Heart Attack: Symptoms, Signs

Brief overview

Symptoms: severe pain in the left chest area/behind the sternum, shortness of breath, feeling of oppression/anxiety; especially in women: Feeling of pressure and tightness in the chest, discomfort in the upper abdomen, shortness of breath, nausea and vomiting.
Causes and risk factors: Mostly blood clots blocking a coronary vessel; high blood pressure, high cholesterol, obesity, little exercise, diabetes, and smoking increase the risk
Examinations and diagnosis: physical examination, echocardiogram (ECG), cardiac ultrasound, blood tests, cardiac catheterization
Treatment: First aid, surgery with dilatation of the narrowed cardiac vessel (balloon dilatation), installation of a stent, medication (e.g., lysis therapy), bypass surgery
Prognosis: With early therapy, good prognosis, but no complete cure; without treatment, life-threatening; possible complications include cardiac arrhythmias, formation of (further) blood clots, aneurysm, stroke, chronic heart failure, mental illnesses
Prevention: Healthy lifestyle, regular exercise, normal body weight, low stress.

What is a heart attack?

The heart’s pumping function is disturbed or completely impeded – it stops. This cuts off the blood supply to the body and its organs, which is why a heart attack is life-threatening. In some people, the symptoms are not very severe. Nevertheless, medical experts do not speak of a mild heart attack.

According to the guidelines of the European Society of Cardiology (ESC) and the German Society of Cardiology (DGK), doctors first distinguish between acute myocardial damage and acute myocardial infarction in terms of the type of heart attack. The latter is only present if the myocardial damage is related to ischemia, i.e. is actually due to an oxygen deficiency.

Symptoms of a heart attack

In the event of a heart attack, there is no time to lose. The earlier it is recognized and treated, the greater the chances of survival. That’s why you should call 911 at the slightest suspicion and first symptoms of a myocardial infarction – even at night or on the weekend!

It is important to know the heart attack symptoms in men and women in order to be able to react quickly. But be careful: the typical signs do not always show up. In addition, a woman’s heart attack symptoms are often different from a man’s.

How to recognize a heart attack

The classic sign or early warning signs of a heart attack (“heart attack”) are sudden severe chest pain, specifically in the front left chest area or behind the breastbone. The pain often occurs at rest, for example in the morning hours or during sleep, and is usually pressing, stabbing or burning. They last for at least five minutes, according to the German Heart Foundation.

Many symptoms often become noticeable weeks or a few days before the onset of an acute or severe heart attack. The severity of the symptoms ultimately determines the duration of a heart attack.

Other typical heart attack symptoms include:

Feeling of anxiety or tightness: those affected often describe this severe constriction feeling figuratively as “as if an elephant were standing on my chest”.
Fear feeling/panic attack up to the death fear: The strong fear is often accompanied by cold sweat, a pale face color and cold skin. However, not every panic attack is associated with a heart attack. Accordingly, it is necessary to distinguish – panic attack or heart attack.
Sudden severe shortness of breath, loss of consciousness or severe dizziness: these non-specific symptoms may have other causes besides a heart attack. They also occur more often in women. In the case of shortness of breath, many sufferers also have blue lips due to the lack of oxygen.
Drop in blood pressure and pulse: Despite an initial often rising blood pressure, this fluctuates and drops in the course of a heart attack in many sufferers. The pulse also fluctuates during a heart attack and is ultimately significantly lower. How high the pulse is during a heart attack depends on the individual case. However, it falls well below the normal value of 60 to 80 beats per minute. As a result, it is sometimes not palpable.

The signs of a heart attack depend, among other things, on which coronary vessel is affected. For example, occlusions of the right coronary artery often lead to a so-called posterior wall infarction. They tend to cause discomfort in the upper abdomen. If, on the other hand, the left coronary artery is occluded, an anterior wall infarction results. In this case, the pain is more likely to be localized in the chest area.

How does a heart attack manifest itself in women?

