This is a good, tough question. There’s the quick answer, and then there’s the longer version/message. Let’s start simple, and then go through the process of ruling out a heart attack.
First and foremost, the only way to know if you are having a heart attack is to be evaluated in an emergency room.
There’s no way around this. If you feel like you’re having a heart attack for any reason, then you need to go to an ER as soon as possible. DO NOT DRIVE YOURSELF. If you truly believe you are having a heart attack, then driving on the road could be more dangerous than driving drunk. If you lose consciousness, then you are now potentially going to kill someone else on the road. Call 911 or have someone else drive if you think you’re having a heart attack, and get to an ER as soon as you can.
What is a Heart Attack?
Simply put, it’s when blood flow to your heart is blocked in at least one place. Your heart is basically the hardest working muscle in your body, and it needs a constant supply of blood to provide it with oxygen to live, electrolytes for proper electrical conduction, and other nitty gritty elements found in your blood that I won’t cover here. If blood supply is cut off to your heart, the muscle starts to die. The larger the supply of blood cut off to your heart, the more likely the heart attack is to be lethal.
A good way to describe a heart attack is to compare it to choking. Let’s say you give a friend of yours named Art a large gumball because you’re feeling nice and generous. And since you’re in such good spirits, you also tell Art the best joke he’s ever heard in his life. Unfortunately, Art starts laughing before he gets a good bite into that gumball and accidentally inhales it. The gumball lodges in Art’s airway between his throat and his lungs, and Art can no longer breathe. Art is choking.
If Art were an artery (he’s named “Art” on purpose—tee-hee) leading back to your heart, you’d be having a heart attack. The gumball would be the clot and Art’s lungs would be the heart tissue not getting oxygen. Get it? Good, because Art is totally going to die if we don’t help him out right away.
Lucky for Art, you know the Heimlich maneuver (now mostly called “abdominal thrusts”), and you get to it fast. A couple of thrusts later, the gumball flies out and Art can breathe again. (If you don’t know what the Heimlich maneuver, sign up for a first aid class right now and learn CPR and basic life-saving skills. Seriously. It’s easy and the world would be a little bit safer if everyone took the time to actually learn these skills. YOU CANNOT LEARN THEM FROM TV SHOWS. ACTORS GIVE TERRIBLE CPR.)
Art thanks you for saving his life, but, remembering that you both gave him the gumball and told him the joke, he decides to spend the rest of the day away from you.
What Art experienced would be a simple version of a major heart attack. If a large artery to your heart gets blocked off completely and suddenly, you are going to have some awful, insufferable symptoms, if not sudden death. Not every heart attack is reversible, unfortunately. Sometimes that gumball gets lodged in there really well and no one is around to perform the Heimlich. It’s sad, but it unfortunately happens.
As for the rest of the types of heart attacks, there is hope and potential treatment. And the only way to capitalize on modern medicine’s ability to help you survive a heart attack is to get yourself evaluated at an ER as soon as possible.
But…What are the Signs and Symptoms of a Heart Attack?
This is where it gets a little muddy. Of course, chest pain is a sign of a heart attack. But there are a lot of different vessels of different sizes around your heart, and depending on which vessel is blocked off, as well as all sorts of other factors of which we aren’t completely aware, everyone can experience different symptoms of a heart attack.
Generally speaking, the larger the vessel being blocked off, the more likely you are to have major symptoms. Or not. Everyone is a bit different, and there are a lot of different ways people experience heart attacks. Some get the classic pressure and pain in the middle of their chest that radiates down their left arm, other people feel like they are having some mild indigestion. Men and women typically present with heart attack symptoms differently, and women’s symptoms are typically more subtle. (Or perhaps men are just more likely to complain about their pain—am I right, ladies? I’m not in this case, though. Just making a joke. This is a heart attack, not the man-flu.)
Considering the fact that there are different types of heart attacks that can present differently in every single person and might vary in their symptoms depending on the person’s sex, the list of possible symptoms of a heart attack kinda look like a frustrating entry from WebMD. (I HATE WebMD, by the way. This will be a future topic. For now, just do us all a favor and do NOT go to WebMD. EVER. Please?) The (incomplete) list is as follows:
- Chest pain, pressure, tightness, discomfort, squeezing, or any other way to describe “My chest doesn’t feel normal, and it keeps not feeling normal.”
- Pain in any area around or near your chest—arms, neck, back, jaw, stomach—with or without the chest pain
- A feeling of being short of breath, whether you are having chest pain or not.
- Nausea with or without vomiting
- Sweating (usually a cold sweat)
- Dizziness or lightheadedness
- And all sorts of other things that could be a sign of a heart attack, which you can read in articles here and here.
Doesn’t that list suck? If you spend enough time staring at it, you can totally think, “Oh man, I just coughed once…am I having a heart attack?”
