A comprehensive review of the latest research has underscored the critical importance of recognizing the diverse and evolving symptoms associated with various cardiovascular diseases (CVDs). A significant finding from this new American Heart Association (AHA) scientific statement, published today in the Association’s esteemed journal, Circulation, highlights that men and women frequently experience these symptoms differently. Furthermore, the statement emphasizes that symptom presentation can shift over time, spanning months or even years, and exist on a spectrum of intensity, reflecting the long-term nature of cardiovascular disease development.
The scientific statement writing committee meticulously examined current research to compile a detailed compendium of symptoms for six key cardiovascular conditions: heart attack, heart failure, valve disease, stroke, heart rhythm disorders, and peripheral artery and vein disease. Their analysis revealed not only variations in symptom experience over time but also distinct patterns between the sexes. This underscores a critical gap in our understanding and clinical practice, as cardiovascular disease remains the leading cause of death globally and in the United States.
"Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions," stated Corrine Y. Jurgens, Ph.D., R.N., A.N.P., FAHA, Chair of the scientific statement writing committee and an associate professor at Boston College’s Connell School of Nursing. "The scientific statement is a ‘state of the science’ compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting."
The Challenge of Symptom Measurement and Interpretation
A central challenge in diagnosing and managing cardiovascular disease lies in the subjective nature of symptoms, making their accurate measurement difficult. Symptoms may be overlooked or dismissed if individuals do not perceive them as significant or directly related to a known health condition. This can lead to delayed diagnosis and treatment, potentially exacerbating outcomes. Moreover, cardiovascular disease can progress without overt symptoms, and conversely, symptoms can arise without a clear progression of the underlying disease.
"Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease," explained Dr. Jurgens. "However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization. A broader definition of what constitutes an ‘important’ symptom is warranted."
While some symptoms, such as chest pain during a heart attack, are widely recognized, others are less familiar but equally critical. For instance, shortness of breath, fatigue, sweating, nausea, and lightheadedness can be early indicators of serious cardiac events. The statement advocates for establishing a baseline symptom profile for each individual and diligently tracking symptom changes over time to detect any progression, which can be instrumental in timely intervention.
Distinct Symptom Profiles Across Cardiovascular Conditions
The scientific statement delves into the specific symptomologies of the six reviewed cardiovascular diseases, highlighting key distinctions and commonalities, particularly concerning sex differences.
Heart Attack: Beyond the Classic Chest Pain
Heart attack, a critical component of acute coronary syndrome (ACS), is most commonly associated with chest pain. This pain is often described as pressure or discomfort and can radiate to the jaw, shoulder, arm, or upper back. However, co-occurring symptoms such as shortness of breath, sweating, unusual fatigue, nausea, and lightheadedness are also prevalent.
Historically, these additional symptoms were often labeled "atypical," a classification that may have stemmed from the underrepresentation of women in early clinical trials. The AHA’s recent presidential advisory has challenged this terminology, suggesting that the perceived "atypicality" might be a consequence of a skewed understanding derived from male-centric data. Women, in particular, are more likely than men to report a broader spectrum of symptoms beyond chest pain, underscoring the need for a more inclusive approach to symptom recognition.
Heart Failure: Subtle Signs and Broader Manifestations
Shortness of breath is a hallmark symptom of heart failure and a primary reason individuals seek medical attention. However, the statement emphasizes the importance of recognizing earlier, more subtle signs. These can include gastrointestinal issues such as upset stomach, nausea, vomiting, and loss of appetite; pervasive fatigue; reduced exercise tolerance; insomnia; various forms of pain; mood disturbances like depression and anxiety; and cognitive dysfunction often described as "brain fog" or memory problems.
Women with heart failure often report a wider array of symptoms compared to men. They are more prone to experiencing depression and anxiety, leading to a diminished quality of life. Specifically, women may report nausea, palpitations, and digestive changes, alongside higher intensities of pain (beyond chest pain), swelling, and sweating.
"Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death," Dr. Jurgens noted. "Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor heart failure outcomes."
Valve Disease: A Gradual Progression with Overlapping Symptoms
Heart valve disease, a common precursor to heart failure, shares the symptom of shortness of breath. This condition involves issues with the heart’s valves, which regulate blood flow. Problems can range from narrowed or stiffened valves (stenosis) to valves that leak (regurgitation) or fail to close properly (prolapse). In mild cases, individuals may remain asymptomatic for years before experiencing a progressive increase in symptoms similar to those of heart failure. Valve disease can also lead to pulmonary hypertension, or high blood pressure in the lungs. Aortic stenosis, a serious form where the aortic valve narrows, significantly restricts blood flow from the heart.
Women with aortic stenosis tend to report shortness of breath, exercise intolerance, and physical frailty more frequently than men. They are also more likely to be classified in lower functional categories for heart failure according to the New York Heart Association Functional Classification. Conversely, men with valve disease are more prone to reporting chest pain.