The symptoms described above do not always manifest themselves in heart attacks. Women often have different symptoms. While a large proportion of men experience the classic chest pains, these occur in only about one third of women. In addition, female patients more often report a feeling of pressure or tightness in the chest instead of severe chest pain.

In addition, nonspecific complaints are much more often signs of a heart attack in women. These include shortness of breath, nausea, vomiting, and sometimes even diarrhea, as well as abdominal pain, especially in the upper abdomen, which is often mistaken for stomach pain.

Such complaints are often not immediately identified as heart attack symptoms and are taken less seriously. For this reason, women with heart attacks arrive at the hospital on average one hour later than affected men (calculated from the onset of the first heart attack signs). However, rapid medical care is essential for survival.

Harbingers of a heart attack in men

Many heart attacks occur “out of the blue.” There was no prior indication that the blockage of a coronary vessel was imminent. A heart attack sometimes also develops insidiously, with those affected not perceiving the still moderate symptoms as an emergency. In such cases, early warning signs or harbingers herald the heart attack.

For example, many men (and sometimes women) suffer from coronary heart disease (CHD) decades before the heart attack (unnoticed). In this case, the coronary vessels become increasingly narrow due to “calcification” (arteriosclerosis). This increasingly impairs the blood supply to the heart muscle. This can be recognized, for example, by the occurrence of chest pain and/or shortness of breath during physical exertion or emotional excitement. After the end of the stress, the symptoms disappear again within minutes.

Less clear-cut, but certainly observable, are symptoms such as tingling in the left hand. The reduced blood supply, which often affects the left side of the body first, may trigger the tingling or numbness.

However, this symptom is also caused by other diseases, or it occurs briefly due to an incorrect posture in which the blood supply in the arm is partially interrupted and nerves are pinched. In the latter case, the tingling usually subsides as soon as normal posture is resumed.

Heart attack: causes and risk factors

A heart attack usually results from a blood clot blocking a coronary vessel. The coronary arteries are those vessels that supply blood and oxygen to the heart muscle. In most cases, the artery in question is already narrowed beforehand, due to deposits (plaques) on the inner wall. These consist of fats and calcium. Such hardening of the arteries (arteriosclerosis) in the coronary arteries is referred to by physicians as coronary heart disease (CHD).

In the worst case, the patient dies from the heart attack (acute or sudden cardiac death). The consequences of a stroke (cerebral infarction) are similarly severe. The difference between a heart attack and a stroke is that in a stroke, vessels in the brain are blocked.

A heart attack that is due to a vessel blockage because of a thrombus is classified by physicians as a type 1 myocardial infarction (T1MI).

In type 2 myocardial infarction (T2MI), there is no evidence of thrombus or plaque rupture. This form of myocardial infarction is based on an inadequate supply of oxygen, which is also caused by narrowed coronary vessels, for example, due to spasm (cramping) or embolism (entrained thrombus occludes a more distant blood vessel).

Coronary artery disease is considered the main cause of myocardial infarction. Only very rarely are other causes of myocardial infarction present, for example events during bypass surgery. It is even possible to have a heart attack despite having a pacemaker.

Risk factors for heart attack

Some of these risk factors cannot be influenced. These include, for example, older age and male gender. However, something can be done about other risk factors, such as obesity and a high-fat diet. Stress is also one of the causes or risk factors of a heart attack. In general, the more risk factors a person has, the higher his or her risk of heart attack.

