The feeling of a heart attack — which occurs when blood flow to the heart is limited or cut off — is often compared to an elephant stomping on your chest. But the signs can sometimes be far subtler, particularly in women. In fact, one of the most common symptoms in this group is something you might be tempted to push through or ignore: fatigue.
To be sure, exhaustion with a clear cause, such as feeling tired after a long week of work or a few nights of bad sleep, is not something to worry about, said Arash Bereliani, a cardiologist at Beverly Hills Institute for Cardiology and Preventive Medicine. But “a significant, unexplained decrease [in energy] from your baseline” warrants concern, he said.
Research suggests women are more likely than men to experience a range of warning signs in the days and even weeks leading up to a heart attack, with the most common being fatigue, occurring in up to 70 percent of women who have a heart attack.
The reason the two go hand in hand: A drop in blood flow to the heart causes it to “become stiff and not work properly,” Bereliani explained. Over time, it struggles to pump out enough blood, so your other organs and muscles begin to miss out on critical oxygen and nutrients, leading to low energy.
But feeling exhausted, even to an extreme, doesn’t always set off alarm bells — for women or doctors. After all, “so many women are multitaskers and are time-starved and are caregivers and are working and have so many things on their plate,” said Amy Ahnert, a cardiologist with Atlantic Medical Group and director of the Women’s Heart Program at Morristown Medical Center.
In a large study of people under age 55 hospitalized for a heart attack, women were more likely than men to perceive their symptoms as simply stress or anxiety, and also to have seen a provider who did not attribute their symptoms to their heart.
Below, experts explain why severe fatigue often accompanies a heart attack in women and how to tell if your exhaustion is a red flag.
Why fatigue is a common heart-attack symptom in women
The majority of research done on heart attacks has been conducted in men, “and for many years, we deduced that their typical symptoms — chest pain and tightness with radiation down the left arm — would extend to women,” Bereliani said. While it’s since become clear that women often experience other symptoms, science hasn’t quite caught up to explain why.
One theory is related to differences in heart size and anatomy, Bereliani said. A heart attack might activate the nervous system in distinct ways or cause more pronounced changes in blood flow to different organs in men versus women, leading to varying symptoms.
The most common cause of a heart attack, a buildup of plaque inside an artery, also tends accompany a rise in inflammation, Bereliani said. This seems to be more commonly linked with fatigue in women than it is in men (for reasons experts don’t fully understand).
There are also distinctions in the kind of heart disease that tends to strike men versus women. Men are more likely to have obstructive coronary artery disease, which involves plaque blocking one of the three main vessels feeding the heart; women more often have microvascular disease, which occurs when the tiny vessels in the heart get stiff or fail to widen, Ahnert said.
The latter commonly causes fatigue and chest pain in women outside of a heart attack, Bereliani said. But in certain cases, dysfunction in these little vessels can worsen over time, hindering more blood from reaching the heart and ultimately triggering a heart attack (even without a blockage in a main artery). It’s one theory for why certain women experience more incremental or vague symptoms such as fatigue over a longer lead-up period: Rather than a discrete blockage, they have this more “diffused” disease process, Ahnert explained.
How to tell regular tiredness apart from heart-related fatigue
The cardiac kind is usually profound and unexplained by any change in your lifestyle or activity level, Ahnert said. “It’s like, ‘I can’t do anything. I have no energy. I’m weak, and I’m tired.’”
Ordinary tiredness also “improves with sleep or a weekend off,” Bereliani said. But with fatigue from heart disease, he said, you may wake up as tired as you were when you went to bed.
It’s also a red flag if your fatigue tracks with physical exertion, Bereliani said. When you’re just exhausted from a rough week, chances are you can still walk the one mile that you’re used to walking every day, for example. But with heart-related fatigue, a physical task that was once no problem can wipe you out. Bereliani recalled a heart attack patient whose main symptom was that she suddenly couldn’t hold her arms up long enough to blow-dry her hair.
Duration is another factor: If the fatigue seems to linger for days or weeks without an obvious cause, then that’s concerning too, Bereliani added.
Fatigue should also raise your suspicions of a heart problem if it comes alongside other possible cardiovascular symptoms, Ahnert and Bereliani said. While chest pain remains the most common sign of a heart attack across the board, women are more likely than men to have a heart attack without chest pain and to experience a greater number of non-chest-related symptoms, many of which can be subtle or ambiguous. Research also suggests that women might feel a kind of pressure in the chest, as opposed to outright pain. Or they may have pain that emanates from another part of the upper body versus the center of the chest, Ahnert said.
Both experts said women should especially look out for fatigue occurring alongside:
- Chest discomfort
- Jaw, neck or back pain
- Shortness of breath
- Nausea or vomiting
- Indigestion or heartburn
- Sweating
- Disrupted sleep
- Dizziness or lightheadedness
When to see your doctor or go to the emergency room
Feeling a bit fatigued is not necessarily a reason to make a doctor’s appointment. But “if it’s persistent, if it’s exertional, if it’s associated with other symptoms, if it doesn’t get better [in a few days] — then you need to contact your doctor and make sure everything is okay,” Bereliani said.
Above all, Ahnert said, it’s important to trust your instincts. If you feel like something isn’t right, and you’re getting blown off by your health care provider, seek another opinion, she said.
Fatigue that feels debilitating or is accompanied by another symptom that limits your ability to go about your daily life — such as not being able to catch your breath, a distinct new upper-body pain or profuse sweating — is reason to go to the ER, Ahnert said. (It’s safest to call 911 versus getting a taxi or friend to drive, she emphasized, because if you are having a heart attack, you could experience cardiac arrest or a life-threatening arrhythmia while en route.)
Ultimately, Ahnert said, if the thought crosses your mind, it’s usually better to call 911 than to delay. “For the most part, women tend to underestimate their symptoms,” she said. “I’d rather you be wrong and be reassured than to find out afterward that we missed a big heart attack.”
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