AHA Scientific Statement Describes Symptoms of Six Cardiovascular Diseases With Time and Sex Differences

August 18, 2022—The American Heart Association (AHA) announced the publication of a “state of the science” review of the latest research highlighting the most-reported symptoms of various cardiovascular diseases (CVDs). The scientific statement considers six conditions of CVD: heart attack, heart failure, valve disease, stroke, heart rhythm disorders, and peripheral artery and vein disease.

The scientific statement writing committee reviewed current research on the symptoms of these different CVDs and found that symptoms vary over time and by sex.

According to the AHA press release, the statement highlights how men and women often experience different symptoms, and how symptoms are experienced over time, which may be months or years apart depending on the condition, and on a spectrum of severity or intensity, noting the long-term nature of CVD development.

The AHA scientific statement was drafted by Corrine Y. Jurgens, RN, PhD, et al on behalf of the AHA Council on Cardiovascular and Stroke Nursing, Council on Hypertension, and Stroke Council. It is available online ahead of print in Circulation.

Dr. Jurgens, who served as Chair of the scientific statement writing committee, is an associate professor at Boston College’s Connell School of Nursing in Chestnut Hill, Massachusetts.

“Symptoms of these CVDs can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” commented Dr. Jurgens in the AHA press release. “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.”

As noted in the AHA press release, measuring symptoms is difficult because of their subjectivity. Symptoms may go unrecognized or unreported if patients don’t think they are important or related to an existing health condition. In addition, symptoms may occur without changes in disease progression, and disease state may also progress without symptoms.

Additionally, some symptoms are common and well-recognized across many types of CVDs, while other symptoms are uncommon.

Dr. Jurgens explained, “Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to CVD. 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.”

Dr. Jurgens added, “Establishing a baseline symptom profile for an individual and tracking symptoms over time may be helpful to detect changes and any progression of symptoms.”

The AHA press release summarized the statement’s findings as outlined below:

Heart Attack

• Heart attack is one of several conditions that falls under the broad category of acute coronary syndrome (ACS).
• The most frequently reported symptom of ACS, particularly heart attack, is chest pain, often described as pressure or discomfort, and it may radiate to the jaw, shoulder, arm, or upper back.
• The most common co-occurring symptoms are shortness of breath, sweating or a cold sweat, unusual fatigue, nausea, and lightheadedness.
• Women are more likely than men to report more symptoms in addition to chest pain.
• These co-occurring symptoms have often been referred to as “atypical” but an AHA presidential advisory that was announced in May 2022 explained that this label may have developed because of the lack of women included in the clinical trials from which the symptom lists were derived (Wenger et al; Circulation. 2022;145:e1059-e1071).

Heart Failure

• Shortness of breath is a classic symptom and a common reason that adults with heart failure seek medical care.
• Early and more subtle symptoms, however, should be recognized as signs to consult with a health care professional.
• These symptoms may include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance (related to fatigue and shortness of breath); insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).
• Women with heart failure report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life compared with men with heart failure.
• As with heart attack, women are more likely than men to report different symptoms.
• In heart failure, women report nausea, palpitations, and digestive changes, as well as higher intensity levels of pain (in other areas of the body, not just 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,” advised Dr. Jurgens in the AHA press release. “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

• Heart valve disease is a common cause of heart failure and shares the symptom of shortness of breath. Problems with heart valves include stenosis, prolapse, regurgitation, and atresia.
• In mild cases of valve disease patients may have no symptoms for years, then develop progressively more symptoms similar to those associated with heart failure.
• Valve disease can also cause high blood pressure in the lungs, or pulmonary hypertension.
• Women with aortic stenosis more frequently report shortness of breath, exercise intolerance, and physical frailty, and they are more likely to have lower scores on the New York Heart Association Functional Classification versus men.
• Men with valve disease are more likely to report chest pain than women with valve disease.

