Emotional Health and fitness Also Essential To Heart Attack Restoration
Article by James Lozen
Heart Attack RecoveryOne of the most necessary thing soon after an individual has had a heart attack will be the restoration section. If not appropriately handled, the recovery phase can result in much more harm being carried out towards the heart and the human being not becoming ready to properly recover in the situation that has occurred.Within the past many years, hundreds of thousands of across the country will enter a hospital emergency room or be brought in by an ambulance complaining of chest discomfort or other symptoms that recommend they may be getting a heart attack. According to the statistics surrounding heart illness and heart attack, what takes place in the course of recovery is essential as nearly one million folks don’t totally recuperate from a heart attack, and finish up dying.Since it is actually such a prevalent condition within society, it’s important to comprehend the necessary actions for heart attack recovery. When somebody is taken into a hospital, the hospital physician could have enough expertise to deal with the physiological and biological issues concerning a heart attack. They’ll know what medicines to prescribe to guarantee restoration, and what check the individual will have to undergo to monitor that they can be recovering adequately. Nonetheless, some sufferers will require help with their psychological wellness, and not only their physical well-being in the course of the restoration section.In regards to a person’s emotional wellness it can be achievable to experience shock, angry, and sadness. Lots of many people really feel that they may be invincible and when a heart attack happens, it is actually a reminder of that they may be human and that their physique is suffering from an disease. They may be typically in denial that it could occur to them, as they have recognized individuals who have experienced heart attacks. Some persons will even go as significantly to deny that it did take place as they can be still in a state of shock.Following the state of shock and denial wears off, the individual can expertise something from worry that it’s going to come about once more to anger that it did occur, or perhaps a combination of the two feelings. The final section within the recovery from the emotional wellness of heart attack individuals is unhappiness and accepting that the heart attack did bring area. For everybody how rapidly the heart attack patient moves by means of these steps will rely on emotionally mature and secure they are as an particular person. That is why many hospitals provide mental counseling to sufferers who have not long ago acquired a heart attack.Discover more about heart attack symptoms in females visiting my dedicated heart attack website now!
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Leave a commentSymptoms Of Heart Attack In Women
Article by alice rose
It has been revealed in recent research and survey that a heart attack is the number one killer disease among women. Every year, large numbers of women loose their life due to these conditions. Most often women do not recognize this condition until they are subjected to the severe attack. There are different causes of attack, that’s why it becomes a leading killer for both men in women. But nowadays, there are excellent treatments that can save lives and present disabilities. The question is what causes heart attacks? And how can we avoid it? Is there any special procedure that we can do to avoid it?
Evaluation by a physician is necessary to determine which heart disease treatment is appropriate, assuming any treatment at all is needed. Self-diagnosis or self-treatment of chest pain is never appropriate. Never forget that a heart attack does permanent damage to the muscle of the heart. Many women die before receiving medical attention. Their symptoms may have been absent, too sudden, or had not been diagnosed previously. Also, most women are not aware that they have heart problem.
The typical signs of heart attack they have learned to recognize don’t match with the symptoms they are having or heart attack has mostly been seen as a “man’s” affliction (in spite of statistics stating otherwise); They are too preoccupied with other things – such as running errands, caring for children, or working at their place of employment. Heart attack symptoms can be understated especially with people who are suffering from other health complications such as diabetes.
For example, the common symptoms of a heart attack are not the same as diabetes such as the deep chest pains. You could also argue that women who experience pains in their chest may also not be the common symptoms of a heart attack. Children who have one or more parent with heart disease are at risk for developing it themselves. African Americans tend to suffer more from extreme high blood pressure than Caucasians, therefore increasing their chances for heart disease and heart attacks.
Silent heart attacks can happen especially to those with prior heart attacks and who have diabetes and are over the age of 65 and those prone to strokes. The symptoms of a silent heart attack can be vague and mild but one must remember that they can be just as serious and life threatening as heart attacks with a severe chest pain.
Silent heart attack and its atypical signs
Article by Groshan Fabiola
During heart attack one might feel dizzy although is not a common symptom it has been observed at some people with heart attack. Heart attacks are more often in the morning because of the amounts of adrenaline in the blood. Too much adrenaline in the blood may determine formation of clot and rupture of plaque. Cardiac pain is dull, vague and has been described as pressure, fullness, squeezing and other sensation of discomfort. Studies have shown that heart attacks are more frequent in winter, diabetic people have silent heart attacks which means that there is no pain in the chest.
