Silent Heart Attacks and Type 2 Diabetes

Written by Sari Harrar

With commentary by Elsayed Z. Soliman, M.D., MSc., M.S., study senior author and director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.

Not all heart attacks announce themselves with Hollywood-style crushing chest pain and a drenching, cold sweat. When researchers from Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, checked the hearts and medical records of 9,498 people over nine years, they found1 nearly equal numbers of untreated, silent heart attacks and recognized heart attacks that had received medical attention.

A silent heart attack may be missed because the symptoms are mild or seem like another, less-urgent health issue – such as indigestion, heartburn, the flu, fatigue or an ache-y muscle – notes Elsayed Z. Soliman, M.D., MSc., M.S., study senior author and director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. “People may also decide not to go to the hospital if they’re not sure it’s a heart attack, or if the hospital is far away, they don’t have health insurance or are concerned about the cost of care,” Dr. Soliman told

But in the study, published May 16 in the journal Circulation, that proved deadly. People who’d had silent heart attacks were three times more likely than those who hadn’t had a heart attack at all to die. Typically, people who’ve had a silent heart attack miss out on emergency care that can save heart muscle during a heart attack such as fast treatment with procedures that open blocked arteries in the heart. They may also miss out on stepped-up attention to blood pressure, cholesterol, diet, exercise and stress afterwards that lower risk for future problems.

Dr. Soliman says silent heart attacks are a particular concern for people with diabetes. High blood sugar, high blood pressure and cholesterol problems raise risk for heart events, but  nerve damage can make warning signs of an attack impossible to feel. “People with diabetes may have an impaired perception of chest pain, a key symptom that compels people to go to the hospital,” he says.

The study is part of the on-going Atherosclerosis Risk in Communities research project involving white and African-American volunteers from Maryland, Minnesota, Mississippi and North Carolina. Participants underwent electrocardiograms to measure electrical activity in the heart; abnormalities can signal that a silent heart attack has happened. Silent heart attacks seemed to be slightly more common in African-Americans than whites. They were also more common in men in general, but raised risk for future deaths more in women.

Once discovered, a silent heart attack needs aggressive treatment to prevent future attacks, Dr. Soliman says. “A silent heart attack is a heart attack,” he says. “Doctors need to help patients who have had a silent heart attack quit smoking, reduce their weight, control cholesterol and blood pressure and get more exercise.”

That doesn’t mean everyone needs an EKG. “If you are at high risk for a heart attack because you have diabetes, high blood pressure, high cholesterol, smoke or a family history of heart disease or sudden cardiac death, your doctor can determine whether or not you need one,” Dr. Soliman says. 

People at high risk for heart trouble due to diabetes and other factors should also pay attention to heart-attack symptoms that whisper instead of shouting – particularly unusual fatigue, shortness of breath or pain in the chest, shoulders, arms or back that come on during regular exercise or physical work. “Symptoms during activities you used to perform without any unusual sensations are important to watch for,” he says.


1. Zhang ZM, Rautaharju PM, Prineas RJ et al: Race and Sex Differences in the Incidence and Prognostic Significance of Silent Myocardial Infarction in the Atherosclerosis Risk in Communities (ARIC) Study. CIRCULATIONAHA.115.021177. Published online before print May 16, 2016,

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