If a middle-aged man starts clutching his chest, sweating profusely, and gasping for air, everyone knows he’s probably having a heart attack. It’s the “Bollywood drama” depiction of heart problems, says Dr. Basel Ramlawi, a cardiothoracic surgeon with Main Line Health in Philadelphia. “It’s the most dramatic way—but not the most common way—in which patients present.”
Heart problems can actually be quite subtle, he clarifies, and they tend to show up differently in everyone. While someone having a heart attack might, in fact, grab their chest, others—especially women and people with diabetes, who often have nerve damage that prevents them from feeling pain—won’t necessarily experience any chest discomfort at all. Other heart conditions can appear in equally varied ways.
[time-brightcove not-tgx=”true”]There’s good reason to pay attention to even the most understated symptoms: “Your heart is the lifeline of your whole body,” Ramlawi says. “It’s the pump that supplies blood to every other organ in the body, and if it doesn’t work well, then the fuel that supplies the rest of the body isn’t getting to where it needs to be.”
With that in mind, we asked cardiologists to share the weird symptoms that patients often brush off—but which could actually signal a serious heart problem.
People who have experienced heart palpitations describe their symptoms in interesting and wide-ranging ways, says Dr. Edo Paz, a cardiologist at White Plains Hospital in New York and senior vice president of medical affairs with the app Hello Heart. Some say it feels like a goldfish is flipping around in their chest. Others report a sinking feeling. “Imagine that feeling when you’re in an elevator and it starts to descend quickly, and everything drops,” he says.
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Even if you’re tempted to brush off the strange sensations, it’s important to bring them up with your doctor, who will likely do an EKG and send you home with a heart monitor. It’s possible you could have a heart rhythm disorder like atrial fibrillation, or Afib. “When we’re trying to evaluate palpitations, we want to identify whether there’s an actual arrhythmia underneath it,” Paz says. “An arrhythmia is not a symptom. That’s a diagnosis.” He suggests keeping a log of when you experience palpitations, as well as what might have triggered them: a fight with your spouse? Exercising? Many of his patients also take advantage of the ECG feature on their smartwatch, which provides useful data for their doctors.
If you have pulsatile tinnitus, you’ll hear rhythmic sounds—like whooshing or thumping—in one or both ears. Annoying, right? It’s also an atypical heart symptom, says Dr. Heather Gornik, a cardiologist and vascular medicine specialist who’s a professor in the school of medicine at Case Western Reserve University. “Sometimes there are peripheral symptoms that one wouldn’t think are cardiovascular at all that could be a manifestation of cardiovascular disease,” she says. “And the one I see the most is patients who have a pulsating sound in the ear,” often in tune with their heartbeat.
That sound can signal carotid artery stenosis—narrowing of the blood vessels that carry blood from the heart to the brain—or the rare vascular disease fibromuscular dysplasia. The latter affects women more than 90% of the time, Gornik says, and can be associated with artery blockages and tears, as well as aneurysms. “People hear this pulsating sound, and they think nothing of it,” Gornik says. “But it’s something that needs to be taken pretty seriously.” If you’re suddenly experiencing new and persistent whooshing in your ear, call your doctor, she urges.
Notice you’re not able to walk as far anymore, or that your legs feel tired or painful as you plod along? Don’t ignore it. “The legs have a lot of clues about the cardiovascular system,” Gornik says. A condition called peripheral artery disease (PAD), for example, occurs when the arteries that carry blood from the heart to the legs get clogged; it’s associated with an increased risk of heart attack, stroke, and early death. “That can manifest with leg pain while walking, or just tiredness in the leg, and it’s important to identify the condition,” she says.
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If your symptoms persist for a week or two, see your doctor, Gornik suggests. They’ll likely do a physical exam and an ankle-brachial index test, which measures blood pressure in your legs and arms. “PAD can be a serious condition that could lead to amputation,” Gornik says. “But also, if you have it, it means you likely have heart artery blockages, so you need to have your heart managed appropriately, too.”
Swollen feet, legs, and ankles—often called peripheral edema—can be a telltale sign of congestive heart failure. Blame it on gravity: When the heart is unable to pump blood effectively because it’s too weak, that blood drops to the lowest part of the body and gets trapped there, Ramlawi explains. So when should you see a doctor? “If it’s in both feet, not just one, and it comes back the next day or the day after,” it’s time to investigate what’s causing it, he says.
