Heart disease rarely announces itself. It builds quietly over years, and by the time it is obvious it has usually been present for a long time. The signs below are the ones people most often explain away - as age, as heat, as acidity, as being out of shape. Most of the time that explanation is right. Occasionally it is not, and the cost of being wrong is very high.
This article is about knowing which is which, and what to do about it.
When to stop reading and call for help
Some symptoms are not something to monitor. If you or someone near you has chest pain or pressure lasting more than a few minutes, especially with breathlessness, sweating, nausea, or pain spreading to the arm, jaw or back:
- Call 108 for an ambulance (or 112). Do not drive yourself.
- Sit down and stay still while you wait.
- If the person is unconscious and not breathing normally, start chest compressions and keep going until help arrives.
An ambulance is not just transport. Treatment starts inside it, and arriving by ambulance is usually faster into the right part of the hospital than arriving at the front door. In a heart attack, muscle dies by the minute, and that damage cannot be undone later.
1. Chest pain, pressure or tightness
The classic sign, and still the most important one. It is often described less as pain than as a weight, a squeezing, or a band across the chest. It may come on with exertion - walking uphill, climbing stairs, hurrying for a bus - and ease within a few minutes of stopping.
That pattern, called angina, is the one to take seriously precisely because it goes away. Discomfort that reliably appears with effort and settles with rest is the heart saying it is not getting enough blood when it is asked to work.
2. Breathlessness
Getting out of breath sooner than you used to, doing something you have done for years, is worth asking about. So is waking at night short of breath, or needing more pillows than you once did to sleep comfortably.
Breathlessness has many causes, most of them not cardiac. But a heart that is not pumping efficiently backs fluid up into the lungs, and this is often how that first shows.
3. Pain that spreads
Cardiac pain is not always felt in the chest. It can be felt in the left arm, in both arms, in the jaw, the neck, the upper back, or the upper abdomen - sometimes with no chest discomfort at all.
Upper abdominal discomfort is the one most often mistaken for indigestion. If antacids are not helping, and the discomfort came on with exertion or arrived alongside sweating or breathlessness, treat it as cardiac until a doctor says otherwise.
4. Unusual or extreme tiredness
Not ordinary tiredness. This is exhaustion out of proportion to what you have done - finding a flight of stairs or a routine household task draining in a way it simply was not a few months ago.
It is easy to put down to age, work or poor sleep, which is why it gets missed. The useful question is not "am I tired?" but "could I do this last month?"
5. Palpitations or an irregular heartbeat
An occasional skipped beat is common and usually harmless. What is worth reviewing are palpitations that:
- last more than a few minutes, or keep coming back
- arrive with dizziness, breathlessness or chest discomfort
- feel fast and completely irregular, with no pattern to them
A persistently irregular rhythm can raise the risk of stroke, and it is treatable once it has been identified. An ECG recorded during an episode is often all it takes to find it.
6. Swelling in the ankles, feet or legs
Swelling that is worse by evening, that leaves a dent when pressed, and that affects both legs can be a sign the heart is not clearing fluid efficiently. Sudden swelling in one leg is a different problem and also needs same-day attention.
Swelling alongside breathlessness, or weight gain over days rather than months, should be reviewed promptly.
7. Dizziness, light-headedness or fainting
Standing up too quickly makes most people light-headed. What matters is fainting during exertion, fainting with no warning at all, or fainting alongside palpitations or chest discomfort.
Any faint that causes an injury, or that happens while exercising, should be investigated rather than waited out.
8. A persistent cough, or wheezing when lying flat
A dry cough that will not settle, sometimes worse on lying down, is occasionally fluid in the lungs rather than an infection or an allergy. A cough lasting more than three weeks deserves a look whatever the cause turns out to be.
9. A cold sweat with nausea
Breaking into a cold sweat for no clear reason, particularly alongside nausea, breathlessness or a strong sense that something is badly wrong, is a recognised presentation of a heart attack.
It is easily dismissed as a stomach upset or the heat, and it is one of the reasons people arrive at hospital late.
10. A drop in what you can do
Less a symptom than a pattern. Heart disease often shows first as a quiet narrowing of life - taking the lift instead of the stairs, walking the shorter route, skipping the market on a warm day. Each of those decisions looks sensible on its own.
If your ordinary week has shrunk over the past few months and you cannot quite say why, that is worth a conversation.
Signs that are more common in women
Women having a heart attack are more likely than men to have symptoms other than chest pain, and are more likely to be diagnosed late as a result. Watch particularly for:
- breathlessness or unusual fatigue with no chest pain at all
- nausea, vomiting, or discomfort mistaken for indigestion
- pain in the jaw, neck, upper back or between the shoulder blades
The advice is the same, but the threshold for acting on it should be lower, not higher.
Who should be checked even without symptoms
The most useful checks happen before there is anything to report. Consider a cardiac assessment if you have:
- a family history of heart disease, especially before the age of 60
- diabetes, high blood pressure or raised cholesterol
- a history of smoking or any tobacco use
- a largely inactive routine, or significant recent weight gain
South Asians tend to develop coronary artery disease earlier, and at lower body weights, than many other populations. "I am not overweight" and "I am only in my forties" are not reassurance on their own.
What a first assessment usually involves
Most first visits are straightforward and take a morning:
- History and examination - what you have noticed, and when it started
- ECG - a recording of the heart's electrical activity
- Blood tests - cholesterol, blood sugar and related markers
- Echocardiogram - an ultrasound of the heart's structure and pumping
- A treadmill test, where symptoms appear with exertion
Anything further is arranged only if these suggest a reason for it.
The thing worth remembering
Almost everyone who has had a heart attack can, afterwards, name the weeks when something felt different. The symptom was noticed. What was missing was a reason to act on it.
Take that reason from here: a symptom that is new, that is getting worse, or that appears with exertion should be looked at. The visit that finds nothing is not a wasted visit. It is the outcome you want.
This article is general information, not a diagnosis. If you recognise something here, speak to a doctor about your own situation - and if you are having symptoms right now, call 108.
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