Chest pain: what to do in the first hour
Most chest pain is not a heart attack. But the treatment for the ones that are works best in the first sixty to ninety minutes, and almost every delay we see is caused at home, not at the hospital.
Heart muscle dies by the minute. Knowing which pain to take seriously, what to do while waiting, and — above all — not driving yourself, is the difference between a recovered heart and a permanently weakened one.
In the treatment of a heart attack there is a phrase we use constantly: time is muscle. From the moment a coronary artery blocks, the heart muscle it supplies begins to die, and it keeps dying until the artery is opened. Restore flow within the first hour or two and most of that muscle survives. Restore it after twelve hours and a good deal of it does not, permanently.
Which means the most important decisions in a heart attack are usually made by a family in a sitting room, long before anyone in a hospital is involved. This article is about those decisions.
What a heart attack tends to feel like
It is often not the clutching, dramatic chest pain of films. The commoner description is duller and vaguer, which is exactly why it gets explained away as gas or indigestion.
- Pressure, tightness, heaviness or squeezing in the centre of the chest — many patients describe a weight sitting on them
- Lasting more than a few minutes, or going away and coming back
- Spreading to the left arm, both arms, the jaw, the neck, the upper back or between the shoulder blades
- With cold sweat, nausea or vomiting, breathlessness, or a sense of dread that the person cannot account for
- Brought on by exertion or stress, and eased by rest — that pattern in particular deserves attention even when each episode is brief
What to do, in order
- Stop what you are doing and sit down. Do not walk it off, do not finish the task, do not go and lie down alone in another room.
- Call for help immediately — an ambulance, or a family member who can drive you. Say the words 'chest pain'; they change how you are triaged on arrival.
- Chew a plain aspirin — not the enteric-coated kind if a plain one is available, and chewed rather than swallowed whole, because it acts faster. Skip this if you are allergic to aspirin, have been told not to take it, or are actively bleeding.
- Loosen tight clothing and stay still. Do not eat or drink anything else.
- If you have been prescribed a nitrate spray or tablet for angina, use it as instructed.
- Gather the medicine boxes and any previous ECG or reports into a bag while waiting. This saves real time at the other end.
“Do not drive yourself. If you lose consciousness at the wheel, you have turned a survivable heart attack into a road accident with two casualties.”
And do not wait to see whether it settles. The commonest thing we hear from patients who arrived six hours late is that they thought it was gas and were waiting for it to pass. Arriving at an emergency room with indigestion costs you an evening and an ECG. Arriving late with a heart attack costs you heart muscle you do not get back.
If someone collapses
If a person is unresponsive and not breathing normally, start chest compressions immediately: heel of the hand in the centre of the chest, hard and fast, about twice a second, letting the chest come fully back up between compressions. Do not stop to check for a pulse repeatedly, and do not stop until help arrives. Hands-only compressions done imperfectly are far better than nothing done perfectly.
The causes that are not the heart
Most chest pain we assess turns out to be muscular, acid reflux, anxiety, or inflammation of the rib cartilage. Reflux burns and comes with an acid taste; muscular pain is tender to press on and changes with movement or position; anxiety-related pain often comes with tingling in the hands and rapid breathing.
But none of those distinctions is reliable enough to use on yourself for a first episode. Getting an ECG and being told it is your stomach is a completely acceptable outcome — the reassurance is worth the visit, and we would far rather see fifty cases of reflux than miss one infarct.
Afterwards
If you have had a heart attack or been diagnosed with angina, the medicines you are discharged on — antiplatelets, statins, beta blockers, blood pressure drugs — are not a temporary course. Stopping an antiplatelet early after a stent can block that stent, which is a genuinely dangerous event. Bring every box to your follow-up and we will go through what each one is for, because a medicine you understand is a medicine you keep taking.
If you get chest tightness on exertion that settles with rest, do not wait for something worse. Book an assessment this week — that pattern is often the warning that precedes an event, and it is the most treatable point in the whole story.
Dr. Sarah Aslam
Consultant Cardiologist, MBBS, FCPS (Cardiology)
Written and clinically reviewed by the team at Aslam Clinic. Every article is checked by a practising clinician before it is published.
Questions about this?
Message us on WhatsApp and talk it through with a clinician.