Male sex: Sex hormones apparently have an influence on the risk of heart attack, because women before menopause have a lower risk of heart attack than men; they are then better protected by female sex hormones such as estrogens.
Genetic predisposition: In some families, cardiovascular disease is clustered – genes seem to play a role in the development of a heart attack. The risk of a heart attack is therefore hereditary to a certain extent.
Higher age: With increasing age, the degree of arteriosclerosis increases. This means that the risk of heart attack also increases.
Excess weight: It is generally unhealthy to put too many kilos on the scale. This is even more true if the excess weight is concentrated on the abdomen (instead of the hips or thighs): Belly fat produces hormones and messenger substances that, among other things, increase the risk of cardiovascular diseases such as coronary heart disease and heart attacks.
Lack of exercise: Adequate exercise has many positive effects on health. One of them: regular physical activity prevents hardening of the arteries and coronary heart disease by lowering blood pressure and improving cholesterol levels. These protective effects are absent in people who do not exercise.
Smoking: Substances from tobacco smoke promote the formation of unstable plaques that break up easily. In addition, smoking any cigarette constricts blood vessels, including coronary arteries. Most patients who suffer a heart attack before the age of 55 are smokers.
High blood pressure: Constantly elevated blood pressure levels directly damage the inner walls of blood vessels. This promotes deposits on the walls (arteriosclerosis) and thus coronary heart disease.
Diabetes mellitus: In diabetes, blood glucose levels are abnormally elevated. In the long term, this damages the blood vessels – a risk factor for arteriosclerosis and coronary heart disease.

It is disputed whether an elevated level of the protein building block (amino acid) homocysteine is also a heart attack risk factor.

Some health insurers or insurance companies offer so-called rapid heart attack tests; these are usually various questions that can be used to roughly determine the general risk of a heart attack. However, these quick tests do not replace a diagnosis by a doctor.

Heart attack: How does the doctor make the diagnosis?

The urgent suspicion of a heart attack arises from the patient’s symptoms. But the signs are not always clear. That is why various examinations are necessary. They help to confirm the diagnosis of myocardial infarction and to rule out other diseases that trigger similar symptoms (chest pain, etc.). These include, for example, inflammation of the pericardium (pericarditis), rupture of the large artery in the body (aortic dissection) or pulmonary embolism.

Physical examination

ECG

Electrocardiography (ECG) is the most important supplementary examination procedure when a heart attack is suspected. The doctor attaches electrodes to the patient’s chest. These record the electrical excitation in the heart muscle. Characteristic changes in this electrical activity of the heart indicate the size and location of the infarct. It is important for therapy planning to distinguish between a heart attack with and without ST-segment elevation:

ST-segment elevation myocardial infarction (STEMI): In this form of myocardial infarction, a specific segment of the ECG curve (the ST segment) is elevated in an arc. The infarction affects the entire heart wall (transmural myocardial infarction).
Myocardial infarction without ST-segment elevation (NSTEMI or non-STEMI): In this inner wall infarction (non-transmural infarction), the ST segment is not elevated on the ECG. Sometimes the ECG is even completely unremarkable despite typical infarct symptoms. In this case, the diagnosis of myocardial infarction can only be made if certain “cardiac enzymes” are detectable in the blood by a blood test.

Cardiac arrhythmias can also be detected on the ECG. These are by far the most frequent complication of a recent heart attack.

In addition, the ECG helps to distinguish an acute myocardial infarction from an old heart attack that occurred some time ago.

Some infarctions do not show up on the ECG immediately after they occur, but are not visible until several hours later. For this reason, doctors perform several ECG examinations several hours apart when a myocardial infarction is suspected.

Cardiac ultrasound (echocardiography).

If the ECG shows no typical changes, although the symptoms indicate a heart attack, a cardiac ultrasound through the chest may help. The technical term for this examination is “transthoracic echocardiography”. The physician uses it to detect disturbances in the wall movement of the heart muscle. This is because when blood flow is interrupted by the infarction, the affected section of the heart no longer moves normally.

Blood test

However, in the classic tests used for this purpose, the concentration of the enzymes in the blood rises measurably at the earliest about three hours after the heart attack. However, newer, highly refined methods, known as high-sensitivity troponin assays, accelerate and improve diagnosis.

Cardiac catheterization

A cardiac catheter examination can reveal which coronary vessel is occluded and whether other vessels are narrowed. The function of the heart muscle and heart valves can also be assessed with the help of this examination.