Stroke: Recognizing the Urgency Beyond the Obvious
Strokes, occurring when blood supply to the brain is disrupted by a blockage or rupture, typically present with recognizable symptoms that necessitate immediate emergency response. The American Stroke Association advocates for the F.A.S.T. acronym to quickly identify stroke: Face drooping, Arm weakness, Speech difficulty, and Time to call 9-1-1. Additional symptoms include confusion, dizziness, loss of coordination, and visual disturbances. Prompt recognition and treatment are crucial to mitigate long-term disability or death.
However, women experiencing strokes may exhibit less common symptoms in addition to the classic signs. These can include severe headaches, altered mental states, coma, or stupor. Cognitive impairment following a stroke can also affect an individual’s ability to perceive or report their symptoms accurately. Post-stroke care should include screening for anxiety, depression, fatigue, and pain, as these can manifest months after the event.
Rhythm Disorders: Palpitations and Varied Presentations
Heart rhythm disorders, or arrhythmias, are often characterized by the sensation of an abnormal heartbeat, known as palpitations, which can feel irregular, rapid, fluttering, or halting. Fatigue, shortness of breath, and dizziness are also shared symptoms with other cardiovascular conditions. Less frequently, chest pain, fainting, and anxiety may accompany rhythm disorders.
A notable sex and age difference exists: women and younger adults are more likely to experience palpitations, while men may be asymptomatic. Older adults are more prone to experiencing less common symptoms or no symptoms at all. Disparities also exist among racial and ethnic groups; for example, Black adults report more palpitations, shortness of breath, exercise intolerance, dizziness, and chest discomfort compared to Hispanic or white individuals.
Peripheral Artery and Vein Disease: The Silent Progression
Peripheral artery disease (PAD), affecting arteries in the lower extremities, can lead to reduced blood flow to the legs. While some individuals remain asymptomatic, the classic symptom is claudication – pain in the calf muscles during walking that subsides with rest. However, pain in other leg areas, feet, and toes are more common. PAD, when symptomatic, is linked to an increased risk of heart attack and stroke, with men facing a higher risk than women.
"Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease," Dr. Jurgens commented. "However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms."
Depression is a frequent comorbidity among individuals with PAD, particularly women, the elderly, and those from diverse racial and ethnic backgrounds. Its prevalence increases with the severity of PAD.
Peripheral vein disease (PVD) can also manifest with no symptoms or with leg pain. Typical symptoms include leg pain and achiness, a feeling of heaviness or tightness in the legs, fatigue, cramping, restless legs syndrome, and skin irritation. Younger adults (under 65) are more likely to report pain, heaviness, achiness, and fatigue compared to older adults. These vein disease symptoms can occur even without visible signs.
Sex differences in PAD are particularly pronounced. Women are more likely to report pain in areas other than the calf or experience no symptoms. Their symptoms can be complicated by the misconception that PAD is more common in men or by confusion with other conditions like osteoarthritis. PAD tends to progress more rapidly in women, significantly impacting their quality of life.
The Interplay of Depression, Cognitive Function, and Symptom Reporting
The scientific statement also sheds light on the significant influence of mental health on symptom perception and reporting. National survey data reveals that individuals with cardiac disease experience depression at roughly twice the rate of those without any medical condition (10% vs. 5%). A previous AHA scientific statement from 2014 suggested that depression should be considered a risk factor for poorer outcomes following acute coronary syndrome events or diagnoses.
The current statement highlights that persistent chest pain, heart failure, stroke survivors, and individuals with peripheral artery disease commonly experience depression and/or anxiety. Furthermore, cognitive changes after a stroke can profoundly affect how symptoms are experienced or even noticed. The writing group strongly advises regular assessments of cognitive function and depression levels throughout the course of any cardiovascular disease. This is crucial because these factors significantly impact a person’s ability to detect symptoms and recognize changes in their condition.
"Symptom relief is an important part of managing cardiovascular disease," concluded Dr. Jurgens. "It is important to recognize that many symptoms vary in occurrence or severity over time, that women and men often experience symptoms differently, and factors such as depression and cognitive function may affect symptom detection and reporting. Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk."
This pivotal scientific statement was meticulously prepared by a volunteer writing group representing the American Heart Association’s Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. These statements are designed to foster greater awareness of cardiovascular diseases and stroke, empowering individuals and healthcare providers to make more informed health decisions. While they outline the current state of knowledge and identify areas for future research, they do not provide treatment recommendations. Official clinical practice guidelines are developed separately by the AHA. The implications of this statement are far-reaching, promising to refine diagnostic approaches, personalize treatment strategies, and ultimately improve the quality of life for millions affected by cardiovascular disease.