Symptoms
If you feel an intense and suffocating pain in the chest for more than 15 minutes and doesn’t stop at nitroglycerin it means that you are having a heart attack. It is indicated to take aspirin and drink water that helps the heart getting more blood if you are having a heart attack indeed. Sometimes the heart attack symptoms may act as an indigestion with a sensation of fainting and pain in the middle of the abdomen.
Silent heart attacks
Silent heart attacks are the most dangerous ones because people don’t know what’s happening they consider it’s only a state of moment and forget soon about the discomfort and indisposition felt and do not announce a doctor which has a vital risk. Silent heart attacks are those attacks that have no warning symptoms or signs, or may appear atypical signs such as: nausea, sweating, headache and dizziness. Silent heart attacks are common in people older than 65 years and diabetics and women.
American Heart Association and other experts suggest that we should pay attention to the following signals: pain, squeezing, fullness in the center of the heart, pain radiating in the shoulder and arms, burning, pressure, heavy weight. Other symptoms may be: fainting, nausea, sweating, shortness of breath, anxiety, irregular heart rate, pallor, anxiety, nervousness. If you notice any of these symptoms you should address immediately to the emergency medical services at 911 or begin the CPR.
The doctor will diagnose the heart attack after studying several tests: EKG a device that gives the graphical record of the heart’s electrical activity, a physical examination and knowing the complete medical history of the patient, high enzymes in the blood appear in heart attack, those steps are also helpfull. Cardiac enzymes may be determined later in the intensive care unit and urgent care setting so they confirm or infirm the suspicions of heart attack.
Often heart attack is slowly with mild pain and the person in cause doesn’t understand what’s happening, on the other hand the heart attack might be intense and movie-like. The most common signs are: chest discomfort which may be felt as pain, pressure, squeezing, fullness and which may last for minutes. Other symptoms are: pain in both arms, neck, stomach, back, shortness of breath, nausea, cold sweating.
Heart Attacks: Causes and Risk Factors
Article by John Parks
What is a Heart Attack?
When the flow of blood to the heart is obstructed, a heart attack occurs. If the blood flow is not restored quickly, lack of oxygen can cause damage to that part of the heart muscle and it can begin to die. Therefore, if you think you or someone else is having a heart attack, get help immediately. Treatment for a heart attack has a better chance of minimizing damage to the heart if it is given within one hour of the first symptoms.
People who have heart attacks most likely suffer from coronary artery disease which is brought about by the build up of fatty material known as plaque inside he coronary arteries. These arteries supply the heart with blood and oxygen. This buildup can take many years to occur. When a heart attack happens, some of this build up splits off and causes a clot. A big enough clot can partially or entirely prevent blood from getting to the heart muscle.
After having a heart attack, other problems can develop that include irregular heartbeats and even heart failure. Both of these conditions can cause death.
The heart muscle can heal and healing normally begins soon after the heart attack is over. Generally, it takes about two months. The heart attack created a wound on the heart, and as it heals, a scar forms. Unfortunately, this scar tissue does not function as well as muscle tissue of a healthy heart. The ability of the heart to pump efficiently is decreased and that decrease in pumping is directly related to the size of the scar.
What are the Risk Factors? (Who is at Risk?)
There are a lot of risk factors for heart attacks. Some are out of your hands, but there are others that you can control. The risk factors that you can’t control are:
1. Getting Older – About 83 percent of deaths from coronary heart disease occur in people over 65. Women over 65 who have heart attacks are less likely to recover than men.
2. Gender – Men are at much greater risk for heart attacks and they are more likely to have them earlier in life.
3. Heredity (and Race) – Children who have one or more parent with heart disease are at risk for developing it themselves. African Americans tend to suffer more from extreme high blood pressure than Caucasians, therefore increasing their chances for heart disease and heart attacks. American Indians, Mexican Americans, native Hawaiians, and some Asian Americans all have a greater risk of heart disease.
If you fall into any of these risk categories, you should make every effort to manage other risk factors that are controllable, like the following:
1. Smoking – Smokers up their risk factor two to four times more than those who don’t smoke.
2. High Cholesterol – The higher the cholesterol, the higher your chances of getting coronary artery disease. You should use diet and exercises to lower cholesterol, and if that fails, talk to your doctor about medication.
