Heart attacks do not respect time, place or circumstances. These can happen to anyone, anytime, and apparently out of the blue, perhaps even depriving the unsuspecting victim of life.
Symptom of Pain
The first symptom of heart attack, in a majority of the cases, is a severe and prolonged pain in the middle of the front of the chest.
In some, the pain may be severe enough to be described as the worst pain the patient has ever experienced. The pain is often accompanied by weakness, sweating, nausea, vomiting, giddiness and anxiety.
The patient may be stricken while at rest or at work, awake or asleep. Master and his colleagues in 1941 noted that among 1108 heart attacks, 52 per cent occurred while the patient was asleep or resting, 21 per cent during mild routine activity, 16 per cent while the patient was walking and 9 per cent during moderate activity.
In only 2 per cent was there a history to unusual physical exertion. These figures roughly correspond to the percentage of time spent on these activities during the 24 hours.
The pain, to begin with, may be relatively mild but with persistent discomfort which soon becomes severe; or it may be terribly severe from the very start. The pain of heart attack is different from other acute pains in the chest which one might have experienced.
It has the quality of constriction. To describe it, the patient uses words such as squeezing, constricting, choking, vice like or like a heavy weight.
In most cases, the pain is situated behind the sternum. Often it spreads to both sides of the front chest, especially to the left and may reach down to the upper abdomen.
The pain frequently goes up the shoulders and jaw and down both the arms. If and when it involves the neck, it gives a sensation as if some unseen hand is clutching or choking the neck.
The pain in the upper extremities, more often in the left, may either extend continuously from the shoulder to the fingers or reach only to the arm or skip directly to the forearms or wrists.
There may be only a dull ache, weakness of the wrists associated with severe pain behind the sternum or a little to the left.
The pain persists in varying degree for at least an hour, but often several hours, and occasionally for one to three days.
The pain may not be constant even though prolonged; after an hour or two of severe pain, it may lessen perceptibly or subside entirely only to recur for hours in irregular fashion.
If it occurs in a patient of angima pectoris, he at once realizes that this is a new and different pain which began while he was sleeping or was at rest, and did not subside while he rested and also was not relieved by taking the usual dose of nitroglycerin.
The pain in heart attack is due to diminished supply of oxygen to the heart muscle and this pain is a prolonged one because obstruction somewhere in the coronary arteries has blocked the supple of blood to the affected area.
Although pain is the most common presenting symptom, it is by no means always present; a minimum of 15 to 20 per cent of myocardial infarcts are painless.
The frequency of such silent infarcts is probably even higher than this estimate, because patients without pain may not seek medical attention.
The incidence of painless infarcts is greater in patients with diabetes mellitus, and it increases with age. In the elderly, myocardial infarction may present as sudden onset of breathlessness, which may progress to pulmonary oedema.
Other less common presentations in the absence of pain include sudden loss of confusional state, a sensation of profound weakness, the appearance of arrhythmia, or merely an unexplained drop in arterial blood pressure.
While pain is the most prominent symptom in most of the cases of heart attack, there are cases in which this is not so.
The first and the most prominent symptom may be a state of shock in which the patient at once passes. He suddenly experiences weakness which slowly or rapidly may develop into intense prostration or collapse.
He may unexpectedly slump if he is standing or walking. He may lose consciousness because of less blood going to the brain.
In middle cases, the patient may complain only of feeling weak, dizzy, faint or nauseated, or less specifically of feeling ‘sick’. These symptoms may be very transient and associated with cold sweat.
Sometimes there is a terrifying inexplicable fear of impending doom, out of proportion to the symptoms.
In a case of severe shock, the patient may have cold, clammy limbs and tip of the nose; a rapid, and barely perceptible pulse; pallor or bluish tinge (cyanosis) and a low blood pressure (below 80 mm. Hg.)
Respiration may be rapid and shallow. The facial expression is often drawn and anxious. The patient’s intellect may be clear, but often he is mentally befogged and apathetic. His temperature may be subnormal. There is notable diminution in passing urine.
This may last from a few hours to one to four days. In fatal cases, it may persist longer and until the patient succumbs. Often in such cases, shock is accompanied by pulmonary oedema.
The symptoms of shock are due to the sharp and sudden reduction in the output of blood by the heart (cardiac output) resulting from heart injury.
The term ‘heart failure’ does not mean that the heart has stopped working or is in danger of doing so. It only means that the heart muscle has weakened to such an extent that it is not able to pump and supply blood adequately where it is needed.
A sudden onset of pulmonary oedema may be the first and is often the dominant manifestation of heart attack.
Pulmonary oedema is the sudden out-pouring of blood serum into the lung alveoli from the lung capillaries whose walls become more permeable because of lack of oxygen.
The attack may appear suddenly and without warning, causing oppression in the chest and intense suffocating breathlessness. The respiration becomes noisy and asthmatic or bubbling in character.
A copious white or pinkish foamy phlegm may be coughed up or merely wells up from the respiratory passages and out of the mouth and nasal passages.
Moist rales (sounds) are heard throughout the chest in the front as well as the back. The patient may be deeply blue(cyanotic) or may present a pale appearance due to the combination of pulmonary oedema with shock.
A patient may complain of a strange sense of mid-sternal uneasiness associated with apprehension, and a fast pulse.
If he has had a heart attack before and develops such a sensation at some later time, he must get himself examined by his doctor.
Similarly, those with a family history of heart attack and those with high-level of cholesterol in the blood, must get themselves examined in such a situation.
Pain or numbness in the jaw often occurs as part of radiating chest pain, but may occur alone. It usually occurs in the lower-jaw, on either or both sides.
Toothache may indeed be a dental problem, but if the aching tooth is a healthy one, the pain may be a symptom of heart attack.
Rarely, a heart attack may present itself as numbness of the left or both the wrists.
A sudden sweating in a middle aged or old man without any obvious reason, must be looked in for heart disease.
In a case of heart attack, when the symptoms are relatively mild or the distribution of pain atypical, the diagnosis may be very difficult indeed.