A heart attack is often imagined as sudden, crushing chest pain, but for many women the warning signs can be far less dramatic. One of the most common is severe, unexplained fatigue, which research suggests can appear days or even weeks before a heart attack. Cardiologists speaking to The Washington Post explained how to distinguish potentially heart-related exhaustion from ordinary tiredness.
Feeling worn out after several sleepless nights, a stressful week or unusually demanding activity is generally not cause for alarm. What deserves attention, cardiologist Arash Bereliani said, is “a significant, unexplained decrease [in energy] from your baseline.”
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Women may feel this heart attack warning sign days or weeks before chest pain
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Studies have found that women are more likely than men to experience warning symptoms before a heart attack, and fatigue is among the most frequently reported. Research has found it in as many as 70% of women who suffer a heart attack.
One explanation lies in what happens when blood flow to the heart begins to deteriorate. With less blood reaching the heart muscle, its ability to function efficiently can decline. The heart may then struggle to circulate enough oxygen-rich blood to the rest of the body, leaving muscles and organs with less oxygen and nutrients and creating an overwhelming sense of exhaustion.
The difficulty is that fatigue is an extremely common complaint, particularly among women juggling work, family and other responsibilities.
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.
That can make an important cardiovascular warning sign easy both for patients to dismiss and for doctors to overlook.
One large study involving heart attack patients younger than 55 found that women were more likely than men to interpret their symptoms as stress or anxiety. They were also more likely to have previously consulted a health professional who did not recognize their symptoms as being related to the heart.
Why women may experience different heart attack symptoms
For decades, much of the medical understanding of heart attacks was based on studies conducted predominantly in men. As a result, the classic picture of a heart attack became chest pain or tightness radiating down the left arm.
“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.
Doctors now know that women can experience a wider range of symptoms, although researchers are still working to understand exactly why those differences occur.
One possible explanation involves anatomical differences, including heart size, as well as differences in how the nervous system responds when the heart is under stress. Changes in circulation during a heart attack could also affect organs differently in women and men.
Inflammation may play a role as well. The plaque buildup that causes many heart attacks is often accompanied by inflammation, and that inflammatory response appears to be associated with fatigue more commonly in women, although the reason remains unclear.
There are also differences in the forms of cardiovascular disease more commonly seen in men and women.
Why unexplained fatigue can be an early warning sign of a heart attack in women
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Men are more likely to develop obstructive coronary artery disease, in which plaque narrows or blocks one of the major arteries supplying the heart. Women are comparatively more likely to suffer from coronary microvascular disease, involving the heart’s much smaller blood vessels.
Those tiny vessels can become stiff or lose their ability to expand properly, limiting blood flow even without a major artery becoming completely blocked.
Microvascular disease itself can cause fatigue and chest discomfort. In some cases, however, dysfunction in those small vessels can worsen and substantially reduce blood supply to the heart.
That may help explain why some women experience more gradual or vague warning signs over a prolonged period rather than a single dramatic symptom immediately before a heart attack.
When fatigue becomes a warning sign
Heart-related exhaustion tends to be substantially different from the tiredness caused by a busy schedule or lack of sleep.
“It’s like, ‘I can’t do anything. I have no energy. I’m weak, and I’m tired,’” Ahnert said.
Normal tiredness usually improves after adequate rest. By contrast, someone experiencing cardiovascular-related fatigue may sleep through the night and still wake feeling just as exhausted.
Another important clue is what happens during physical activity.
A person who is merely tired may still be able to complete an ordinary daily activity such as walking their usual distance or climbing stairs. With heart-related fatigue, activities that were previously effortless may suddenly become exhausting.
Bereliani recalled one heart attack patient whose principal warning sign was an abrupt inability to keep her arms raised long enough to blow-dry her hair.
Persistence matters too. Fatigue that continues for several days or weeks without an obvious explanation warrants more attention than a short-lived period of tiredness.
Concern should increase further when exhaustion appears alongside other possible cardiovascular symptoms.
Chest pain remains the most common heart attack symptom overall, but women are more likely than men to have heart attacks without classic chest pain. Some may instead experience pressure or discomfort rather than outright pain, while others feel pain elsewhere in the upper body.
Doctors say unexplained fatigue is particularly concerning when it occurs together with chest discomfort, pain in the jaw, neck or back, shortness of breath, nausea or vomiting, indigestion or heartburn, sweating, disturbed sleep, dizziness or lightheadedness.
When should you seek medical attention?
Occasional tiredness on its own is not necessarily a reason to seek medical care.
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.
Ahnert also stressed that patients should take seriously a persistent sense that something is wrong, particularly if their symptoms are being dismissed.
If fatigue becomes debilitating or occurs alongside a symptom that interferes with normal activity, such as severe shortness of breath, new upper-body pain or heavy sweating, emergency evaluation may be necessary.
In the United States, Ahnert recommends calling 911 rather than being driven to hospital if a heart attack is suspected, since cardiac arrest or a dangerous abnormal heart rhythm can occur on the way.
Women in particular, she said, have a tendency to underestimate the seriousness of their symptoms.
“I’d rather you be wrong and be reassured than to find out afterward that we missed a big heart attack.”