One of the most important pieces of advice given to new interns when they start working in a hospital for the first time, is this:

"If you hear hoofbeats, think of horses, and not zebras".

After all, horses are a lot more common than zebras, and brand new doctors tend to think of all of the unusual things they recently learned in medical school.  But, someone with undiagnosed heart disease may be that rare zebra.  I am amazed at the unusual presentations that many of my patients have, rather than the classic chest discomfort suggesting impending cardiac doom.

One of the most unusual symptoms occurred in a patient that I saw recently.  He had been complaining of left flank pain and saw his family doctor.  After having an unremarkable CAT scan, he started having what he described as a rushing or pulsating feeling down his arms.  Each episode lasted about one minute, and a couple of these episodes seemed worse after eating.  His doctor was frustrated with the lack of a diagnosis, and sent him to me for further testing.  His stress test was very abnormal, so he had a successful stent put in a coronary artery, with complete resolution of his discomfort.

This case was a true zebra.  Other unusual signs of potentially missed coronary disease that I have seen include arm pain, neck discomfort, shortness of breath, intense sweating, jaw discomfort, and one patient who presented with discomfort in his ears only when he was active.  Even unusual shortness of breath during sex can be a warning.

Women are much more likely to have unusual warning signs, often ignored because they are so zebra- like.  Squeezing or pain in the arm, jaw, back or neck, unusual stomach discomfort, profound sweating, shortness of breath, and even intense fatigue can be the presenting complaint in some women.

Here are 10 things that you should know about an impending heart problem:

1. Angina (heart discomfort) can be an early warning sign that often occurs before an actual heart attack.  It can be typical (chest pressure with activity) or atypical (like the examples above).

2. If you are experiencing chest discomfort, unusual shortness of breath, discomfort of the arms with activity, unusual sweating, jaw discomfort, or any sudden change in how you are feeling, discuss this with your doctor as further testing might be in order to exclude a heart problem.  Although these symptoms are often not heart related, they need to be checked out.

3. Know your risk. It is higher if you smoke, have high blood pressure, diabetes, high cholesterol, are overweight, or have a family history of heart problems. 
4. People who have inflammatory diseases such as rheumatoid arthritis or lupus may be at increased risk of having a coronary problem.
5. Silent heart attacks can occur, more commonly in diabetics, because pain sensations can be decreased due to neuropathy.
6. Having a stress test, or a special kind of screening test called a calcium scoring CAT scan can often exclude the heart as a source of the problem.
7. If you have sudden shortness of breath, chest discomfort or heaviness, which occurs at rest or with low levels of activity, this may no longer be an attack of angina, but could be an actual heart attack.
8. If you think you might be having a heart attack, call 911,  chew an aspirin (so it can begin working immediately), and do not wait to call your doctor the next day.
9. During the early moments of a heart attack, the heart muscle is vulnerable to possibly fatal irregular heartbeats, so it is important not to drive to the hospital, but to call for an ambulance.
10. Act quickly, as damage can be reversed if too much time has not gone by.

Dr. David Becker is a board certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. and has been in practice for 25 years. In 1993, after extensive research, Dr. Becker launched Healthy Change of Heart™, an innovative 10-week program designed to reverse heart disease and improve quality of life through diet, exercise, and stress management. Since then, thousands of patients have participated in the program, achieving significant results in improving cardiac wellness.


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