23.4 — Recognising a Heart Attack and a Stroke

In a large-vessel stroke, around 1.9 million neurons die every minute that treatment is delayed.

Each hour of delay ages the brain by roughly 3.6 years.

And in a heart attack, heart muscle begins dying within 20 to 30 minutes of the artery blocking, with the amount of muscle saved falling steeply for every hour that passes.

Both conditions have treatments that work extremely well and only if they arrive in time.

Which makes recognition — by the person themselves, or by whoever is standing there — the step that decides the outcome.

And in both, the commonest reason for delay is not transport. It is the person deciding to wait and see.

Heart attack

What is happening

A plaque in a coronary artery ruptures. A clot forms on it and blocks the artery (Chapter 18.3).

The heart muscle downstream is starved of oxygen and begins to die.

Time is muscle. Muscle that dies does not regenerate — it is replaced with scar, which does not contract. Which is why someone treated in 90 minutes may have near-normal heart function and someone treated at 12 hours may have heart failure for life.

The symptoms

Chest pain or discomfort — the classic presentation.

Central, described as pressure, tightness, heaviness, squeezing or a band around the chest. People frequently say "like an elephant sitting on me" or hold a clenched fist to the chest — a gesture so characteristic it has a name.

Frequently not described as pain at all, which is why asking "do you have chest pain" can get a "no" from someone having a heart attack. Ask about discomfort, pressure or tightness.

Radiating to: the left arm, both arms, the jaw, the neck, the back between the shoulder blades, or the upper abdomen.

Lasting more than 15 to 20 minutes, and not relieved by rest.

With any of: sweating — often profuse and cold; nausea or vomiting; breathlessness; light-headedness; and a sense of impending doom, which sounds dramatic and is a genuine and frequently reported symptom.

And an important discriminator: angina eases with rest and with glyceryl trinitrate within a few minutes. A heart attack does not.

The presentations people miss

And these matter enormously, because they account for a large share of deaths from delay.

Women are more likely to present without classic chest pain — with breathlessness, unusual fatigue, nausea, back or jaw pain, or indigestion-like discomfort.

Women are more likely to have their symptoms attributed to anxiety or indigestion, more likely to delay calling, and have worse outcomes as a result. This is a documented pattern, not a theoretical concern.

People with diabetes may have a silent heart attack, because nerve damage blunts the pain (Chapter 20.6). Presenting instead with breathlessness, confusion or collapse.

Older people — frequently present with breathlessness, confusion, weakness or a fall rather than pain.

And a heart attack presenting as indigestion is common enough that new severe indigestion, particularly with sweating or breathlessness, in someone over 40 or with risk factors, should be treated as cardiac until proven otherwise.

What to do — exactly

1. Call an ambulance immediately.

Say clearly: "I think this is a heart attack. There is chest pain." Those words prioritise the call.

Do not drive to hospital. An ambulance carries an ECG, defibrillation, oxygen, drugs and trained staff, and — critically — it can take the person directly to a hospital with a catheter laboratory rather than the nearest one. People have arrested in the car park of a hospital they drove themselves to.

2. Sit them down, in a comfortable position.

The recommended position is sitting up, leaning back at roughly 45 degrees, with knees bent — often described as the W position. It reduces the work of the heart and eases breathing.

Do not let them walk about.

3. Give aspirin 300 mg, chewed.

Unless they are allergic to it, or have been told not to take it.

Chewed, not swallowed whole, because it is absorbed far faster through the lining of the mouth.

And this genuinely matters: aspirin in the early phase of a heart attack reduces mortality by around 20 percent. It blocks platelets from adding to the clot (Chapter 22.5). It is one of the highest-value actions a bystander can take, and it costs pennies.

If they are already on daily low-dose aspirin, still give the 300 mg.

4. Their own glyceryl trinitrate spray or tablets, if they have them and have used them before.

Under the tongue. It may relieve the pain; it does not treat the blockage.

Do not give it if they have taken sildenafil or a similar drug for erectile dysfunction in the last 24 to 48 hours — the combination causes a catastrophic drop in blood pressure.

5. Keep them calm and warm, and stay with them.

Loosen tight clothing.

6. Be ready to start CPR.

Around a third of heart attack deaths occur before reaching hospital, mostly from an arrhythmia in the first hour. If they collapse and stop breathing normally, start compressions immediately (Chapter 23.2).

7. Gather their medication and note the exact time symptoms started.

That time determines which treatment they are eligible for. It is one of the first things the hospital will ask.

What happens next

In hospital: an ECG within 10 minutes, and blood troponin — a protein released by dying heart muscle.

A STEMI — the pattern showing complete artery blockage — goes straight for primary angioplasty, where a catheter is passed to the blockage, a balloon opens it and a stent holds it open.

The target is under 90 minutes from arriving to the artery being opened, and under 120 minutes from the first medical contact.

Where angioplasty is not available in time, clot-dissolving drugs are given instead.

And outcomes have improved dramatically over three decades — hospital mortality from heart attack has fallen substantially — almost entirely because of speed.

Stroke

What is happening

Two kinds (Chapter 18.6):

Ischaemic — around 85 percent. A clot blocks an artery in the brain.