Stroke

• A stroke typically causes recognizable symptoms that prompt emergency help. Recognizing stroke symptoms is critical since immediate treatment may help prevent or reduce the chance of long-term disability or death.
• F.A.S.T. is the American Stroke Associate’s acronym to guide all people in recognizing stroke symptoms and seeking medical attention and stands for face drooping, arm weakness, speech difficulty, and time to call 911.
• Other symptoms of stroke are confusion, dizziness, loss of coordination or balance, and visual changes.
• In addition to the common symptoms, women experiencing a stroke are more likely than men to have less familiar symptom. These include headache, altered mental state, coma, or stupor. A stroke may also impair thinking, which may, in turn, impact the individual’s ability to recognize new or worsening symptoms.
• Some symptoms may linger after a stroke and require continued care whether these symptoms require rehabilitation or become disabilities.
• Poststroke screening should include assessment for anxiety, depression, fatigue, and pain. Poststroke pain may take months to develop, with most reports occurring at 4 to 6 months after a stroke.

Rhythm Disorders

• Arrhythmias symptoms are often described as the feeling of an abnormal heartbeat or palpitations that may be irregular, fast, fluttering, or halting.
• Other symptoms include fatigue, shortness of breath, and dizziness, all of which are shared with other CVDs.
• Less commonly, chest pain, dizziness, fainting or nearly fainting, and anxiety may occur in some patients with heart rhythm disorders.
• Women and younger adults with rhythm disorders are more likely to experience palpitations, while men are more likely to experience no symptoms.
• Older adults are more likely to experience either uncommon symptoms or no symptoms.
• Differences in symptoms have also been found among patients from diverse racial and ethnic group. Data indicate Black adults report experiencing more palpitations, shortness of breath, exercise intolerance, dizziness, and chest discomfort in comparison to patients who are Hispanic or white.

Peripheral Artery and Vein Disease

• Peripheral artery disease (PAD) may have no symptoms or may develop the classic symptom of claudication, which is pain in one or both calf muscles that occurs while walking and subsides with rest.
• However, pain in other parts of the legs and in the feet and toes are the most common symptoms of PAD rather than calf pain.
• PAD with symptoms is associated with an increased risk for heart attack and stroke, with men at higher risk than women.
• Depression occurs frequently among patients with PAD, especially women and patients who are elderly or from diverse racial and ethnic groups.
• Depression is also more likely to occur among people with more severe PAD.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease,” advised Dr. Jurgens. “However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms.”

• Peripheral vein disease (PVD) may cause no symptoms, or it may cause leg pain.
• Typical leg-related PVD symptoms include leg pain and achiness, heaviness or tightness in the legs, fatigue, cramping, restless legs syndrome, and skin irritation.
• One study showed that adults younger than age 65 were more likely than older adults to report pain, heaviness, achiness, and fatigue.
• Symptoms of PVD sometimes occur even when there are no visible signs of the condition.
• Sex differences in vein and artery disease are mainly seen among those patients with PAD.
• Women are more likely to report pain in other places than the calf muscle or no symptoms at all.
• Women’s symptoms are often complicated by the mistaken belief that PAD is more common among men, or the symptoms are confused with those of other common conditions such as osteoarthritis.
• PAD is also more likely to progress quickly in women and affect quality of life.

Other Factors That Influence Symptoms

• Patients with cardiac disease have approximately twice the rate of depression compared to people without any medical condition (10% vs 5%), according to national survey data.
• Depression should be considered a risk factor for worse outcomes after an ACS event or diagnosis, as suggested in a 2014 AHA scientific statement (Lichtman et al; Circulation. 2014;129:1350-1369).
• Patients with persistent chest pain, patients with heart failure, as well as stroke survivors and patients with PAD commonly have depression and/or anxiety.
• In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.
• Regular assessments of cognitive function and depression levels throughout the course of any CVD should be conducted because they have a strong influence on a patient’s ability to detect symptoms and any changes in their condition.

“Symptom relief is an important part of managing CVD,” concluded Dr. Jurgens in the AHA press release. “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.”