3. High Blood Pressure – This can make the heart work harder and increase your chances of heart attack and even stroke. Again, if diet and exercise don’t work to lower blood pressure, speak to your doctor about prescription medication.
Lack of exercise and obesity are also risk factors for heart attack and heart disease that can be controlled by you. Stress is also a contributing factor in that it affects behavior, like causing you to over eat, smoke, or drink alcohol.
For more information on heart disease, visit http://symptomsheartdisease.net
Panic Heart Attack Symptoms
Article by Oscar Orihuela
Panic Heart Attack Symptoms
Often times people end up going to a hospital thinking they are suffering a heart attack when in reality they are suffering a panic attack. The symptoms of a panic attack are very much alike the symptoms of a heart attack. In this article I will cover the symptoms of a panic attack and the symptoms of a heart attack.
Heart attack symptoms vary and are very similar to the symptoms of a panic attack. These symptoms are uncomfortable pressure, fullness, squeezing(tightening) and pain of the chest lasting for a few minutes. Pain also spreads to the shoulders arms or neck. The pain intensity might be mild to intense. It can feel like tightness, burning, pressure or heavy weight. It is usually located on your torso area around your upper abdomen, chest, jaw, neck, and the insides or your arms and shoulders.
Other heart attack symptoms include anxiety and nervousness with cold sweaty skin. Your skin color could turn pale. Your heart rate increased or becomes an irregular heart beat. You also get the feeling of impending doom which is brought on by the onset of these symptoms. Do note that not all these symptoms occur during a heart attack. You may have one, or several of them combined.
Panic attack symptoms are similar to heart attack symptoms. The panic attack symptoms can include racing or pounding of heart known as palpitations, chest pains, upset stomach, dizziness, nausea, you can experience difficulty in breathing. Hot chills and flashes are also common panic attack symptoms. A sense of terror, a feeling that you must escape your surroundings, a fear of losing control and fear of dying are common panic attack symptoms.
These panic attack symptoms also last for a couple of minutes and due to their intensity can easily be confused with the symptoms of a heart attack. Typically people who have panic attacks don’t know they are having one. They assume they are having a heart attack and go to the hospital. The hospital can likely diagnose it as a heart attack because the symptoms are so similar. Also, people who suffer from panic attacks are likely to have several throughout the year.
These panic attack can be brought on by post traumatic disorders, intoxication, and withdrawal from medications or drugs. However, most panic attacks are brought on by stress and anxieties that one goes through every day activities.
Going to the hospital due to a panic attack can lead to very expensive medical bills. You don’t have to suffer anymore from panic attacks. There are safe cures that you can purchase on the Internet that can treat your panic attacks and make them go away for good. The best product that on the market right now that treat and keeps panic attacks from occurring again is known as Panic Away. You can find it right here: Panic Away
Heart Attack Treatment Tips
Heart attack treatment has remained a common talk of the world as there is overall belief that no healthcare delivery facility is ideal for proper management of heart attacks. The good news is that heart attack treatment and prevention are available to people who are ready to adhere to certain precautionary measures.
All said and done, the few most important things one needs to do when ever heart attack symptoms are identified is to give the right first aid to the patient, before any medical assistance arrives. There are some important once we shall discuss. Fist and foremost, the patient needs to relax and come out of stress.
Cayenne strengthens every blood vessel in the body including tiny capillaries that bring nutrients and oxygen to every cell and remove the toxic waste products from the cells. Hot peppers even keep the blood from sticking together preventing dangerous clots.
All of these actions help cayenne prevent heart attacks and strokes. Herbalists agree that hot peppers are the number one herb for the heart.
Your diet can be a big factor in your risk for a heart attack. A diet high in saturated fat and cholesterol can narrow your hearts arteries. Instead eat heart healthy meals with lots of fruits and vegetables and omega 3-fatty acids. Along with diet and exercise, managing stress, and doing things like not smoking and limiting your alcohol intake can assist in the prevention and treatment for a heart attack.
Chest discomfort – this occurs in the center of the chest and may last a few minutes. It feels like uncomfortable pressure, squeezing, fullness or pain. This discomfort may also be mild or severe and it may come and go. Discomfort can also extend to other parts of the body such as both arms, the back, neck, jaw and even the stomach.