Haemorrhagic — around 15 percent. A vessel bursts and bleeds into or around the brain.

They look identical from outside, which is why a scan is done before any treatment — giving a clot-busting drug to someone with a bleed would be catastrophic.

And this is exactly why "wait and see" is never right: the person on the scene cannot tell which it is, and both need the hospital urgently.

Recognising it — FAST

The test is designed to be usable by anyone, and it catches the large majority of strokes.

F — Face. Ask them to smile or show their teeth. Has one side of the face fallen? Has the mouth or eye drooped?

A — Arms. Ask them to raise both arms and hold them there with eyes closed. Can they keep both up, or does one drift down or fall?

S — Speech. Is their speech slurred? Are they using wrong words? Can they understand you? Ask them to repeat a simple sentence.

T — Time. Time to call an ambulance immediately. And note the time symptoms started.

Any one of the first three is enough. You do not need all of them.

What FAST misses

And this is worth knowing, because around 1 in 7 strokes does not produce facial droop, arm weakness or speech disturbance.

Posterior circulation strokes — affecting the brainstem and cerebellum — present with:

Sudden severe dizziness or vertigo with inability to walk or stand.Double vision or sudden loss of vision.Sudden severe unsteadiness and incoordination.Sudden severe headache with vomiting.Difficulty swallowing.

Other presentations: sudden confusion; sudden numbness of the face, arm or leg on one side; sudden loss of vision in one eye; and a sudden severe headache with no cause, which suggests bleeding.

The extended version some services use is BE-FAST — adding Balance and Eyes to the front.

And the general rule that catches everything: any sudden neurological symptom is a stroke until proven otherwise. Sudden is the word. Stroke symptoms arrive over seconds to minutes, not hours.

What to do — exactly

1. Call an ambulance immediately. Say the word "stroke".

That word triggers a specific pathway — pre-alerting the hospital, taking the person straight to a scanner, and in many systems routing them to a specialist centre rather than the nearest hospital.

2. Note the exact time symptoms started, or the time they were last seen well.

This is the single most important piece of information you can give.

Because treatment eligibility depends on it: clot-busting thrombolysis is generally given within 4.5 hours of onset; mechanical thrombectomy — physically removing the clot with a catheter — within 6 hours routinely and up to 24 hours in selected patients with modern imaging.

If someone wakes with symptoms, the time last seen well is bedtime, not waking. Say that clearly, because advanced imaging can now identify some of these patients as still treatable.

3. Do not give anything to eat or drink. Not even water, and not aspirin.

Swallowing is frequently impaired in stroke, and anything given can go into the lungs (Chapter 9.1).

And aspirin is dangerous here — if it is a bleed, aspirin makes it worse. This is the key difference from heart attack, where aspirin is the right answer. Heart attack: give aspirin. Stroke: do not.

4. Lie them down with the head and shoulders slightly raised, supported.

If they are unresponsive but breathing, use the recovery position, lying on the affected side if you can, so the good side is uppermost.

5. Loosen tight clothing, keep them warm, and stay with them.

6. Do not let them go to sleep to see how it is in the morning.

That sentence is included because it is what actually happens in a large proportion of cases, and it is where the treatment window is lost.

TIA — a transient ischaemic attack

Stroke symptoms that resolve completely, usually within an hour.

And the mistake is treating this as a relief rather than as a warning.

Around 1 in 10 people who have a TIA will have a full stroke within a week, and the risk is highest in the first 48 hours.

A TIA is not "a small stroke that got better". It is an emergency warning that a stroke is coming, and urgent assessment and treatment substantially reduces that risk.

Anyone with resolved stroke symptoms needs same-day medical assessment.

What happens next

Immediate brain scan.

For an ischaemic stroke: thrombolysis with alteplase or tenecteplase, and thrombectomy for large-vessel blockages.

And thrombectomy is one of the most effective interventions in modern medicine. In the right patient, the number needed to treat for one person to be functionally independent instead of dependent is remarkably low — around 3 to 5. Few treatments anywhere are that good.

For a haemorrhagic stroke: reversing anticoagulation, controlling blood pressure, and neurosurgery in selected cases.

Then a stroke unit — and simply being cared for on a specialist stroke unit improves survival and independence measurably, independent of any specific treatment.

And rehabilitation, which continues for months and produces genuine recovery, because the brain reorganises around the damage.

Two comparisons worth holding

	Heart attack	Stroke
Give aspirin	Yes, 300 mg chewed	No
Position	Sitting, leaning back	Lying, head slightly raised
Food or drink	No	No — swallowing unsafe
Key information	Time pain started	Time last seen well
Word to say	"Chest pain"	"Stroke"

And the thing both have in common: the person almost always waits too long.

The median delay from symptom onset to calling for help is measured in hours for both conditions. People wait to see if it passes, they do not want to make a fuss, they think it is indigestion, they wait for a partner to come home, they go to bed.

If you take one thing from this page: the correct response to a possible heart attack or stroke is to call immediately, and being wrong about it costs nothing at all.

What the next page fixes

Chapter 23.5 covers anaphylaxis and severe asthma attacks — two emergencies that can kill within minutes, and where a bystander with an auto-injector or an inhaler is the treatment.