If you think you or someone near you is having a heart attack right now, stop reading and call your local emergency number (911 in the US) immediately.
Most people picture a heart attack as sudden, crushing chest pain followed by a collapse. Often it isn’t like that. Many heart attacks start slowly, or with symptoms that don’t seem to involve the heart: breathlessness, nausea, an aching jaw, or unusual tiredness. Women and older adults are more likely to have these less familiar symptoms. They are also more likely to wait before getting help, and that delay costs heart muscle.
This article is part of our complete, evidence-based guide to heart health. It covers the classic warning signs, the ones that get missed, what the research shows about who misses them, and what to do in the first few minutes.
This is general information, not medical advice. It cannot tell you whether a symptom is or isn’t a heart attack. When in doubt, call emergency services.
The Classic Warning Signs
The American Heart Association (AHA) lists these as the main warning signs of a heart attack:
- Chest discomfort. Usually in the centre of the chest. It may feel like pressure, squeezing, fullness, or pain. It can last more than a few minutes, or go away and come back.
- Discomfort in other areas of the upper body. This includes pain or discomfort in one or both arms, the back, neck, jaw, or stomach.
- Shortness of breath. It can happen with or without chest discomfort.
- Other signs. These include breaking out in a cold sweat, nausea or vomiting, and lightheadedness.
Notice that the word “crushing” isn’t on the list. Many people feel pressure, tightness, or something like indigestion rather than pain.
Heart Attacks Without Chest Pain Are Common
Chest pain or discomfort is still the most common symptom for both men and women. But a large share of heart attacks arrive without it.
The biggest study of this used the US National Registry of Myocardial Infarction. Researchers led by John Canto analysed 1,143,513 patients treated for a heart attack between 1994 and 2006, and published the results in JAMA in 2012. Overall, 35.4% of patients arrived at hospital without chest pain. That figure was higher in women (42.0%) than in men (30.7%).
The global GRACE registry found a lower but still important figure. In a 2004 analysis in the journal Chest (Brieger and colleagues), 8.4% of 20,881 patients with acute coronary syndromes had no chest pain (the studies defined symptoms differently). Within that group:
- About a quarter (23.8%) were not initially recognised as having a heart problem.
- They were more likely to be older, female, or have diabetes.
- They were less likely to get standard heart treatments, and their in-hospital death rate was 13%, compared with 4.3% for patients with typical chest pain.
Put simply, the people whose symptoms don’t match the stereotype are often the ones who are sickest, and the ones most likely to be missed.
Warning Signs in Women
Women’s heart attacks are not a completely different illness. The AHA notes that chest pain or discomfort is the most common symptom in women too. But women are somewhat more likely to also have:
- Shortness of breath
- Nausea or vomiting
- Back or jaw pain
What the VIRGO study found in younger women
The VIRGO study looked closely at younger adults. Researchers interviewed 2,009 women and 976 men aged 18 to 55 who had been hospitalised with a heart attack. The results were published in Circulation in 2018 (Lichtman and colleagues).
Most patients of both sexes had chest pain, pressure, tightness, or discomfort: 87.0% of women and 89.5% of men. The difference was in what came with it. Women were more likely to have several additional symptoms, such as indigestion, nausea, or stomach discomfort, and pain in the jaw, neck, arms, or between the shoulder blades. Women were also more likely to have three or more of these extra symptoms.
The most worrying finding was about interpretation. Women in VIRGO were less likely than men to think their early symptoms were heart-related. Their healthcare providers were also less likely to connect those symptoms to the heart.
The age pattern
In Canto’s registry study, the sex gap in “no chest pain” heart attacks was largest in younger patients and had almost disappeared by age 75. Women also had higher in-hospital death rates than men of the same age, with the biggest gap in younger patients. Because younger women are often seen as “low risk,” they are easy to overlook, by others and by themselves.
Women tend to wait longer
A 2017 study in the Journal of the American Heart Association looked at 6,022 patients with a major type of heart attack (STEMI) in the ISACS-TC registry. The median time from first symptoms to arriving at hospital was 270 minutes for women, compared with 240 minutes for men. Much of that gap came before anyone called for help. The researchers concluded that pre-hospital delay helped explain why women in the registry had higher death rates after a heart attack.
Warning Signs in Older Adults
With age, heart attacks are more likely to show up as something other than chest pain. In GRACE, older age was one of the clearest predictors of a heart attack without chest pain. Clinical reviews of heart attacks in older adults describe the same pattern. In older patients, symptoms may centre on:
- Shortness of breath, especially with little effort
- Fainting or near-fainting
- Sudden confusion or a change in mental state
- Unusual weakness or fatigue
These are easy to blame on age or a chest infection. If an older relative suddenly becomes breathless, confused, or faint for no clear reason, consider a heart cause and get help.