Relax. I’m not here trying to add to the information on the internet that brings people into ER’s unnecessarily. Usually, there is a combination of the symptoms above and they come on rather rapidly. Of course, if you have concerns, then get yourself to an ER as soon as possible. But if you only started having the symptoms after reading the list of symptoms, I’m thinking you’re having anxiety, and I’m sorry I triggered yours. And if you’re prone to anxiety, it’s probably best if you don’t hunt down signs of life-threatening events on the internet. Put the internet down and walk away. And please, avoid WebMD at all cost. In order to cover their tails, they basically say everything could be a sign of death. Including and not limited to a cough. (Yes, I seriously hate WebMD.)
The main thing to keep in mind, if you are seriously concerned about ever having a heart attack, is your risk factors. Age, of course, is a risk factor. The older we get, the more likely it becomes that our bodies will kill us spontaneously. That’s just the hard truth. And yes, genetics seem to play a big role in heart attack risk. If you have any direct family members who have experienced and/or died from a heart attack, that increases your risk of having one considerably. It might seem like poor luck to get genetics like that, but without them you wouldn’t exist, so stop complaining.
The rest of it is really mostly controllable. If you are overweight, eat a terrible diet, and don’t ever exercise, then you are more likely to have a heart attack. Smokers definitely have a higher risk, as do drinkers. If you have other diseases or health problems related to circulation, then your odds of having a heart attack are higher. The most common health problems increasing risk are high cholesterol, high blood pressure, diabetes, lung disease, and so on. In the business, we call these health problems “comorbidities” for a reason.
But chances are, if you’re reading this article and feel fine, you are fine. But maybe, if you’re concerned about your risk of heart attack now, get out there and make a change. You can start by taking a CPR class.
Full disclosure: I have my own risk factors to work on, so I’m not judging in any way.
What will you do to me in the ER to Rule OUt a Heart Attack?
To best describe this, I need a patient.
Poor Art. He’s having a really crappy day. First, some jerk makes him choke on a gumball, and now he’s having chest pain. He thinks it may be anxiety-related, seeing as how he nearly died earlier today, but since his dad died of a heart attack, he’s not taking any chances.
Art is 25 years old, so he’s not high risk. He’s also a fit fellow with no other major medical history. He has no prescribed medications. When he arrives at the ER, he sees that it’s busy. Part of him considers leaving, since he’s pretty sure it’s not a heart attack, but he decides it’s better safe than sorry, plus he got his poor mom to drive him here and she’s too worried to let him go home anyhow. The healthcare professional at triage (the front desk) hears that Art is having some mild to moderate mid-sternal chest pain. Art denies any shortness of breath, any pain radiating anywhere else, or other symptoms. He offers his negative health history but includes the family incidence of a heart attack on his father’s side.
The first thing to do in most ER’s when someone complains of chest pain is to get a basic set of vital signs and an EKG as soon as is feasible for however busy the ER is. But just know that not all chest pain is going to make the staff run around screaming in panic.
This is okay, and it even makes sense. Let’s say there’s a line of people behind Art all waiting to come back. Everyone is line is complaining of chest pain. Some look like Art, but then there’s an elderly lady on oxygen breathing heavily in a wheelchair, unable to walk without losing her breath. There’s also a guy sweating profusely and white as a ghost. Since they’re all complaining about chest pain, I take them back in the order they arrived, right?
Art and the people like him look fine and are acting fine. The woman and the man need to be seen first. In fact, the triage person asks the healthy-looking people to step aside for a moment so they can get the woman and the man who are in high distress back to be seen as soon as possible. This is smart. It doesn’t happen often that people are asked to cut in line, but it does happen. Triage is an art form, and the people working it are some of the hardest working and wisest medical professionals around, and they’re tough as nails—or, at least, they should be, because they are going to get yelled at a lot. In fact, another young man gives the woman doing triage a lot of gruff about being cut in line, as he is having chest pain, too. He is doing well, though. Same as Art. But Art trusts the process and waits for his turn to be seen.
Because it’s an incredibly busy day and the triage person had to take two people back immediately, both of whom were experiencing life-threatening heart attacks, Art has to wait for a bit before being called back for vital signs. He’s still being patient. He knew he was in for a wait walking into an ER. “If I’m waiting, that means I’m doing better than most of the other people here,” Art says to himself. Art is wise, and he’s a good man, making me feel particularly bad about that whole gumball incident.
After about fifteen minutes, Art is called back for vital signs and a second round of triage. His blood pressure, pulse oximetry, pulse rate, respiratory rate, and temperature are taken (If you want some good background info on these, check out my previous post about the monitors), and they are all within normal limits. It’s a good start.
