Heart attack warning signs and what to do in the first minutes to save a life

What are the warning signs of a heart attack?

The best known sign of a heart attack is pain, pressure, heaviness or squeezing in the centre of the chest that lasts more than a few minutes, or goes away and comes back. The pain may spread to the arm, especially the left, or to the neck, jaw, back or upper stomach. It often comes with shortness of breath, a cold sweat, nausea or vomiting, a pale face, and an odd sense that something is badly wrong.

If you or someone near you has these signs, do not wait to see whether they pass. Call an ambulance now, and finish reading this page afterwards if you want to. A heart attack (myocardial infarction) happens when one of the coronary arteries that feed the heart muscle becomes blocked, and part of the muscle starts to die. Every minute before the artery is reopened means more heart muscle lost for good.

The trouble is that many people in our region explain the pain away as something else: a chill in the stomach, trapped wind, indigestion after a heavy family meal, or tiredness from work. So they take a painkiller or a cup of aniseed tea and wait for morning. That delay is the most dangerous part of the whole story, because the treatment that reopens the artery works best in the first hours.

Keep one simple rule for yourself and your family. Any chest pain you cannot explain that lasts more than five minutes is treated as a heart attack until a doctor proves otherwise. Going to emergency and finding out it was indigestion costs you nothing, while staying at home with a heart attack can cost a life.

What does heart attack pain feel like?

Many patients describe the pain as a heaviness, as if someone were sitting on their chest, or a tight band, or an intense burning in the middle. It is rarely a sharp, needle-like pain in one small spot you can point to with a finger. More often it is spread out, so people show it with the flat of their hand. It may not even be very severe, and that is what fools people, because a heart attack does not always look like the television version where someone suddenly collapses clutching their chest.

Chest pain remains the most common symptom in both men and women. A 2019 study in the Journal of the American Heart Association followed 1,941 patients who arrived at emergency with a suspected heart attack, and found that chest pain was the presenting symptom in 91 percent of men and 92 percent of women. So chest pain is the rule, but there is an important minority who come with other symptoms.

The symptoms that come with the pain matter as much as the pain itself. A heavy cold sweat without heat or effort is a sign to take seriously, especially alongside pain in the chest or upper stomach. So are sudden breathlessness, dizziness, feeling faint, and intense fear with no obvious reason.

Pay attention to timing too. Pain that comes on with effort, such as climbing stairs or walking fast, and settles with rest may be angina, an early warning that the arteries are narrowed. If the pain starts while you are resting, carries on despite rest, or starts coming with less effort than usual, that is more serious and needs emergency care.

Heart attack symptoms without chest pain

Some people have a heart attack without obvious chest pain, and they are the ones most likely to be treated late. Most of them are women, people with diabetes, and older adults. They may feel sudden extreme tiredness with no explanation, breathlessness, nausea and vomiting that they put down to food poisoning, or pain in the jaw, between the shoulder blades or in the upper stomach.

Women in particular sometimes have symptoms that are easy to dismiss. The Global Registry of Acute Coronary Events (GRACE), published in Heart in 2009 and covering more than 26,000 patients, found that men and women presented with chest pain at similar rates, but jaw pain and nausea were more frequent in women. Many mothers bear these symptoms quietly, finish the housework, and do not ask for help because they do not want to trouble anyone.

People with diabetes may have nerve damage from years of high blood sugar that dulls their sense of pain, so a heart attack can pass with mild pain or almost none. If you have diabetes, or someone in your family does, take sudden breathlessness, unusual severe tiredness or a cold sweat more seriously, even without pain.

Older people may also show a heart attack as sudden confusion, general weakness, or a fall. If a grandparent suddenly changes for no clear reason, do not assume it is just old age, and get medical help.

What should I do in the first minutes?

The first and most important step is to call your country's ambulance number, not a relative who is a doctor and not the local pharmacy. Give the call handler your exact address and say the person has chest pain and you suspect a heart attack. Open the front door or send someone to the building entrance or the street to guide the ambulance, especially in neighbourhoods where streets have no clear names.

Help the person sit in a comfortable position with their back supported, and do not let them walk around or climb stairs. Loosen tight clothing at the neck and chest, and reassure them calmly. Do not give them food, and do not make them drink lots of water or herbal tea.

Aspirin can help slow the growth of the clot, but give it only if the emergency call handler advises it, and check that the person is not allergic to aspirin and has not been told by their doctor to avoid it. The call handler decides whether it should be chewed and how much. If a doctor has already prescribed the person a spray or tablet under the tongue for angina, they can use it as their doctor showed them.

If the person collapses and stops breathing normally, start pressing hard and fast on the centre of the chest, and ask the call handler to guide you step by step. If there is an automated external defibrillator (AED) nearby, as in some shopping centres and airports, send someone to fetch it immediately, because it talks you through what to do.

Why you should not drive yourself to hospital

In our region the usual way to reach hospital is the family car or a taxi. It feels faster, but it takes away important things. Ambulance crews can record an electrocardiogram (ECG) at home or on the way, give oxygen and medicines, deal with a cardiac arrest if it happens, and phone ahead so the catheter lab team is ready before you arrive.

The Gulf Registry of Acute Coronary Events (Gulf RACE) studied patients in 65 hospitals in six Arab countries in 2007. Of 7,859 patients who came in through emergency, only 17 percent used an ambulance, ranging from 2 percent in Yemen to 37 percent in Oman. Those who arrived by ambulance were less likely to have a major delay and received their ECG and artery-opening treatment sooner.

A 2020 study in the Saudi Medical Journal of 200 patients at the Madinah Cardiac Center found that the median time from the start of symptoms to arrival at hospital was 3.7 hours, and 63 percent arrived more than two hours after their symptoms began. Arriving by ambulance was one of the factors linked with less delay.

