Almost nobody dies of not knowing the symptoms of a heart attack. People die of having an explanation — indigestion, a pulled muscle, stress, being too young — and spending two hours on it.

Your explanation, and what it does not cover

Choose the explanation you have already reached for — everybody has one — and then mark what is actually happening. Nothing is saved and nothing leaves the page. If somebody is unresponsive or not breathing normally, stop reading and call the emergency number: 112 in Europe.

Where the two hours actually go

• The explanation arrives before the symptom is finished. The mind reaches for the most recent plausible cause — the meal, the lifting, the argument — and then spends the next hour collecting evidence for it instead of testing it. This is not stupidity; it is how everybody reasons under threat.
• It does not look like the films. People expect sudden crushing pain and a collapse. What most heart attacks actually do is build over minutes to an ache, a pressure, a heaviness, with sweating and nausea — and something that builds gradually reads as something benign.
• Not wanting to make a fuss is the commonest single reason. Interviews with survivors return to it again and again: not wanting to waste an ambulance, not wanting to be wrong in front of the neighbours, waiting for a spouse to come home so as not to bother anybody.
• Symptoms that come and go get read as symptoms that are gone. An artery closing and opening again produces exactly that pattern, and the gap in between is when people decide it was nothing.
• The wrong number gets dialled. Ringing a GP surgery, an out-of-hours line or a relative adds a triage step for a condition where the correct destination is an ambulance, and every one of those steps was measured in the studies of delay.
• Somebody drives. A car has no monitor, no oxygen, no aspirin and no defibrillator, and a quarter of the deaths happen before hospital, mostly from a rhythm that a crew standing next to you can shock.

What it actually feels like, which is the part nobody is taught

• Pressure rather than pain. A weight, a tightness, a band, a fullness, a vice; often described with a fist rather than a fingertip. It is frequently called discomfort rather than pain by the person having it, which is one reason the word "pain" on a phone call is misleading.
• The reach. Jaw, teeth, throat, neck, either arm — not only the left — the wrist, the upper back between the shoulder blades, the upper stomach. A heart attack that presents as toothache or as indigestion is not rare or exotic.
• The company it keeps. Sweating, nausea, vomiting, breathlessness, a grey colour, an overwhelming sense that something is badly wrong. Those features do more to separate a heart attack from a benign explanation than the pain does.
• Sometimes no chest symptom at all. Breathlessness, exhaustion, sudden collapse of stamina, confusion in an older person, vomiting, or simply feeling terrible. Commoner in women, in diabetics and over seventy — the same groups that then wait longest and are treated latest.
• Brought on by effort, relieved by rest. That pattern, at any intensity, is angina and it is the warning that precedes many heart attacks by days or weeks. It is also the single most useful thing you can say on the phone.
• Not a heart attack: a stopped heart. If somebody is unresponsive and not breathing normally, that is cardiac arrest, and the answer is the emergency number and chest compressions immediately, not a page about explanations.

The things people treat as an all-clear, which are not one

• "It eased off." Arteries close, open a little and close again. Easing off is what it does mid-event, and the gap is the window in which treatment works best, not proof the event has finished.
• "The antacid worked." Antacids relieve cardiac pain often enough that emergency departments treat a response to one as meaningless. The same goes for a glass of milk, a burp, or being sick.
• "I had a normal tracing last year." A tracing is a picture of one moment. A normal one from any moment other than this one says nothing about now — and even during a heart attack, the first tracing can be normal, which is why they repeat it and take blood.
• "I am too young or too fit." Age moves the odds, not the presentation, and it is precisely why younger people are sent home from emergency departments with a diagnosis of muscular pain. Cocaine, heavy smoking, a strong family history and pregnancy all bring it forward.
• "There is no chest pain." A third arrive without it. In a diabetic, nerve damage blunts the signal, and the presentation may be nothing but breathlessness, sweating or exhaustion.
• "I can press on the sore spot." A tender chest wall makes muscular pain more likely and does not exclude anything, because somebody with a strained muscle can also be having a heart attack. Tenderness is a point in favour, not a discharge.
• "The doctor on the phone said it was probably indigestion." Nobody can rule this out on a telephone, and no clinician who was there in person would try without a tracing and a blood test. If the symptoms are current, the phone call is 112, not a triage line.

What to do in the first ten minutes, in order

• Call the ambulance. 112 in Europe. Not a taxi, not the GP, not a relative first, and not the internet. If the symptoms are happening now, that call is the treatment starting.
• Stop and sit down. On the floor with something behind the back is better than a chair somebody might fall off. Standing, walking to the car and carrying anything all cost heart muscle.
• Aspirin, chewed, unless you were told not to. Three hundred milligrams — one adult tablet or two low-dose ones — chewed rather than swallowed whole. Skip it if there is a known allergy, if a clinician has said not to, or if the person is not fully alert. It is one of the few things a bystander can do that measurably saves lives.
• Unlock the door, and put the phone on speaker. Then find the medicines list, or the box, and put it by the door. Both take a minute and both save the crew several.
• GTN if it is prescribed. One dose, sit down, and again after five minutes. If it is still there after the second dose, that is the moment the leaflet itself says to call, and it is the answer to "is this just my angina".
• Be ready to do compressions. If they stop responding and are not breathing normally: hard and fast in the centre of the chest, and let the call-taker count for you. That is the part that decides survival if the rhythm goes.

What people believe, and what is so

The drill: 16 explanations

Sixteen ordinary evenings — the man who had a big meal before the tightness started, the woman told it was a panic attack, the runner who is too young for this, the person whose angina spray has stopped working. Each one has a benign explanation that fits well enough to buy an hour. Pick the move; every answer explains why.

The card

Print it and put it inside a kitchen cupboard door. The point of a card is that it works when the thinking has gone.

🖨️ Print the card