When tiredness is a sign you’re having a SILENT heart attack

The trip had been months in the planning. A ten-day tour of Washington, Atlantic City and New York seemed the perfect way for Anthony Cottrell and his wife, Ellen, to celebrate their silver wedding anniversary.

But as the couple toured the U.S. capital city, Anthony, then 48, found himself feeling increasingly tired. 

‘I just couldn’t work it out,’ reflects Anthony, a transport coordinator from Durham. 

‘I was used to walking a lot but suddenly I just felt sluggish. We’d walk for 20 minutes and then I had to sit down for a while. Ellen and I put it down to jet lag, or that I wasn’t as fit as I thought I was.’

In fact, Anthony was experiencing the fallout from a silent heart attack.

Hollywood may have us believe heart attacks involve dramatic chest pain. Yet many can be overlooked — vague symptoms dismissed as a virus or fatigue. Occasionally, there are no symptoms at all.

But silent myocardial infarction (SMI) — as it is medically known — accounts for up to 50 per cent of the 100,000 heart attack hospital admissions each year.

They’re ‘silent’ since they lack the intensity of classic heart attacks, such as chest pain, stabbing pain in the arm, or sweating and shortness of breath.

Yet internally they’re identical to a normal heart attack — the blood supply to the heart is suddenly blocked by a build-up of fat and other substances in the arteries that feed it — causing damage to the tissue. The damage can be cumulative, leading to potentially fatal blockages.

Sometimes SMI is truly silent,’ says Jerome Ment, a consultant cardiologist at University Hospitals Birmingham NHS Foundation Trust.

‘That is, there are no symptoms at all. Patients may come in for a routine operation and, as part of the preparation, have an ECG — electrocardiogram — a simple test to check the heart’s activity.

‘The results might show damage that tells us they have had a heart attack even though they, say, have been playing golf three times a week. Inevitably, it comes as a shock.’

The problem has been compounded by the pandemic since many people stayed away from hospitals.

In the first month of lockdown, a survey by the British Heart Foundation found 84 per cent of doctors said the number of people coming to hospital with even the most serious type of heart attack — where there is almost a complete blockage — had fallen.

There are obvious risk factors for having a heart attack such as excess weight or a family history of heart issues, but often it can be difficult to predict who may have one, says Dr Ment.

‘We know, for example, that those with type 2 diabetes are more vulnerable to silent heart attacks. This may be because the condition impairs the nerve supply to the heart so there is no pain. But then more women suffer silent heart attacks than men — and we don’t know why.’

Not all heart attacks need immediate treatment, though unchecked they can be fatal.

‘A complete blockage of the arteries is very time dependent — the longer you wait, the more damage to the heart muscle,’ he says. If you’ve had, say, vague flu-like symptoms for a number of weeks then see your GP so you can be referred for further tests.

‘You can’t mitigate against silent symptoms,’ says Dr Ment. ‘That’s why it’s important to live a healthy lifestyle and be aware of the risk factors and that not all heart attacks present with chest pain.’

As Anthony knows, the symptoms can be so general. Although his sluggishness disappeared towards the end of his ten-day holiday, it returned around eight weeks later. 

‘Again, I thought it was over-tiredness,’ says Anthony, four years since his heart attack. As the grandfather of two recalls: ‘I went to my GP and told him I had back pain and felt shaky, too. He carried out some blood tests but they were normal.’

Yet a few days later, when Anthony was hanging up washing, he felt overwhelmed with fatigue.

‘I slumped to the floor,’ he recalls. ‘I also felt breathless. I rang 111, for advice rather than thinking it was something serious, and was shocked when they sent an ambulance. I imagined this was protocol and so I wasn’t frightened.’

Once in hospital, an ECG and tests to measure troponins — proteins released into the bloodstream during a heart attack — revealed the problem. Anthony had suffered a silent heart attack.

Further scans revealed his right artery was fully blocked and had been, doctors estimated, for about 18 months.

‘I was astonished, speechless,’ he says. ‘I thought that when heart attacks happen you keel over with chest pain.

‘Even more shocking was that doctors said that had my left artery been blocked as well, it could have been fatal.’

Anthony hadn’t experienced problems until his trip in June because his heart muscle, doctors told him, had developed small blood vessels in other coronary arteries to reroute the blood flow to the heart.

Treatment for silent heart attack, once diagnosed, is the same as it would be for any form of heart attack — and usually involves medication such as aspirin to disperse any clots blocking the blood flow to the heart.

Doctors will then look at ways to prevent problems in the future, such as an angioplasty — where a special kind of balloon is gently inflated inside the coronary artery to improve blood flow.

Anthony is being treated with statins and a drug called isosorbide mononitrate, which improves blood flow by relaxing the blood vessels of the heart. 

Doctors are now talking about fitting a stent — a short tube that acts as a scaffold to keep the artery open.

But four years on, Anthony is still suffering with the fallout of his heart attack and the damage it did to his heart.

‘It has taken a long time to get to where I am,’ he says. ‘For the first month I couldn’t go out at all; I just felt so sluggish.

‘When I first recovered I used to go to the supermarket and would gauge how far down the aisles I could go before I had to sit down. Even though I’m back at work, I can get tired if I do a pile of ironing.

‘I would love to build up energy to play with my grandchildren. Ellen and I would love to go travelling on the west coast of America. But I’ve no idea when I’ll be able to do that again.’