After waiting a little longer, Art is called back again for a 12-lead EKG. This is a great diagnostic tool, and it’s one of the central assessments in diagnosing a heart attack. A 12-lead is basically a picture of a heart’s electrical activity taken from several different angles. If a portion of the heart is in distress, it will change the pathway of electrical conduction, and these changes can be seen on a 12-lead EKG. The 12-lead is a detailed test, far more detailed than basic continuous cardiac monitoring at the bedside when the wires stay on your chest the entire time.
The process of taking a 12-lead is fairly simple. The operator puts your patient information into the machine, and then they place the stickers onto your body for connecting the machine’s wires. This requires chest exposure, just so you know. There are six stickers that have to go on your chest. Two to the left and right of the center of your chest, another sticker below the sticker to the left, and then three more going underneath the left breast area. I am always respectful with women and give them a heads up about the sticker placement. In most cases, bras can stay on. But if the bra is a sports bra or it takes up extra real estate on the chest that would get in the way of proper sticker placement, then it might have to come off. This is rare, but it happens. Just to clarify why, I’ve included a picture of EKG placement stickers here.
And for men, keep in mind that the stickers have to be able to keep in contact with the skin. So…this might require a spontaneous shave. Deal with it, though. This shave might save your life. You’re there to be evaluated for a life-threatening condition, after all. Don’t let some chest hair get in the way.
The four other stickers go on (or near) the four extremities. There are several possible placements, and different people use different sites. Some go with the wrists and the ankles, some go with the shoulders and upper thighs. There is not really a wrong way, as long as these stickers are symmetrically and consistently placed. For those of you cringing about an extremity sticker being placed on an upper thigh, I guess you’ve never done a 12-lead on an amputee.
After the stickers are all carefully arranged, the proper wires are attached to them. Don’t worry, the wires are there to receive electrical activity from your body—you do not get shocked during an EKG. Once all of the wires are attached, the next part is mostly, AHEM, the responsibility of the patient.
I can’t tell you how many times I’ve taken an EKG and asked a patient to be still and silent, and they decide that this is the best time to talk about EVERYTHING ON THEIR MIND.
Don’t be that person. The 12-lead EKG is important as hell. Don’t mess with that test. Be as still as possible and DO NOT TALK during that test. Why? We’re reading electrical signals that are really rather precise. So just do us and modern medicine a favor and stop moving and talking for five, maybe ten, damn seconds.
Art was a great patient. He stayed perfectly still and remained silent during his 12-lead. The lines on the paper were without any of the artifact (wobbly thick lines from movement and other outside factors) that makes reading the damn things far more difficult than necessary. His result was that his heart is in what we call a normal sinus rhythm, which is perfect. This gives all the healthcare personnel around him a great breath of relief, as the charting has become a lot more simple—er, I mean…he’s going to be okay. We’re fairly sure, at least.
This normal 12-lead EKG result just eliminated almost all of the major cardiac events. At the very least, it made the likelihood of Art experiencing a cardiac event that would result in sudden death incredibly minimal. This is great news, but it unfortunately means that Art can wait longer in the waiting room. There are still no beds, and Art’s condition is considered to be stable.
“If I’m waiting, that means I’m doing better than most of the other people here,” Art says to himself once more. And now I love Art to pieces. What an understanding guy.
Finally, after waiting ever so patiently, Art is called back. he gets a room with a tiny, uncomfortable cot. The nurse puts several pieces of equipment on him: a blood pressure cuff on his arm, a pulse oximetry probe on his finger, and five stickers on his chest connected to wires to monitor his heart rhythm in real time. (Once again, for more info on this stuff, read my post on monitors.) The stickers for continuous cardiac monitoring are purely for heart rate and real-time observation of any rhythm changes. The 12-lead is more accurate, but basic cardiac monitoring is still great, as well as essential, in a chest pain patient.
The doc orders some basic medications to give Art for his chest pain (which Art says is a 3/10. If you want some info about the pain scale, I wrote a little something for ya). In most standard sets for treatment of chest pain, a full dose of aspirin (324 milligrams) is given once, and up to three tablets of nitroglycerin are given sublingually (to dissolve under the tongue) five minutes apart to help resolve the chest pain. (Then maybe some Tylenol to help with the headache nitroglycerin gives most people.)
Other medications might be given for different circumstances, but these are two standard medications given to help with chest pain that is otherwise not symptomatic. Medications are a slippery slope that can result in a long, long post (this one is already quite long), so I’ll take a pass this time and promise to do posts about medications sometime in the future. For now, I’ll keep the descriptions to basic procedures.
The next step is everyone’s least favorite: the IV start. (I will definitely cover this in greater detail in the future, don’t worry.) An IV placement in a chest pain patient is standard. If something goes wrong, having an IV placed can be the difference between life and death. With an IV, we can give essential medications immediately. Plus, in the ER at least, when we start an IV we can use that to get your initial blood work. That means only one poke (hopefully) and two tasks accomplished. Hooray, right?
“I…um…I don’t like needles,” says Art.
