Chest pain and shortness of breath are the symptoms that many of us associate with heart attacks. But other signs of a heart attack seem to happen silently, and often go unnoticed.

“It’s not necessarily that the heart attack is silent, it’s that people feel symptoms differently,” explains Tracy Patel, MD, a cardiologist with the Hartford HealthCare Heart & Vascular Institute.

Dr. Patel explains why people experience heart attacks differently, and other warning signs you should know about.

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Feeling pain differently

According to Dr. Patel, certain groups of people may experience different heart attack symptoms.

People with diabetes, for example, do not feel pain the same way others do, largely due to the condition’s impact on nerves. In addition, blockages are often slow to form in the elderly. These populations might experience heart attacks as shortness of breath or severe fatigue instead.

“A heart attack in different regions of the heart can also cause different symptoms,” Dr. Patel says, explaining this is due to the different functions of heart regions and how nerves transmit pain to the brain. “I am much more concerned with the statement: ‘It’s not chest pain, it’s pressure.’”

Silent heart attack signs

Here are heart attack signs you might ignore:

  • Chest pressure. Instead of sharp pain, as Dr. Patel notes above, you might experience heaviness in the chest, like you’re being hugged tightly.
  • Sore back, chest or arms. This may come and go and feel like a strained muscle. It can occur while exercising, and be caused by a blockage limiting blood flow to the heart.
  • Fatigue. When heart attack reduces blood flow to the heart, it stresses the heart muscle and leaves you feeling exhausted.
  • Shortness of breath. Notice if you suddenly have trouble climbing a flight of stairs or bringing groceries into the house, especially if it takes a long time to recover.
  • Excessive sweating. Hot flashes aside, sudden bouts of sweating, especially when not exercising or being active, can signal a heart attack.
  • Trouble sleeping. Waking up gasping for air in the middle of the night or panting when getting up in the morning might indicate blocked blood flow to your heart.
  • Stomach issues. These can range from sudden heartburn – which can indicate angina, or blocked blood flow to the heart – to nausea and vomiting, especially in women.
  • Tightness in neck. Call your healthcare provider if you have unexplained pain in the neck or jaw, or tightness in the throat.
  • Dizziness. Also report unexplained light-headedness and fainting.
  • Sense of doom. This general feeling that something isn’t right is more than just intuition.

“It’s also good to know that conditions like angina worsen in the cold, which increases blood vessel constriction, and raises cortisol levels in the body,” Dr. Patel notes. “If someone says, ‘I only get chest pressure or tightness when walking outside in the cold,’ it may be a real warning statement.”

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When in doubt

It’s important to know your body and its reactions to different situations. Understanding silent symptoms can help you spot trouble, Dr. Patel says. In addition, she says people need to understand these symptoms usually worsen with physical exertion and improve with rest.

“When in doubt, get it checked out!” she says.