Are You Tired? It Could Be Your Heart

For several weeks before his fatal heart attack, Jon felt tired all the time. He did not want to get up in the morning. He needed to go home and take a nap at noon. He fell asleep in front of the television set. And he lost interest in his wife, his kids, his friends, and his hobbies.

On the day of his fatal heart attack, Jon said something about chest pain, but it was too late. Thinking Jon was just depressed, his wife didn't call for an ambulance. She had thought she could finally persuade him to get into mental health counseling.

Fatigue Is a Better Predictor of Heart Attack than Chest Pain

The simple reality is that many men and most women who have heart attacks don't get chest pain. In a study conducted in Korea, 57% of people admitted to hospital for myocardial infarction (heart attack) had the classic pain in the middle of the chest. In 28%, however, there was "pain all over", and 15% had little or no chest pain at all. A study of women who had had heart attacks conducted by researchers at the University of Arkansas found that 4% of women who had heart attacks had no symptoms at all and 36% had chest pain, but 73% reported unusual fatigue in the days and weeks leading to their heart attack.

The evidence is strong that severe fatigue is a better predictor of heart attack than chest pain. The problem is that people who feel fatigued are more likely just to go to bed than they are to call for emergency medical care.

Moreover, if you tell the ambulance driver "I just feel so tired," it's unlikely you will be transported to the hospital with lights and siren. People who have heart attacks with the stereotypical prodrome of chest pain and sweating are nearly 30% more likely to die even if they get treatment--probably because the majority of emergency medical personnel, emergency room physicians, and cardiologists simply do not take fatigue seriously.

Non-Invasive Tests Not Always Inclusive

If you report to a hospital with vague symptoms of a heart attack, you will almost certainly have blood drawn to test for an enzyme called troponin. You are also likely to be tested for another enzyme called CCK. This enzyme measures damage to your heart caused by loss of circulation, and it is used to diagnose a heart attack.

If your symptoms are just fatigue and vague aches and pains, however, especially if you don't have good health insurance, your cardiologist may just order a stress test or an ultrasound of your heart. These tests often detect clogged arteries that are causing a heart attack. In about 6% to 12% of cases, however, these non-invasive cardiovascular testing methods fail to detect arterial damage, and the patient is sent home without ever having the angiogram that could definitively detect disease. Without this now-common but somewhat expensive procedure, death often follows.

How Can You Tell Whether You Are Experiencing Heart Attack Or Fatigue?

To make sure that you get the right treatment, it is essential that you and your doctors have a sense of whether you are experiencing a heart attack or overwhelming fatigue from some other cause. Since arterial imaging is all too often inaccurate, resulting in false negative results in up to 1 in 8 cases, and since heart enzyme levels are not enough, it is very important that you and your doctors understand the nature of your fatigue. The problem with assessing fatigue is that nearly everyone has a different view of what fatigue is.

Interruption of Basic Day-to-Day Activities

One way of thinking about fatigue, and measuring fatigue as a symptom of heart disease, is to consider it functionally. How badly does fatigue interfere with your day to day activities?

If you have fatigue that makes you feel too tired to take care of household chores, or to get dressed when you get out of bed, and you are too tired to go to work, you are far more likely to be suffering heart disease than if you just don't feel like parasailing, hang gliding, or taking a mountain hike. There is a standardized scale for measuring this kind of fatigue known as the Fatigue Symptom Inventory (FSI).

Changes in Mood

Another way of assessing the likelihood that fatigue is related to heart disease is by measuring changes in mood. Researchers at the University of Minnesota created an instrument known as the Profile of Mood States (POMS) to capture the specific changes in mood that are most frequently associated with heart disease. People who have had just had or who are about to have a heart attack, it turns out, generally experience high degrees of frustration. They "should" be able to perform daily life or work or recreational activities, but they just can't. In people who are already taking statin medications for cholesterol or inflammation, it is also common to experience vague aches and pains, memory loss, and general feelings of helplessness.

Cardiologists have tried to link changes in mood to changes in ejection fraction (the amount of blood the heart can pump with each beat), but what they found is that ejection fraction does not really make a difference in mood. Everyone who has heart disease tends to feel lousy.

Quality of Life

It is also common for people who are just about to have a heart attack to make a complaint on the lines of "My life is totally going to hell." As people have less and less energy and more and more pain, they lose control of the events of their lives. Although most people who have heart attacks do not hit rock bottom in their personal affairs, a surprisingly high percentage do.

The Short Form 36-Question Survey (SF-36) is designed to give doctors an indication of the effects of fatigue on quality of life. Replete of questions such as "Do you feel full of vitality?" and "Is today a great day?" this test often elicits responses in which the potential heart attack patient tells the psychologist what to do with the test. General grouchiness and a dismal outlook on life, it turns out, are highly predictive of heart disease. And the sooner treatment is initiated, the sooner heart function may be restored and the sooner life may resume its quality.