The First Signs Of Heart Disease Aren’t What You Think...

Added: 2026-05-14

[00:00:00]So, I've seen thousands of heart attacks over the last 10 years. Literally thousands. It's one of the most common things we see in the A&E. But the thing about heart disease is that it doesn't always look or present the way that most people would assume. And I say this because most of the people I diagnose with some form of heart disease weren't expecting it. Most patients don't get the crushing chest pain or the dramatic collapse. just, you know, a normal Tuesday morning where the stairs feel a bit harder than they did 6 months ago or a bit of an odd sensation in the chest or the neck. That's it. That is often how heart disease generally starts. And most people put this down to something else without a second thought. So what I want to talk about today is that gap the years between when cardiovascular disease begins and when it announces itself loudly enough that somebody calls an ambulance. And that gap is enormous.

[00:01:01]And what fills it isn't silence. It is signals. Really important signals that are quiet, easy to rationalize, and almost universally ignored until it's too late. And I've watched this play out more times than I can count. And if you want more of a reason to actually believe what I'm saying, then trust me when I say that we actually have a lot of health care professionals who come to the A&E and don't recognize their own heart symptoms. And indeed, my own dad many, many years ago when he was about 40 years old actually had a heart attack and didn't recognize it at the time. And he's a paramedic. So, you know, even the most clued up people don't always recognize these symptoms. So, what I'm going to talk about in this video is really, really important to understand as you get older. A lot of people picture heart disease as like a blocked pipe where rubbish builds up and the fluid can't get through and the pump sort of breaks. And that's not entirely wrong, but it misses the starting point by almost a decade, sometimes more than that. The real story begins at the inner lining of your blood vessels. So, think of your arteries almost like a garden hose pipe. The water that flows through that is your blood, but the coating on the inside of that hose is an incredibly thin living layer of cells called the endothelium. And this layer does something remarkable. It constantly produces a molecule called nitric oxide, which acts as almost like a built-in relaxant for your blood vessels. It keeps them soft and flexible and importantly open. It damps down inflammation. It tells the vessel wall to stay calm. Now, imagine that you're running that hose with really hot, sugary, slightly corrosive water for years and years. Well, that lining will get rougher. It will degrade. It will produce less nitric oxide. So, the host pipe will stiffen. And once that lining is damaged, the body's immune system starts responding to the injury. It starts sending cells to the vessel wall that eventually contribute to the fatty plaques that we associate with heart disease. And here's the thing that should make you pay attention to this.

[00:03:28]This process, the early sort of degrading of that vessel lining can be detectable on imaging a full decade or more before anything clinically happens.

[00:03:40]So that's 10 years at least of silent change before a heart attack. And during all of that time, you feel completely fine. Now, when the blood vessels that the heart is actually pumping against start to stiffen, the heart doesn't give up. It adapts. It works harder. The muscle starts to thicken in the same way that your bicep will grow when you lift heavy things repeatedly. Now, initially, that keeps everything ticking over nicely. But a thicker hard is less efficient. It needs more oxygen per beat. And crucially, it starts to struggle with the relaxation phase, the moment between beats when the heart fills back up with blood. So try and think of this like a sponge. So a healthy heart muscle squeezes and then springs back open easily, drawing blood into the heart. But a thickened, stiff heart muscle squeezes, okay, but it doesn't spring back as well. So filling that heart becomes a bit sluggish. And when you exert yourself and your body suddenly demands more blood flow, the heart simply can't keep up. And this is one of the most underdiagnosed early stages of cardiovascular disease. And this doesn't show up on a routine ECG.

[00:04:59]It won't be caught in a standard GP check, but it shows itself in daily life in the moments where effort suddenly feels a bit harder than it used to. And there's a second thing happening simultaneously as well. So the arteries that feed the heart muscle itself, the coronary arteries, they supply blood during the relaxation phase between those beats. So if those arteries have early narrowing from plaque and the heart is also beating harder and faster because it's working against stiffer vessels, then the math, you know, sort of starts going wrong. The heart is demanding more oxygen but getting slightly less. And that doesn't cause a heart attack. Not yet. But it creates a kind of chronic quiet oxygen debt that the heart silently adapts to. And that adaptation has big consequences down the line. Now the early symptoms of cardiovascular disease are well pretty boring to be honest. They are the symptoms of a busy week or being a bit out of shape or getting older. And that is exactly what makes them dangerous. So take tiredness for example. And I'm not talking about the exhaustion after a long run. I mean the unusual fatigue after climbing just one flight of stairs, after walking from the car to the supermarket entrance or carrying their shopping bags from the car into the house. And people will notice this somewhere quietly. They know it is different from how they used to feel, but quite often they don't say anything because what are they going to say? Oh, I just got a bit tired walking upstairs.

[00:06:34]To a lot of people it will sound ridiculous but not to us, not to doctors who are actually listening to you. So, you know, it goes unreported and we don't hear about these symptoms. And then we've got breathlessness as well.

[00:06:47]And the key word here is new breathlessness. Not breathlessness that you've had your whole life from being sedentary, but a change, something that used to be easy becoming effortful. And sometimes this is one of the ones that I find most striking. You know, people start sleeping with an extra pillow without really consciously deciding to.