It’s also smart to keep an eye out for “abrupt color changes,” Gornik points out. In addition to causing your leg or legs to swell up, blood clots could turn them purple or, in some cases, “totally pale and white.” Blood clots are a medical emergency in their own right—and can lead to heart attack and stroke—so if you notice these changes, seek treatment right away, she urges.
Angina—the technical name for chest tightness—can spread to the jaw or neck. It’s typically triggered by exertion, like walking uphill, or emotional stress, says Dr. William Zoghibi, chair of cardiology at Houston Methodist. “It radiates,” he says. “You’re going to localize it most often in the upper extremities. People think about the arm, but they don’t think about the jaw or neck as often.” If your pain or discomfort is triggered by exertion and relieved by rest, or if it comes and goes, get it checked out, Zoghibi advises. Your doctor will likely do a stress test and run imaging to figure out if you have a condition putting you at heightened risk of a heart attack or stroke.
After having a heavy meal, you might experience chest discomfort “or a lot of belching,” Zoghibi says. It was definitely the spicy tacos, right? Not so fast: Chest pain that’s similar to indigestion or heartburn can signal ischemic heart disease, he says. Though people often dismiss it as a run-of-the-mill gastrointestinal symptom, it’s best to monitor it closely—and, if it gets worse or doesn’t go away, to call your doctor.
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It’s also important to pay close attention to nausea. For both men and women, the most common heart-attack symptoms are chest pain and shortness of breath. “But women are much more likely than men to present with what we call atypical symptoms,” Paz says. That includes nausea, which you should take particularly seriously if you’re also experiencing jaw or back pain, lightheadedness, or unusual fatigue.
If you’re experiencing carpal tunnel symptoms, you might notice your wrist hurts after typing on your work laptop; maybe you get a “pins and needles” feeling in your fingers, or hand weakness that makes it tough to grip your dog’s leash. Especially when accompanied by shortness of breath, these symptoms can indicate cardiac amyloidosis, Zoghibi says. “It’s a problem of protein misfolding,” he explains. “The protein, which is called amyloid, starts depositing in different parts of the body. It can deposit in the heart, in neurological areas, and in the area of the carpal tunnel.” The good news, Zoghibi adds, is that there’s now effective treatment for the condition; 10 years ago, that wasn’t the case.
Classic chest pain typically feels like pressure, fullness, or squeezing, and it often gets worse with exertion and then goes away before coming back again later. People who are experiencing aortic dissection, meanwhile—a tear in one of the body’s major arteries—describe sudden, stabbing pain in the middle of the chest that radiates to their back. It can be lethal if not caught in time, Ramlawi stresses. “If this goes unrecognized for just one day, close to 25% to 50% of people would be dead,” he says. “We usually put them in a chopper and transfer them to a big emergency center where they undergo immediate open heart surgery.” If detected quickly, there’s a good survival rate, he adds. “The problem is that oftentimes, patients don’t recognize it. They brush it off as something else, and they stay home and don’t come to the hospital.” If you experience this kind of stabbing pain, treat it as an emergency.
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Valvular disease is a growing focus area in the diagnosis and treatment of heart disease, says Dr. Charles Davidson, an interventional cardiologist who’s vice chair of clinical affairs in the department of medicine at Northwestern University Feinberg School of Medicine. While coronary disease occurs when the arteries that supply the heart become blocked, valvular disease indicates that the heart’s valves aren’t working well. Unlike a sudden cardiac event—say, a heart attack—valvular disease develops slowly, over five to 10 years. Many patients don’t experience symptoms until later in the course of disease, if at all, Davidson says.
Those who do detect something is off often report that they’re “feeling a little older, or a little more tired,” he adds. “They don’t really think much of it.” Yet, perhaps without even noticing, they cut back on their activities or make tweaks to the way they approach their daily routine. When a doctor asks if they can walk up two flights of stairs, someone with valvular disease might respond: “Well, sure. But I have to stop after the first flight.” Or maybe the question is about whether they can clean the whole house. Davidson often sees people reply in the affirmative—but when he asks if they can do it all at once, they say no, they have to take breaks.
Pointing out these changes to everyday abilities is essential, Davidson says, because the earlier doctors figure out there’s a problem, the faster they can treat it. “Don’t wait until you feel awful,” he stresses. “Get on it early—if nothing else, [your screening test] will be reassuring.” Therapies have markedly evolved in recent years, he adds, and so far this year, he’s successfully treated two men over age 100—meaning factors like age are no longer an automatic deterrent to overcoming a heart problem.
