosis and treatment with angioplasty and thrombolytic ("clot-busting") drugs can often clear the blocked artery causing the heart attack. Doing so not only lowers the chances of dying, but also reduces the likelihood of long-term damage to the heart muscle. Another important concern is that heart-attack victims are especially vulnerable to arrhythmias (abnormal heart rhythms). When a patient is monitored in the hospital, doctors can quickly treat these arrhythmias with medications or electrical shocks. Without medical care, the risk of sudden death due to an abnormal heart rhythm is high; thus, untreated heart attacks are believed to be the cause of a large proportion of the unexpected deaths that occur each year outside hospitals. Unfortunately, many people who have heart attacks do not go to the hospital quickly - and some never go at all.

Some of these individuals have the classic symptoms of heart attacks, but they either do not understand their significance or simply do not want to acknowledge the implications. They tell themselves (and their families) that it's probably just heartburn, and an antacid will do the trick. Or they keep trying nitroglycerin tablets and hope that the discomfort will go away. And sometimes they do nothing at all but grit their teeth and hope for the best. Other patients, however, delay going to the hospital (or fail to go at all) because their heart attacks do not cause the "classic symptoms" for which they have been taught to be on the alert. Such individuals may experience any one of the symptoms listed above or may have no symptoms at all. Their "heart-attack experience" may include only vague symptoms, for example, an aching left wrist or a feeling of nausea. Chest symptoms (if they occur at all) may not feel like a pressure or a pain but might be described a "numbness" or some other sensation.

Quieter Is Not Better

Many patients (and doctors) assume that "silent" heart attacks, those characterized by these unusual symptoms, are smaller and less likely to be harmful. Often, these heart attacks are discovered only when a physician performs an electrocardiogram as part of a physical or some other medical evaluation. Patients often say, with a note of hope, "I didn't even have any chest pain," keeping their fingers crossed that the absence of chest pain is a good sign.

Unfortunately, the opposite may be true. A recent study analyzed the outcomes for 434,877 patients with heart attacks who were treated at 1,674 hospitals across the country. The researchers found that one third of the patients did not experience any chest discomfort, sensation, or pressure. Nor did they have arm, neck, or jaw pain before reaching the hospital or before a doctor diagnosed the heart attack.

Who were these patients with unusual heart-attack symptoms? The study investigators identified six factors that appear to increase the likelihood that a person might experience a heart attack without chest pain. These include: