Fatigue as a Prodromal Symptom of Myocardial Infarct
To the Editor:
I was pleased to read, in the paper from McSweeney and colleagues,1 that the importance of unusual fatigue before myocardial infarction has been redescribed.
In the 1970s, Peter Nixon and I reported this symptom as a frequent precursor to myocardial infarction in both sexes.2,3 In a series of 40 consecutive survivors of acute myocardial infarction, 77% reported increasing and abnormal fatigue for 6 weeks to 3 years before the attack. Excessive sleeping at inappropriate times was reported by 80% and other common symptoms included general slowing down, lessening of libido, and reduction of social activities.
Kinlen4 had also reported similar symptoms, described to him by the wives of those who had died suddenly from coronary heart disease (CHD). “It was striking how often a certain pattern of changed behavior was described…He might complain of tiredness or of ‘getting old’…going to bed earlier in the evening or falling asleep in chairs where this was previously very unusual.”
We attributed preinfarction fatigue to early left ventricular dysfunction. The presence of an atrial gallop5 suggests CHD as the cause rather than the constellation of other conditions associated with tiredness.
It should be possible to test whether fatigue is an indicator of CHD by adding a question about tiredness to one of the current long-term prospective epidemiological studies
In an age of angiograms and echocardiograms, carefully listening to the patient and examining the heart in the left lateral position have seemed less important. As a result, it may be that we miss the opportunity of detecting the earliest clinical indicators of CHD.
McSweeney JC, Cody M, O’Sullivan P, et al. Women’s early warning symptoms of acute myocardial infarction. Circulation. 2003; 108: 2619–2623.
Nixon PGF, Bethell HJN. Coronary deaths: how unexpected? Br Med J. 1971; 2: 486–487.
Kinlen LJ. A Community Study of Acute Myocardial Infarction and Sudden Death [PhD thesis]. Oxford, UK: University of Oxford; 1969.
Bethell HJN, Nixon PGF. Atrial gallop in coronary heart disease without overt infarction. Br Heart J. 1974; 36: 682–686.