aAt first it seemed like a routine call – something paramedics had dealt with countless times before. A man in his mid-50s was having a heart attack, and his doctor called for emergency support. But when the paramedics arrived, the doctor pulled them aside and told them something strange: The man had no cardiovascular symptoms whatsoever.
The man had come to his doctor’s office because he had woken up early the previous morning with sweating and a sharp pain in his left wrist. These symptoms soon subsided and he went back to sleep. Later, after spending his day, he visited his doctor to report the incident. The man showed no outward signs of heart problems; He was breathing and behaving normally – asking about “all the fuss” – and his heart rate and blood pressure hadn’t risen. However, when his doctor performed an electrocardiogram – a test that measures The electrical activity of the heart– It clearly showed that the man had a heart attack. The paramedics repeated the test and came to the same conclusion. Later, further examinations at the hospital confirmed the attack and revealed a partial blockage in one of the man’s coronary arteries. Surgeons placed a stent in the blocked artery, and after a few days in the hospital, the man went home.
The man’s experience was documented in a 2017 medical case report in Irish Journal of Paramedicsand explains something experts call a “silent heart attack.” This is a type of attack that does not cause typical or obvious symptoms. “Severe chest pain that spreads down the left arm is the classic symptom,” says Dr. Amjad N. Makarios, MD, professor of cardiology at the Zucker College of Medicine in Hofstra/Northwell in New York. “With silent ischemia, which is more common in people with diabetes, people may have atypical symptoms, or they may not have symptoms at all.”
By some estimates, nearly 1 in 4 heart attacks are “silent.” This is likely an underestimated number because many of these Heart attacks are not recognized and unreported; Most are only recognized after the fact with an electrocardiogram or other test. While about half of silent heart attacks involve atypical symptoms, the other half are thought to cause no symptoms at all. Research has found that people with type 2 diabetes may be twice as likely to have a silent heart attack as those without diabetes.
Silent heart attacks are dangerous precisely because they often go undetected. Some studies have found that people who have had a silent heart attack are more likely to die than those who have had a heart attack with known symptoms. “Compared to those who’ve had a heart attack, those who’ve had a silent heart attack have a three times greater likelihood of dying from heart disease in the future,” says Dr. Nathan Wong, director of the university’s Heart Disease Prevention Program. California, Irvine.
How can type 2 diabetics protect themselves from silent heart attacks? Here, Wong and others explain everything you need to know — whether you have type 2 diabetes or are caring for someone with the condition.
Not too silent
The term “silent” heart attack is somewhat of a misnomer. While it is estimated that half of these attacks cause no symptoms at all, experts say that many, if not most, silent heart attacks are likely to cause symptoms that people miss or misunderstand. “I think if you go back and take a really detailed medical history of people who’ve had a silent heart attack, most of the time they’ll have symptoms,” Makarios says.
For example, the middle-aged man with the silent Heart attack– The one who wondered what all the fuss was about – woke up early in the morning with wrist pain and unexplained sweating. These symptoms — and especially their timing — indicate the possibility of a heart attack, Makarios says. “Most heart attacks happen early in the morning when cortisol is high,” he explains. Cortisol is a hormone that increases the activity of the sympathetic nervous system that includes the heart, and its levels tend to peak in the morning. “If someone wakes up from sleep with symptoms, it’s something we always take very seriously,” he adds.
While the morning hours can be particularly perilous, silent heart attacks don’t follow any set schedule. Makarios says the possible signs and symptoms of a silent heart attack are numerous. These symptoms include dull chest or left arm pain, shortness of breath, fatigue, dizziness, sweating, jaw or back pain, nausea, heartburn, or indigestion. Pay special attention to symptoms that appear suddenly, he says, or those that represent a change from your baseline. “If you suddenly go up a flight of stairs and you’re puffing and puffing, that’s more worrying than your protracted symptoms,” he explains. I tell diabetics not to reduce their symptoms. You better go in. “
If your medical care provider suspects you’re having a heart attack, he or she may be able to confirm it with an electrocardiogram (EKG), echocardiogram, or one of several other diagnostic tools.
The link between diabetes and silent heart attacks
A common complication of type 2 diabetes is nerve damage, also known as neuropathy. This nerve damage is caused by high blood sugar levels, and can cause numbness, tingling, pain, sensitivity, and weakness — often in the feet or other extremities. In such cases it is called “peripheral neuropathy”.