Bless his soul. Of course he doesn’t like needles. He’s sane. If he looked his nurse in the eye and said “I love needles!” His nurse would consider adding on a psychiatric evaluation. So, yeah, Art’s nurse gets it. But the blood work is essential in ruling out anything potentially life-threatening. So, being a good patient, Art holds still while the nurse (or it could certainly be a medic) starts his IV and gets the initial blood work. Despite hating the entire process, Art does as he’s told and everything goes well. He now has an IV placed and the blood work is going back to the lab.
“So…what are they looking for in the blood?” asks Art. Great question.
I won’t cover all of the different blood tests here, but let’s touch on the main one in terms of ruling out a heart attack causing chest pain in a healthy young man with a normal 12-lead.
Basically, troponin is a type of protein that helps with muscle contraction. It shouldn’t be in your blood in high amounts, and if it is, the likely source is from damage to heart muscle cells. They typically elevate within four hours of heart damage and the persist in the blood for up to 14 days, making them a good indicator of heart distress.
Art’s 12-lead was normal and his troponin level came back as normal, so the doctor feels fairly confident that Art did not have a heart attack. However, considering Art’s family history and the fact that it can take up to four hours for troponin to show up in the blood, the ER doc asks Art to stay for another blood draw for a second troponin level three hours after the first one was taken. Wanting to play it safe, Art agrees.
So, what does Art have to do during this time while he waits? He just has to be patient. And he shouldn’t have anything to eat or drink, just in case he ends up needing an invasive procedure. Since Art knows this, he doesn’t bug the nursing staff to “sneak him something,” as wanting to be snuck food is basically saying you don’t believe or trust the staff at the place you came to for emergent care. (Seriously. No one is actually starving in the ER more than the staff working, so stop asking.)
When the three hours is up, more blood is taken from Art, and then he has to wait another 40 minutes or so for the result. Thankfully, after Art waits patiently, he finds out that the troponin level is still normal. Had Art had more risk factors or had been older, the doc might have suggested he be admitted for further observation, but in this case, the doc is fine with letting Art go home, as long as he makes an appointment to follow-up with a cardiologist. Art is happy to do so, and is discharged home feeling much better.
Some doctors would still insist on Art being admitted for observation. Just listen to your ER doc and discuss a plan with them if you ever find yourself in this situation.
What about after discharge?
After going to the ER for chest pain, definitely see a cardiologist. It doesn’t frankly matter that we ruled out most life-threatening things in that moment—you had an event that you thought was a problem with your heart and the ER sent you home telling you to talk to a heart specialist, SO DO THAT.
I can’t tell you how many times I’ve had patients come in for recurring chest pain, AKA: patients we saw recently for the same thing, and when we ask if they followed up with their cardiologist, they say, “Oh, I thought you guys found that everything was alright, so I decided not to.” NO. We told you that your life wasn’t at risk at that moment. That’s our specialty: EMERGENCIES. You weren’t found to be having an emergency, so you were sent home. Because we don’t actually specialize in hearts, we told you to make an appointment with a heart specialist. Of course we will see you and treat you again, but we will have to start the above process all over from the beginning. And when we discharge you, WILL WILL, ONCE AGAIN, TELL YOU TO MAKE AN APPOINTMENT WITH A CARDIOLOGIST.
Art did make an appointment with a cardiologist. They decided what testing was right for making sure Art’s heart was in great condition. Art and his cardiologist created a health plan together for avoiding any future cardiac problems. Art really is a great, stand-up kinda guy.
I really feel bad about that whole gumball thing.
Have a question for the nurse? Ask here.
Who am I to give advice? Your answer is here.
And, of course, feel free to leave a comment. I’m okay with being corrected or engaging in conversation.
American Heart Association information on heart attacks: https://www.heart.org/-/media/data-import/downloadables/pe-abh-what-is-a-heart-attack-ucm_300314.pdf?la=en&hash=B0B06F4C5D26295179CD8BD1B05204585CBBEBF1
Mayo Clinic information on heart attacks: https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106
A series of cartoons on how to perform the Heimlich maneuver in different positions, just in case you’re too lazy to take a class on basic lifesaving skills: https://www.wikihow.com/Perform-the-Heimlich-Maneuver
A list of classes you can take to save a life one day, just in case you aren’t lazy and care about being prepared to help a fellow human some day: https://elearning.heart.org/courses?utm_source=google&utm_medium=cpc&utm_term=aha%20cpr%20classes&utm_campaign=Brand%20-%20Heartsaver&gclid=CjwKCAjw7_rlBRBaEiwAc23rhvCyCg63DLoM6VEd-S0vg9QSLO5xwtzr6DzLa8QVEr_JouUFxFiXyRoC–gQAvD_BwE
A basic explanation of troponin: https://labtestsonline.org/tests/troponin#