During the cardiac catheter examination, the physician inserts a narrow, flexible plastic tube into the leg artery (femoral artery) and pushes it forward against the blood flow to the heart. In most cases, coronary angiography is performed as part of the examination, i.e. the physician injects a contrast medium into the bloodstream via the catheter, which allows the coronary vessels to be visualized in an X-ray image.

Other examination methods

Computer tomography (CT) and magnetic resonance imaging (MRI) offer the possibility of examining for and ruling out other possible diseases with similar symptoms (for example, myocarditis) without surgical intervention. In this way, the diagnosis of myocardial infarction can be additionally confirmed.

Heart attack: treatment

An impending or even existing heart attack requires immediate treatment in order to prevent a deterioration of the patient’s health and possible cardiac death and thus increase the chances of survival. In most cases, this takes the form of first aid.

First aid for heart attack

This is how you provide first aid for a heart attack:

Call the emergency physician at the slightest suspicion of a heart attack!
Position the patient with the upper body elevated, for example by leaning against a wall.
Open tight clothing, for example collar and tie.
Reassure the patient and ask him to breathe calmly and deeply.
Do not leave the patient alone!

What to do if you are alone during a heart attack? If you are alone and suspect a heart attack, do not hesitate! Call the emergency doctor immediately!

What does the emergency physician do?

The emergency physician or paramedic immediately checks the patient’s most important parameters, such as level of consciousness, pulse and breathing. He also connects the patient to an ECG to monitor heart rate, heart rhythm, oxygen saturation and blood pressure. The emergency physician or paramedic uses this to determine whether the patient is having a heart attack with ST-segment elevation (ST-elevation myocardial infarction, STEMI) or a heart attack without ST-segment elevation (non-ST-elevation myocardial infarction, NSTEMI). This distinction is important for the choice of immediate therapy.

Oxygen is administered to the patient via a nasal probe when oxygen saturation is too low and in cases of respiratory distress or acute heart failure.

The emergency physician also administers nitrates to the patient, usually in the form of an oral spray. These dilate the blood vessels, lower the heart’s oxygen requirement and reduce pain. However, nitrates do not improve the prognosis for a heart attack.

If cardiac arrest threatens during transport to the hospital, the emergency physician or paramedic immediately starts resuscitation with a defibrillator.

Surgery

The further treatment of myocardial infarction depends largely on whether the heart attack is a ST-segment elevation myocardial infarction (STEMI) or a non-ST-segment elevation myocardial infarction (NSTEMI):

STEMI: The first-line therapy in these patients is acute PTCA(percutaneous transluminal coronary angioplasty). This means dilating the narrowed heart vessel with the aid of a balloon (balloon dilatation) and keeping it open by inserting a stent. If necessary, the doctor will also perform lysis therapy (thrombolytic therapy) in the case of STEMI (administration of drugs that dissolve the blood clot in the heart vessel). Bypass surgery may be necessary down the road.

Depending on the severity of the heart attack, the extent of the operation and the patient’s general state of health, it may be necessary to place the heart attack victim in an artificial coma. This is to improve the recovery process, as the heart is exposed to less stress in a comatose state.

Medication

In the event of a heart attack, the doctor usually prescribes medications for the patient, some of which must be taken permanently. The active ingredients that help the patient and the duration for which they are taken depend on the individual risk profile. Common medications for heart attack patients are:

Platelet aggregation inhibitors: active ingredients such as acetylsalicylic acid (ASA) prevent blood platelets from clumping together. In an acute heart attack, this prevents a blood clot from enlarging (or new clots from forming) in the affected coronary artery.
Beta-blockers: These lower blood pressure, slow down the heartbeat and relieve pressure on the heart. If administered early, this reduces the severity of the heart attack and prevents life-threatening cardiac arrhythmias (ventricular fibrillation).
Cholesterol-lowering drugs: Statins lower elevated levels of the “evil” LDL cholesterol. This reduces the risk of another heart attack.