However, neuropathy can also affect the autonomic nervous system, which controls the body’s heart and internal organs. “Neuropathy can cause a loss of sensation in various parts of the body — not just the feet and toes, but also potentially to organs like the heart,” explains Wong. This is sometimes called autonomic cardiac dysfunction or “autonomic neuropathy.” The nerves of the autonomic nervous system can be severely damaged. “The result is that people won’t necessarily feel chest pain, and that’s one of the ways people can feel it silent heart attack It is believed to be linked to diabetes.”
It should be noted that people with type 2 diabetes who have peripheral neuropathy do not necessarily have the type of nerve damage that can mask a heart attack. “Peripheral neuropathy is much more common than autonomic neuropathy, and there isn’t much compatibility between the two,” says Dr. Om Janda, MD, associate professor of medicine at Harvard Medical School and research associate at Harvard’s Joslin Diabetes Center. So if you have peripheral symptoms [neuropathy]This does not mean that you also have to have autonomic neuropathy.”
While a person may not be able to “feel” autonomic neuropathy, there are ways to detect it that do not involve formal medical tests. Orthostatic hypotension — a drop in blood pressure that occurs when a person sits up or stands suddenly — is one indication, Ganda says. If you notice that you feel dizzy or lightheaded after sitting or standing, especially if this is a new symptom for you, it is worth mentioning to your caregiver. “Erectile dysfunction can also be a sign of autonomic neuropathy,” he says. The same applies to gastroparesis, or abnormally slow stomach emptying. This can make you feel full even hours after a meal. It can also cause abdominal pain, heartburn, bloating, or nausea. Again, if you notice any of these symptoms coming on suddenly, tell your doctor.
Researchers believe that other factors — such as a higher-than-average pain threshold, or unusually high levels of pain-numbing hormones — may also contribute to silent heart attacks. But these factors are not specific to diabetics.
How to protect yourself
A lot of time and energy has been poured into a study examining people with type 2 diabetes to assess their risk for heart disease, including silent heart attacks. “Is it better to screen, and can we make a difference if we do?” Makarios says. “The conclusion in most of these studies was no, screening doesn’t make a difference.”
The reason for this is simple: People with type 2 diabetes are already at an extremely high risk of developing heart disease and related complications, he says. In fact, approximately 3 in 4 diabetes-related deaths are caused by poor blood flow to the heart. “The conclusion is that if someone has type 2 diabetes, [their physician] You have to put them on all the medications and other things you need to do for primary prevention of cardiovascular disease,” Makarios says. That definitely means taking a statin to control your blood lipid levels. It also means getting regular checkups with your care team to make sure. Ensure that other heart disease indicators – namely blood pressure, cholesterol levels and blood glucose levels – are under control.
A healthy lifestyle is also an important guarantee. “Almost every day, you should try to exercise for 30 minutes,” Makarios says. Avoiding tobacco and eating a healthy diet also make a difference. “Evidence shows that the DASH diet is very beneficial for people with diabetes,” he says. This diet, which was originally formulated to help people control high blood pressure — a common complication of people with type 2 diabetes — includes eating less sodium and focusing on fruits, vegetables, whole grains, and low-fat animal products.
Ganda says adopting healthy habits early in life can pay huge dividends in the future. “In the United States, there are 96 million people with prediabetes,” he says. He says many of these people don’t know it, and many can avoid progressing to full-blown type 2 diabetes if they modify their lifestyle. Also, rates of type 2 diabetes are on the rise among young adults and even children. “The lack of physical activity is part of that, I think,” he says. “Young people move and exercise less because they spend time behind a phone or computer screen.”
He stresses that some of the variables that lead to type 2 diabetes are out of a person’s control. For example, a person’s genes play a role in pre-determining the risk of developing type 2 diabetes and complications such as heart disease. However, each of us can take steps to mitigate these types of risks. “People born with these genes may express them sooner due to unhealthy lifestyles,” he says.
Perhaps the most important takeaway for type 2 diabetics: Understand that your heart is at risk. “Diabetes is really a cardiovascular condition,” says Wong. “Most people with diabetes eventually die of a heart attack, stroke, or other complications of cardiovascular disease.”
He says learning about this and doing something about it — monitoring your blood pressure and other indicators of heart health, living a healthy lifestyle, and watching for subtle symptoms of heart problems — are essential to protecting yourself from a silent heart attack.
“I think the main theme here is that prevention is key,” Wong adds.
More must-read stories from TIME