Diets control is another noteworthy factor in the cure and treatment of a heart attack. Prescribed diets are those that limit calories. Also the restrictions in sodium and cholesterol intake are very important. The physical educator can work with the dietician in teaching the patient suffering from heart disease the rationale of the diet as well as helping him plan appetising menus that conform to the diet prescription.
In medical terms, a heart attack is called myocardial infarction, since there is no blood supply to the cells of the heart muscle – myocardium. It is also called coronary thrombosis or coronary occlusion. The forming of plaque is called atherosclerosis. This process of plaque building up occurs even from the childhood stage, often in an asymptomatic manner.
Eat healthy in combination with exercise. It is important to eat foods that are low in cholesterol and saturated fat. The in take of omega-3 fatty acids reduces the chances of sudden death. It is also important to eat on time and in small portions. Skipping meals leads to heartburn, which causes unnecessary complications. A low amount of spice, salt and fatty substances ensures a healthier heart.
Before the patient is discharged from the hospital, a treadmill test and angiography is performed to verify if the patient is experiencing pain. A rehabilitation course is prescribed that helps in healing the heart faster. These include lifestyle changes, medication, and tips to lead stress-free lives.
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Heart Attack: Ten Things Everyone Should Know
Article by Lynn Woods
Heart disease is the leading cause of death in North America. Heart attacks happen when a blockage in the heart’s arteries reduces or cuts off the blood and oxygen supply to the heart, damaging the heart muscle within minutes. Because heart attacks are so common and the damage is often fatal or irreversible, it’s vital that everyone know the symptoms and how to react quickly.
1) Chest pain is commonly associated with a heart attack, and it is the most frequently reported symptom. But it may not be severe or “stabbing”. Chest pain often feels more like pressure, tightness or discomfort, which may start slowly and build. The pain is often accompanied by shortness of breath.
2) It’s not unusual for a heart attack to cause pain in other areas of the upper body instead of the chest. The pain may radiate down one or both arms, and be accompanied by a tingling sensation in the wrist or hand. Or it may be felt in the back, shoulders, neck, jaw or even the stomach.
3) Other symptoms of heart attack include unexplained indigestion, nausea, vomiting, weakness, light-headedness, breathlessness, palpitations and breaking out into a cold sweat. These may or may not be accompanied by chest pain or discomfort.
4) Many heart attack victims report feeling anxiety and/or a sense of impending doom.
5) Denial is common in people having a heart attack, especially if they are unfamiliar with the symptoms or the symptoms are mild. Many people having a heart attack minimize the situation and don’t want to go to the hospital or to call 911. Take charge and seek medical help if symptoms persist for more than five minutes – don’t wait for the possible victim to agree.
6) It’s not uncommon to have a heart attack and not know it. The Framington Heart Study followed 4000 men for 40 years, and found that one-quarter of their subjects had a heart attack that went unnoticed until they underwent an annual EKG.
7) Getting treatment within the first hour is crucial. Death and permanent heart damage can often be avoided if heart attack victims are treated within the first hour after the start of symptoms.
Nearly half of all heart attacks occur in people under the age of 65. Five percent occur in people under 40.
9) Women are less likely to survive a heart attack than men. And African American women’s death rates are one-third higher than those of white women. African American women suffer more high blood pressure and diabetes, both risk factors for heart disease.
10) Taking an Aspirin at the first sign of symptoms is a good idea if you’re having a heart attack, but might make things worse if you’re having a stroke, which attacks the brain instead of the heart. That’s because some strokes are due to bleeding in the brain, which may be worsened by taking Aspirin.
People who have suffered, or are at risk of suffering, a heart attack will usually be prescribed medication or a combination of medications such as blood thinners (or anti-platelet medication), cholesterol-lowering medications, and beta-blockers. It’s important to take these medications just as your doctor prescribes them, and for as long as you doctor prescribes.
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10 Myths About Heart Attacks Debunked!
There are a number of myths about heart care and more specifically about heart attacks. We obviously want to stay clear of heart ailments so we carry with us a number of beliefs about things that we consider will either keep us safe from or make us more prone to heart attacks. But many of these may be misguiding or downright wrong. So let us do away with the unnecessary fears and learn what will actually help our hearts.
