3.3 — Heart Attack and Stroke: Recognising Them Early

Both are treatable, and treatment is dramatically more effective the earlier it starts.

Which means the highest-value skill here is not treatment. It is noticing, and calling, without waiting to be sure.

The most common error in both is delay — people wait to see whether it passes, and it is the waiting rather than the event that does most of the damage.

Stroke

Recognising it

The test is designed to be usable by anybody, in seconds.

FAST:

F — Face. Ask them to smile. Is one side drooping?

A — Arms. Ask them to raise both arms and hold them. Does one drift down?

S — Speech. Ask them to repeat a simple sentence. Is it slurred, or are they using wrong words, or unable to speak?

T — Time. Any one of these — call immediately.

And the extended version, BE-FAST, adds two that are commonly missed:

B — Balance. Sudden loss of balance or coordination.

E — Eyes. Sudden loss or blurring of vision, in one or both eyes.

Other signs: sudden severe headache with no cause, sudden numbness on one side, sudden confusion.

One is enough. You do not need all of them.

What to do

Call immediately — 112 or 108. Say the word "stroke," because it changes the response and the destination hospital.

Note the time symptoms started. This is the single most useful piece of information you can give, because treatment eligibility depends on it. If they woke with it, the time is when they were last seen normal.

Keep them still, sitting or lying with the head slightly raised.

Nothing to eat or drink. Swallowing is frequently affected and the risk of choking is real.

And do not give aspirin for a suspected stroke. **Some strokes are bleeds, and aspirin makes a bleed worse. This is the opposite of the advice for a heart attack and it is why the two must be distinguished.

Why speed matters, and the encouraging part

Treatments exist and they are time-dependent.

Clot-dissolving medication is standard within about 4.5 hours of onset — and recent guidance extends thrombolysis to selected patients between 4.5 and 24 hours where imaging shows brain tissue that can still be saved.

Mechanical clot removal — thrombectomy — is used up to 24 hours after onset in selected patients, again on imaging criteria.

Which is genuinely good news and it is why the time matters so much: the windows are longer than they used to be, and they still close, and a person who arrives at hour two has far more options than one who arrives at hour ten.

And note: getting to hospital does not commit anybody to anything. It gets them assessed, which is what opens the options.

The one that gets ignored

A transient ischaemic attack — a TIA, or "mini-stroke" — has the same symptoms and they resolve, sometimes within minutes.

People conclude it was nothing.

It is a warning, and the risk of a full stroke in the following days is significantly raised.

Treat a resolved episode as urgent. It is one of the few genuine opportunities to prevent a major stroke, and it is routinely missed.

Heart attack

Recognising it

The classic presentation: central chest pain or pressure, often described as heaviness, tightness or squeezing rather than sharp pain, sometimes spreading to the arm, jaw, neck or back, with sweating, nausea, shortness of breath, or a sense of impending doom.

Lasting more than a few minutes, or coming and going.

And the presentations that get missed, which matter more:

Women more frequently present without dramatic chest pain — with shortness of breath, nausea, unusual fatigue, or discomfort in the back, jaw or stomach.

People with diabetes may have little or no pain, because nerve damage blunts it.

Older people may present with confusion, weakness or breathlessness alone.

And a substantial number of heart attacks present as something that feels like indigestion that will not settle.

The rule: unexplained chest discomfort lasting more than a few minutes, or unexplained breathlessness with sweating or nausea, is a heart attack until a hospital says otherwise.

What to do

Call immediately — 112 or 108.

Sit them down and keep them still. Half-sitting, leaning against something, knees bent, is usually most comfortable and reduces the work on the heart.

Loosen tight clothing.

Give aspirin, if available and they are not allergic and not on a doctor's instruction avoiding it. The usual advice is a single dose of around 300 mg, chewed rather than swallowed whole, because chewing speeds absorption.

Aspirin reduces mortality in heart attack and it is one of the few genuinely useful things a bystander can do.

If they have their own prescribed nitrate spray or tablets for angina, help them take it as prescribed.

Stay with them, and be ready to start CPR (3.2), because a heart attack can progress to cardiac arrest.

Do not drive them yourself

The most common error and the most dangerous.

An ambulance starts treatment on arrival, carries a defibrillator, and can take them to the right hospital. A car has none of that, and if the person arrests on the way there is nobody to help.

Why people delay

And this is worth naming because it is the actual killer in both conditions.

People wait for four reasons: they hope it will pass, they do not want to make a fuss, they are not certain, and they are afraid of what it might be.

All four are understandable and all four cost time that cannot be recovered.

The correction is a rule decided now, calmly, rather than in the moment:

Any FAST sign, even briefly: call.

Any unexplained chest discomfort lasting more than a few minutes: call.

And a false alarm is a completely acceptable outcome. Emergency services would far rather attend a hundred false alarms than one call made forty minutes late, and they will tell you so.

The genuinely hopeful part

Because this chapter should not end on fear.

Both conditions have been transformed in the last few decades.

Heart attack mortality has fallen substantially in countries with fast treatment pathways, and a person who reaches hospital quickly frequently has the blocked artery opened within an hour and goes home within days.

And stroke treatment has changed enormously — thrombectomy in particular has produced outcomes that were not available at all twenty years ago, with many patients who would previously have been severely disabled walking out of hospital.

3.8 covers what recovery actually looks like, and it is considerably more encouraging than most people assume.

The variable that decides which outcome you get is time. And time is the one thing a bystander controls completely.

What to do with this page

Learn BE-FAST tonight. Balance, Eyes, Face, Arms, Speech, Time. One sign is enough.

Note the time symptoms started, or when they were last seen normal. It decides what treatment is possible.

Aspirin for heart attack, chewed. Never for suspected stroke.

A resolved episode is a warning, not a reprieve.

And decide the rule now: any sign, call. A false alarm is an acceptable outcome and a forty-minute delay is not.

Next: 3.4 — choking, severe bleeding and burns: three things where a bystander's hands are the treatment.