Life expectancy after heart attack

Two complications in particular are crucial for the prognosis and life expectancy after an acute myocardial infarction – cardiac arrhythmias (especially ventricular fibrillation) and pumping failure of the heart muscle (cardiogenic shock). Patients frequently die from such complications. The risk is particularly high and life expectancy correspondingly reduced in the case of a “silent” myocardial infarction, since such patients often receive medical help too late.

The long-term prognosis and chances of survival after a severe heart attack depend, among other things, on the following aspects:

Does the patient develop heart failure (see Heart Attack Consequences)?
Can the risk factors for another heart attack (high blood pressure, high cholesterol, etc.) be reduced or eliminated altogether?
Does coronary artery disease (vascular calcification) progress?

Statistically, five to ten percent of heart attack patients die of sudden cardiac death within the next two years after being discharged from the hospital. Patients over the age of 75 are particularly at risk for this.

Follow-up treatment

Very important for a good prognosis after myocardial infarction is the follow-up treatment. Already in the first days after the myocardial infarction, patients start physiotherapy and breathing exercises. Physical activity gets the circulation going again, prevents further vascular occlusion and ensures that the heart recovers after a heart attack.

A few weeks after a heart attack, it is recommended to start cardiovascular training. However, this is far from competitive sports! Recommended sports include walking, light jogging, cycling and swimming. Discuss your individual exercise program with your doctor. You have the option of joining a cardiac sports group: Training together with other heart patients not only brings a lot of joy, but also provides additional motivation.

Since most people with a heart attack are on sick leave for a longer period of time, reintegration into work after rehab is completed is often gradual and slow.

Depending on the severity of the heart attack, it sometimes happens that the patient is unable to care for himself or herself sufficiently, even after surgery. In this case, nursing measures are necessary after the heart attack. In addition, regular check-ups with a doctor after a heart attack are important. In this way, any problems can be detected early and countermeasures can be taken in good time.

Complications and consequences

For many patients, a heart attack has consequences that significantly change their lives. These include short-term consequences such as cardiac arrhythmias. These can take the form of atrial fibrillation or life-threatening ventricular fibrillation.

Brain damage is then often the result, sometimes leading to severe disability. Consequently, heart attacks and strokes have the same underlying causes and risk factors; they are both life-threatening diseases, but their symptoms are very different.

Long-term consequences are also possible after a heart attack. Some patients undergo changes in character and develop depression, for example. Sometimes chronic cardiac insufficiency develops: In this case, scar tissue replaces the heart muscle tissue that has died as a result of the infarction and impairs heart function.

Rehab treatment and a healthy lifestyle help prevent such complications and consequences of a heart attack. You can read more about this in the article Heart attack – consequences.

Heart attack: prevention

You can prevent a heart attack by reducing the risk factors for vascular calcification (atherosclerosis) as much as possible. This means:

Not smoking: If you give up cigarettes & co., you significantly reduce your risk of heart attack. At the same time, the risk of other secondary diseases such as stroke is reduced.

Healthy diet: The right food to prevent heart attacks – a heart-healthy diet is the Mediterranean diet, for example. It consists of lots of fresh fruit and vegetables and little fat. Instead of animal fats (butter, cream, etc.), vegetable fats and oils (olive, rapeseed, linseed oil, etc.) are preferred.
Reduce excess weight: Even a few pounds less will have a positive effect on your health. A healthy body weight can prevent a heart attack and other diseases (stroke, etc.).
Get plenty of exercise: Be physically active on a regular basis. This does not mean high-performance sports: even a daily half-hour walk is better than no exercise at all and reduces the risk of heart attack. Exercise in everyday life (such as climbing stairs, shopping by bike, etc.) also contributes.
Treat risk diseases: Underlying diseases such as diabetes, high blood pressure or elevated cholesterol levels must be treated as optimally as possible. This includes, among other things, the regular use of prescribed medication.