Driving yourself puts you and everyone else on the road at risk, because you could lose consciousness or develop a dangerous heart rhythm at the wheel. If there is no ambulance service where you live, or it would take far too long, have someone else drive you straight to the nearest hospital with an emergency department, not to a private clinic or a small health centre.

Why does every minute count?

When an artery is blocked, the heart muscle cells it supplies start dying within a short time, and the damage spreads the longer the blockage lasts. That is why cardiologists say time is muscle. A heart whose artery is opened quickly keeps its pumping strength, while a heart treated late may be left with lasting heart failure that limits the person's life for years.

There are two main ways to reopen a blocked artery. The first is cardiac catheterisation with balloon angioplasty and a stent, done in hospitals that have a catheter lab. The second is a clot-dissolving drug given into a vein, usually used when catheterisation cannot be reached quickly. The 2011 Gulf RACE comparison in the American Journal of Cardiology noted that most eligible Gulf patients received clot-dissolving drugs, while most patients in the global registry had a catheter procedure.

Doctors call the time between you reaching the hospital door and the balloon opening the artery the door-to-balloon time, and hospitals set themselves short targets for it. But that clock only starts once you arrive. The hours spent at home hesitating cannot be made up by any hospital, which is why the most important decision in saving a heart is made at home, not in the hospital.

At the hospital you will have an ECG straight away and a blood test for troponin, a protein that leaks from damaged heart muscle. The test may be repeated a few hours later for comparison. Read our guide to the troponin test to understand why doctors repeat it and why having it done at a private lab is not enough.

Do young people have heart attacks in the Middle East?

Yes, and more often than many people expect. A 2011 study in the American Journal of Cardiology compared 6,706 patients from the Gulf registry with 4,445 patients from the global registry, and found that the average age of Gulf patients was 56 years against 66 in the global registry, nearly a decade younger. Gulf patients were also more likely to have diabetes and to smoke.

In Oman, a study within the same registry analysed 1,579 patients and found that 7.6 percent were aged 40 or under. Among these young patients, 47 percent smoked compared with 15 percent of older patients, 72 percent were obese, and a family history of heart disease was more than twice as common. Every emergency doctor in the region recognises the picture: a man in his thirties or forties who smokes cigarettes or shisha, carries extra weight, and whose father or uncle had an early heart attack.

So do not tell yourself you are too young for a heart attack. If you smoke, have diabetes, high blood pressure or high cholesterol, or have a relative who had a heart attack before 50 or 60, any chest pain deserves the emergency department whatever your age.

The good news from the same study is that younger patients did better after treatment. Getting a young person to hospital quickly saves decades of working and family life, not only their life on that night.

Is it a heart attack, heartburn or a panic attack?

Heartburn, strained chest muscles and panic attacks can all cause chest pain. The difference between them and a heart attack cannot be told reliably at home. Even doctors only decide after an ECG and a troponin test, and sometimes after repeating both.

Do not rely on popular rules such as pain that eases after burping or an antacid cannot be the heart. Some heart attacks feel exactly like indigestion, and pain can ease for a while for any reason and then return. Likewise do not assume that an anxious person is only having a panic attack, because anxiety and a heart attack can happen together.

Safety lies in the simple rule: if you are not sure, go to emergency. Nobody will blame you if it turns out to be heartburn. And do not go to a private lab for a troponin test and then wait at home for the result, because a single early test can be normal even when a heart attack has just begun.

If you have repeated chest pain and have been to emergency more than once without a heart problem being found, ask your doctor for follow-up to pin down the cause, whether it is the stomach, the muscles or anxiety. But do not let past visits stop you going again if the pain changes in character or gets worse.

Early warnings before a heart attack, and how to protect your heart

Many patients remember afterwards that they had warnings days or weeks before: chest tightness on walking that went away with rest, unusual tiredness, or breathlessness on effort that used to be easy. These symptoms can mean an artery is narrowed and deserve a doctor's visit within a few days, not months. If they start coming at rest or worsen quickly, that is an emergency.

What protects your heart most is something everyone knows but few people do: stopping smoking in every form including shisha, controlling blood sugar, blood pressure and cholesterol, walking most days of the week, and losing excess weight. If you are over 40, or have a family history, ask your doctor for regular checks of blood pressure, blood sugar and blood fats.

If your doctor has prescribed medicines for your heart, blood pressure or cholesterol, keep taking them and do not change them on your own. If a medicine is troubling you, talk to your doctor so they can find a suitable alternative. Many patients in our region stop their medicines once they feel better, and that is one reason heart attacks recur.

Finally, teach your family these signs, and write your country's ambulance number on a piece of paper next to the phone or on the fridge. In a moment of panic people forget the simplest things, and a number written in front of them can save precious minutes.

Sources

• Awad HH, Zubaid M, Alsheikh-Ali AA et al: Comparison of characteristics, management practices, and outcomes of patients between the global registry and the gulf registry of acute coronary events, The American journal of cardiology, 2011
• Fares S, Zubaid M, Al-Mahmeed W et al: Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States, The Journal of emergency medicine, 2011
• ALAhmadi AF, ALSaedi MF, Alahmadi AE et al: Pre-hospital delay among patients with acute myocardial infarction in Saudi Arabia. A cross-sectional study, Saudi medical journal, 2020
• Panduranga P, Sulaiman K, Al-Zakwani I et al: Acute coronary syndrome in young adults from oman: results from the gulf registry of acute coronary events, Heart views : the official journal of the Gulf Heart Association, 2010
• Ferry AV, Anand A, Strachan FE et al: Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria, Journal of the American Heart Association, 2019
• Dey S, Flather MD, Devlin G et al: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events, Heart (British Cardiac Society), 2009
• NHS: Heart attack