[00:07:08]They just sort of find themselves more comfortable slightly upright. Now, medically that has got a name. It's called orthopia. And it happens because when you lie flat, fluid that has been pooling in your legs during the day redistributes towards your chest and puts pressure on the lungs. In an emergency department, that is a big red flag for heart failure. And that is something a little bit different to the heart disease we've just talked about, but let's just include it anyway. In somebody's house is just a new pillow preference. It's just an extra pillow, but to us that means something. And then we've got a gradually rising resting heart rate as well. Most people have no idea what theirs is and have never really tracked it. But a slow upward creep from a stable baseline in the 60s to a persistent reading in the mid to high 70s or 80s can reflect the heart working a bit harder just to maintain normal output. And research, interestingly, has consistently linked elevated resting heart rate to a higher risk of cardiac event like a heart attack or cardiac arrest independent of other risk factors. And this is something you can track really easily just by getting a cheap fitness watch.

[00:08:26]You don't need an expensive Garmin, just anything for 20 or 30 quid that measures your resting heart rate. Another symptom of heart disease is ankle swelling in the evening as well. Nothing dramatic or painful, just a slight sort of puffiness by late afternoon, which happens because the body is retaining fluid as the heart isn't circulating blood quite efficiently enough. And it gets attributed to a long day on your feet or hot weather or a new medication. And then finally, waking in the night feeling a bit uncomfortable or short of breath. though this isn't from, you know, a nightmare or needing to use the toilet, just an unsettled quality to your sleep that wasn't there before.

[00:09:07]Now, none of these symptoms alone is a diagnosis. But when several of these symptoms are presenting together, especially in somebody over the age of 50 with high blood pressure or carrying excess weight around the middle or not sleeping well, that cluster of symptoms is telling a very important story and we need to be thinking about heart disease here. The thing is one of the most important conversations I have is with patients who are surprised like I mentioned earlier. So these are people who have a normal weight. They don't have a diagnosis really. Their bloods came back fine at the last check. They consider themselves to be healthy. And yet insulin resistance, which is the metabolic dysfunction that can precede type 2 diabetes by years or decades, can exist long before your blood sugar comes back abnormal enough to flag on a standard test. And insulin resistance, it drives a hormonal environment that is genuinely toxic for your blood vessels.

[00:10:05]Elevated circulating insulin acts directly on your vessel walls. It promotes inflammation and accelerates the kind of changes that we've been talking about in this video. This is happening in people who have no idea. It is an epidemic at the moment. It is people whose GP has told them that their blood tests are normal. Now, if you pair that with really bad sleep, and the research on this is really quite interesting, then you're compounding the problem significantly. So during deep sleep, your blood pressure naturally dips. That is what should happen normally anyway. The cardiovascular system gets a bit of a rest overnight.

[00:10:45]So if your sleep is fragmented or short or really poor quality, that natural dip doesn't happen. The heart essentially never really fully recovers overnight.

[00:10:58]Now, studies across large populations have shown that people sleeping under 6 hours have significantly higher rates of heart attack and stroke. And the relationship is consistent across different countries and ethnicities and different age groups as well. And clearly this is a really important association. And from my experience, not many doctors seem to tell their patients this. Now, the reason I find all of this quite hopeful, and I genuinely do find this hopeful, despite working in a department where it's full of the consequences of ignoring this stuff, is that the window for changing this trajectory is really big. You know, it's years wide. Aerobic exercise is the most evidencebacked tool that we have for restoring your vessel health. And when you do sustained rhythmic movement like walking briskly or cycling or swimming or rowing, the increased blood flow creates mechanical friction against the blood vessel wall, which is actually a signal that tells the endothelium, that inner lining, to produce more nitric oxide. And studies have shown this happening within weeks of starting exercise, not months or years, but weeks. The biology is more responsive than most people expect.

[00:12:15]Alongside that, reducing refined carbohydrates, not necessarily cutting them out entirely, but meaningfully reducing them, lowers your circulating insulin. It reduces your sympathetic nervous system activation, and it directly reduces the hormonal load on the vascular system. And the other thing, and this is important, is that the mechanism here isn't primarily about losing weight because somebody can be relatively lean and still be carrying significant metabolic risk from a high sugar, high refined carb diet. The other important thing is to monitor your own blood pressure at home. This is something I recommend to all of my patients over the age of 50. Well, to be honest, even younger than that. Anybody who's an adult, in my opinion, should be monitoring your blood pressure. And you shouldn't be relying on your doctor for this either because a validated home monitor used a couple of times a week gives a far more accurate picture than just one reading a year taken at the doctors. The other thing is to take your sleep really seriously. This is a cardiovascular intervention. Sleep is so important for your health and addressing obstructive sleep apnea if it's present and your doctor can do some sleep studies if you've got concerns. So if you wake up in the morning with a really bad head or if you snore really loudly or you never feel sort of truly well-rested, then sleep apnea could be a diagnosis that's being missed here. So after all of that, let me just say that cardiovascular disease is not inevitable. I know it gets presented that way, something that happens when you get older or something to be managed and to be expecting as well. That framing, that sort of picture of cardiovascular disease costs lives. The biological cascade that ends in heart attack or heart failure almost always starts quietly and it unfolds over years and decades. It passes through a very very long window where the signals are present, the biology is still reversible and intervention absolutely works. Now the patients that I see in recess, these people had years of prior signals. There are always always signs and symptoms that present that very often people aren't aware of. And very often they just weren't given a framework to understand what they were noticing like the tiredness on the stairs or that extra pillow or the slightly puffy ankles. The heart rate that used to sit at 65 and now it's 75. These are not the background noise of getting older. They are the cardiovascular system asking very quietly for attention. And unlike a lot of things in medicine, when you give it attention early on, the outcomes are genuinely