People with diabetes were also more likely to have heart attacks without chest pain in GRACE. If you have diabetes, take unexplained breathlessness, sweating, nausea, or fatigue seriously.
“Silent” Heart Attacks
Some heart attacks produce symptoms so mild that nobody recognises them at the time. They’re found later, usually on an ECG (heart tracing).
The ARIC study followed 9,498 middle-aged US adults (aged 45–64) with no heart disease at the start. Published in Circulation in 2016 (Zhang and colleagues), it found that silent heart attacks made up more than 45% of all heart attacks in the group. They were more common in men than women. They weren’t harmless: people who’d had one had a higher risk of later dying from coronary heart disease, or from any cause.
“I’d know if I’d had a heart attack” isn’t always true. If a routine ECG ever shows signs of an old one, ask your doctor what it means for your risk.
Early Warnings: Symptoms That Come Days or Weeks Before
Some people have warning symptoms in the days or weeks before a heart attack, such as chest discomfort that comes on with exertion and fades with rest, unusual breathlessness, or new fatigue. In VIRGO, women were less likely than men to link these earlier symptoms to their heart.
New chest discomfort on exertion, or a change in an existing pattern, needs a prompt medical review, even if it settles down. If it comes on at rest, keeps getting worse, or lasts more than a few minutes, treat it as an emergency.
For a personal account of how warning signs can build up quietly, read what my father’s heart emergency taught me about silent heart blockage.
What to Do in the First Few Minutes
1. Call emergency services. Don’t drive yourself.
Call your local emergency number first. The AHA advises against driving yourself or having someone drive you to hospital. Paramedics can start treatment as soon as they arrive. They can record an ECG, monitor your heart rhythm, and use a defibrillator if your heart stops. They can also alert the hospital so the cardiac team is ready. The AHA’s message is simple: every minute matters, because the longer an artery stays blocked, the more heart muscle dies.
2. Don’t wait to be sure
Many people delay because they don’t want to make a fuss. A false alarm costs you an evening. Waiting during a real heart attack can cause permanent damage.
3. Aspirin: follow the operator’s instructions
You may have heard that you should chew an aspirin during a heart attack. The AHA no longer advises people to take aspirin on their own. Your symptoms might not be a heart attack, and for some people, such as those with certain bleeding risks or an aspirin allergy, aspirin can be harmful. The emergency operator may ask you a few questions and tell you to chew an aspirin if it’s safe for you. Don’t let looking for aspirin delay the call.
Lowering the Odds in the First Place
Preventing a heart attack is better still. Most of the risk comes from factors you can change, such as blood pressure, cholesterol, smoking, diet, and activity. Our heart health guide explains all of them. If you’re starting with exercise, see the best exercise for heart health and how much you need.
Frequently Asked Questions
What are the first warning signs of a heart attack?
The most common is chest discomfort: pressure, squeezing, fullness, or pain in the centre of the chest that lasts more than a few minutes or comes and goes. Other signs include pain in the arms, back, neck, jaw, or stomach, shortness of breath, a cold sweat, nausea, and lightheadedness. Some people have warning symptoms on exertion in the days or weeks before.
Are heart attack symptoms different in women?
Chest pain or discomfort is the most common symptom in women, as in men. But women are somewhat more likely to also have shortness of breath, nausea or vomiting, and back or jaw pain. In a US registry of over 1.1 million heart attack patients, 42.0% of women arrived without chest pain, compared with 30.7% of men. The gap was largest in younger patients.
Can you have a heart attack without chest pain?
Yes. In the large US registry study, about 35% of heart attack patients arrived at hospital without chest pain. This is more common in women, older adults, and people with diabetes. These patients are more likely to be missed at first, so it’s important to take other symptoms seriously.
What is a silent heart attack?
A silent heart attack causes symptoms so mild that they aren’t recognised at the time. It’s usually found later on an ECG. In the ARIC study of nearly 9,500 middle-aged adults, silent heart attacks made up more than 45% of all heart attacks. They still raised the risk of later death from heart disease.
Should I take aspirin if I think I’m having a heart attack?
Call emergency services first. The American Heart Association no longer advises taking aspirin on your own, because the symptoms might be something else and aspirin isn’t safe for everyone. The emergency operator may tell you to chew an aspirin if it’s appropriate for you.
