February is heart awareness month. Awareness is the operative term. Individuals who have cardiovascular problems may not have recognizable symptoms that prompt them to seek appropriate medical attention. The classical breastbone chest pain that goes down the left arm does indeed occur, but doctors know that there are all kinds of unusual presentations for cardiovascular disease. It is further complicated by the facts that gender, culture, and other conditions may confound the way heart disease may manifest itself.

Based on the famous Framingham Heart Study that followed a community for 36 years, we recognize that as many as one in four patients that suffer a heart attack have no clear, discernable event that correlates with the apparent event. High pain thresholds, defective-warning symptoms, unawareness that symptoms other than the classical chest pain, and heartburn-type symptoms may mask or cause patients to misinterpret heart pain as something else.

Coronary artery disease is the leading cause of death in both men and women. The World Health Organization and others estimate that cardiovascular disease will be the leading cause of death worldwide by 2030. The problem is the buildup of cholesterol and other materials into the blood vessels that feed the heart. When the heart muscle that needs the nutrients and oxygen from the arteries fails to get what it needs, an oxygen debt occurs that may cause some discomfort. The heart's pain nerves enter the spinal cord at variable locations with some crosstalk with other nerve fibers coming in near the same area. That's why the brain often misinterprets heart pain as coming from the left arm. But it can confuse the discomfort as coming from the elbow, wrist, abdomen, back, neck and not uncommonly, from the teeth. Most cardiologists have had astute dentists refer patients to them after the patient thought he had a tooth problem. Heartburn-type symptoms, especially if accompanied by nausea and sweating, can actually be cardiac pain.

More women than men die of heart attacks despite the common misperception that coronary disease is mostly a disease of men. Thus patients AND doctors often trivialize women's complaints or look to other causes for symptoms other than typical effort related chest pain. Although many women indeed do present to the doctor with classic symptoms, women may get effort-induced shortness of breath, neck or back pain more than men may. A common cardiac diagnosis like mitral valve prolapse can mimic coronary pain, especially in women.

If one does have symptoms that raise the specter of coronary disease, what should one do? First, one should not to ignore any new or changes in symptoms, especially substantive changes in pattern, duration, or severity. They should contact their doctors with their concerns, and let the doctors sort through the possible causes. A diagnostic test like a treadmill or stress echocardiogram or a nuclear exercise test may add considerably to the resting electrocardiogram, which can be perfectly normal despite significantly closing arteries. And the sooner one with significant disease comes to medical attention, the more likely one will do better.

Last, I would like to make sure that the reader is aware that cardiovascular medicine has broadened the diagnoses that we now consider to be the equivalent of having had a heart attack. That is, some conditions are felt to put the patient at the same risk as someone who has had a bona fide heart attack. These diagnoses include the presence of diabetes, a history of stroke, presence of effort-induced leg or buttock cramps, or amputation of an extremity because of arterial disease.

Be aware that cardiovascular may have protean manifestations. Relating any changes in symptoms, especially those associated with activity, to one's doctor is prudent and may save a life. Yours.