Below are some common misconceptions that we try to clear for you:
If you are fit you are not prone to heart attacks
Most of our doctors, health magazines and elders stress on the fact that those who are overweight, eat out a lot, or do not exercise are more susceptible to heart attacks. While they are not wrong, those who are thin, do regular exercise and eat proper are not safe from heart attacks either. This is because cholesterol depositions which are the most common cause of clogging of arteries can be present in thin people too. Physical appearance can many times mask an underlying health problem.
Moreover heart problems and heart attacks are also genetic. So if you have a history of heart issues in your family you are likely to get it too. There are also factors like diabetes, high cholesterol or high blood pressure that put you at a risk, no matter your weight. Gender and age also matter. So in spite of how healthy you look or feel, get a check up to ascertain your heart’s health!
It’s easy to recognize the symptoms of a heart attack
While we are pretty used to watching men, in the typical Bollywood movies, clutching their chests and falling down from what is apparently a heart attack, it needn’t come so obviously. The classic symptoms of a heart attack include a heavy feeling in the chest that may be painful. But the heaviness or pain may spread to the left arm, neck, or jaw.
Symptoms include:
Chest pain Pressure, heaviness or tightness in the chest Pain or pressure in the neck or jaw Pain or pressure in one or both arms (especially the left) Shortness of breath Sweating Nausea Pain or throbbing between the shoulder blades
Many people suffer from heart attacks but assume it is only a heartburn or fatigue. When it comes to your heart, it’s important to consult a doctor rather than to self diagnose!
No chest pain means no heart attack
Most of us believe that if we were having a heart attack, it would involve having a chest pain. But as mentioned above recognizing a heart attack isn’t that easy. The classic signs include chest pain but it needn’t really cause chest pain. According to CNN, 40 to 60 percent of all heart attacks are unrecognized by their victims. If you’re having some sort of unusual discomfort in your back, chest or upper arms, whether or not it is in the middle of your back or the middle of your chest, don’t wait until your heart stops; go to a hospital and get a check up done.
Women do not suffer from heart attacks
Since womenin movies do not clutch at their hearts and collapse to the floor it is assumed that women do not suffer from heart attacks. True, women are less prone to heart attacks before menopause due to the presence of estrogen, which protects them from heart attacks, but post menopause women are just as prone to heart attacks as men are. In fact, probably more.
According to statistics: [courtesy Women’s Heart Foundation]
Worldwide, 8.6 million women die from heart diseases each year (including heart attacks), accounting for a third of all deaths in women.Women are twice as likely as men to die within the first few weeks after suffering a heart attack.38% of women and 25% of men die within one year of a first recognized heart attack.
Women have the same symptoms as men have for a heart attack
Women do not usually experience the commonly expected chest pain as men do when they suffer from heart attacks. 71% of women experience early warning signs of heart attack with sudden onset of extreme weakness that feels like the flu – often with no chest pain at all. Nearly two-thirds of the deaths from heart attacks in women occur among those who have no history of chest pain at all. Even if they do experience mild chest discomfort they simply do not perceive it to be a heart attack like men do. So they must get any abnormal pain checked up.
Here are some of the symptoms of female heart attack:
Shortness of breathWeaknessUnusual fatigueNauseaDizzinessAbdominal discomfort that may seem like indigestion
Medical professionals are challenged to respond to women’s milder symptoms, due to insufficient information.
If you have chest pain wait and see if it goes away
If you have a pain in your chest, you definitely must not sit around and wait to see if it goes away. If you’re having significant chest discomfort, shortness of breath, or any other symptoms that suggest a heart attack, call a hospital or any clinic’s emergency number. If you delay treatment when you are having a heart attack you could cause irreparable damage to your heart and it could also prove to be fatal.
You cannot die simply out of fear or severe emotions
It is possible to die of fright, or for that matter grief, anger, joy, or just about any other intense emotion. Though usually victims are older and likely to be in unstable health conditions, even younger people could be so affected. It is possible for a terrifying event to trigger a fatal heart attack.
Multiple scientific studies show that important mind and body connections exist for health in general and cardiovascular health in particular. Your levels of stress and wellbeing are extremely important for your cardiovascular health. Higher stress levels or negative emotions like anger or depression could burden your heart pumping due to release of certain hormones in our blood stream like adrenalin. You should therefore look for ways and means to reduce stress and negative emotions in your lives.
