Unusual fatigue and sleeplessness might be early warning signs of a heart attack in women, a study suggests.

The study, published Monday in the American Heart Association journal Circulation, surveyed 515 women who had heart attacks and found that 95% had such symptoms as much as a month before they were stricken.

Chest pains can be early indicator of a heart attack, but 43% of the women in the study said they never experienced chest discomfort, said researcher Jean C. McSweeney.

The study is the first time researchers have identified fatigue and sleeplessness as possible early warning signs of a heart attack in women.

"If we can get women to recognize the symptoms early, we can get them treatment and prevent or delay a heart attack," said McSweeney, a professor at the University of Arkansas for Medical Sciences in Little Rock. "That's why the early symptoms are significant."

The researchers said they do not know whether the findings also apply to men, who tend to have somewhat different symptoms when a heart attack strikes.

The study surveyed women ages 29 to 97 who had been released four to six months earlier from five hospitals in Arkansas, North Carolina and Ohio after suffering a heart attack. They were shown a list of 70 symptoms they may have experienced during the months leading up the heart attack and were asked to rate them based on frequency and severity.

Almost all the women ?a 95% ?a said they had new or different symptoms more than a month before the heart attack that went away afterward.

The most common symptoms reported were unexplained or unusual fatigue, 71%; sleep disturbance, 48%; shortness of breath, 42%; indigestion, 39%; and anxiety, 35%. Only 30% said they experienced chest pain before the heart attack.

The women had more than just ordinary fatigue and sleeplessness.

"The fatigue is unexplained and unusual. They are more tired at the end of the day then they usually are," McSweeney said. "For some, it's so severe that they can't make a bed without resting as they tuck the sheets. It interferes with their normal activities."

The study emphasizes the need to educate patients and doctors about early warning signs, McSweeney said.

"Heart disease is the No. 1 killer of women, yet women are more afraid of breast cancer. They don't realize heart disease is the thing they need to fear," she said.

Dr. Nieca Goldberg, a cardiologist at Lenox Hospital in New York, said the study could change the way doctors practice.

"If doctors are aware of the early warning signs, they will be more likely to accurately diagnose and take care of the problem before a heart attack and it could lead to better heath care for women," Goldberg said.

Goldberg said woman often are not accurately diagnosed because they may not have the classic symptoms seen in men. Those symptoms include pressure in the center of the chest that radiates down the arm or neck.

In contrast, women in the study described aching, tightness and pressure in the back or high chest.

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