If you are young you will have no heart problems
Though predominantly those who are older are more prone to having a heart attack, it is possible to start developing coronary artery disease as a teenager. People in their 20s and 30s have suffered from heart attacks. A heart-healthy lifestyle needs to begin in the childhood, so that kids don’t develop bad habits that they carry to adulthood. Parents should encourage their kids to exercise, limit time spent in front of the television or computer screen, and partake healthy, well-balanced meals.
Children, who are obese, have high blood pressure or a family history of heart disease are at a higher risk. Also, although rare, some children (usually due to genetic differences) can have unusually high cholesterol and thus an increased risk for heart disease.
Another problem today is the kind of lifestyle that we live. Especially the young working population today lives an unbalanced life with no exercise, a lot of junk food and high stress levels. Not to mention overexposure to technology implements that is proving to harm our lives. For this populatonis it especially necessary to have regular checkups and a conscious effort to maintain a well balanced life.
You feel it’s not a heart problem just stress and anxiety
A sudden spurt in your heart beat at rest is the sign of a deeper problem than just probably your seeing your boss seeing what you were looking at on your computer or the fear of a test result. It is possible that you suffer from an irregular heartbeat that requires medication. Similarly, if you often feel like you’re hyperventilating, it’s easy to brand it as anxiety, but it’s worth considering whether you have a heart problem.
In today’s rushed lives, we think that stress and anxiety are just a part of our lives and must be tolerated. But even if you’re sure that your racing heartbeat is only due to stress, you’re still damaging your heart in the long run. Eventually, a constantly speeding heart will weaken the heart’s ability to pump blood to the rest of the body. Stress reduction techniques like yoga, meditation, massage therapy and relaxing baths are just as important to your heart as a healthy diet and regular exercise.
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Heart Attack Signs
Article by Sven Ullmann
Today, people mistake heart attack for cardiac arrest. The differene between the two is actually very distinct. Cardiac arrest is the medical situation when your heart stopped beating. It does not necessarily mean there is something wrong with your heart. It could be a result of a complication. On the other hand, a heart attack is actually a disorder. Also called acute myocardial infarction, a heart attack is characterized by an interruption of the blood supply to a particular part of the heart resulting to oxygen shortage. The area not receiving sufficient oxygen suffers from tissue damage that could lead to tissue death. This is when a person would be experiencing a heart attack.
Since heart attacks are the leading causes of death worldwide, knowing the signs could mean the difference between life and death. Contrary to some belief, heart attacks do not always have to be a “chest-grabbing” incident. Many people experiencing a heart attack actually thought it was just heart burn or chest muscle pains. And it doesn’t even have to be a one-time discomfort. You can experience recurring symptoms, which may feel mild one day and the next day severe, before an actual heart attack happens. So before you put yourself or your loved ones in serious dangers, here are some heart attack signs to look for.
The most classic heart attack sign is a feeling of discomfort in the middle of the chest. It could be a sudden dull pain that could subside after a few minutes. But remember that this kind of chest discomfort always come back. You may also feel an uncomfortable squeezing, pressure of even fullness aside from the mild to severe pain. This chest discomfort is actually because of the oxygen shortage in the heart muscle. Some pain actually spread to the left arm, lower jaw, back and stomach region.
Another heart attack sign is the sudden shortness of breath. This is because the left part of the heart has limited output, eventually damaging the heart. You will also exhibit other heart attack signs such as sweating, nausea, weakness, vomiting, light headedness and palpitations. Some persons lose consciousness when having a heart attack while others die suddenly.
In females, heart attack signs vary a little. The most common signs include weakness, dyspnea and fatigue. Sleep disturbances are also reported for a period as long as a month before an actual heart attack occurs. Not all persons with heart tissue damage will experience pain or discomfort. In fact, almost 30% of heart attack cases did not exhibit classic chest pain or other heart attack signs. It will only be confirmed after a medical investigation is done,
Individuals at risk of a heart attack are those who have a genetic disposition to it (family history), diabetes, obesity, high blood pressure, high cholesterol levels, high LDL levels and low HDL levels. People, who smoke, drink excessively, eat fatty foods, do not exercise and stressed, are also at risk of having a heart attack. These kinds of habits can be severly damaging to your body, and can ultimately prove to be fatal.