When a heart attack doesn’t look like the textbook picture
World Heart Day takes place on 29 September. Its 2026 message, “Don’t Miss a Beat”, is a useful reminder that a heart attack does not always look like the dramatic scene people expect.
Some people experience severe central chest pain and collapse. Others remain conscious and describe pressure, heaviness, tightness, indigestion, breathlessness or simply feeling profoundly unwell.
I can speak with first hand experience on this one. Seven years ago, I was at home alone on a Sunday afternoon. I was in the kitchen doing some baking. I began to feel unwell. Nothing specific, just very restless and a general feeling of unease.
I couldn't settle. I tried sitting down and lying down but couldn't get comfortable and couldn't stay still for more than ten seconds.
Thankfully, having started my career in cardiac nursing, as well as having an acute awareness of family history of heart disease in my paternal line, I didn't leave it long before I called an ambulance. They duly attended, confirmed a MI with ST elevation, and promptly whisked me off to the local hospital where I was taken immediately to the catheter lab and had three stents inserted.
By the time my family arrived from around 90 minutes drive away, I was being transferred to recover in the coronary care unit (the very same unit where I had worked as a newly qualified staff nurse in 1993!).
For adult social-care staff, the important skill is not diagnosing a heart attack. It is recognising that the symptoms could be cardiac and calling 999 without waiting for a textbook picture to develop.
WHAT IS A HEART ATTACK?
A heart attack usually happens when the blood supply to part of the heart muscle becomes blocked. Without enough oxygen, heart muscle begins to suffer damage.
This is different from cardiac arrest. During a heart attack the person is usually conscious and breathing, although they may deteriorate. In cardiac arrest the person is unresponsive and not breathing normally. They need immediate CPR and an AED.
A heart attack can cause cardiac arrest, which is why early recognition, a prompt 999 call and continued monitoring matter.
THE “CLASSIC” SYMPTOM
Chest pain or discomfort is the most commonly recognised warning sign. The person may describe:
- pressure, heaviness, tightness or squeezing in the chest
- a band-like feeling across the chest
- burning or discomfort resembling indigestion
- pain that spreads to one or both arms
- discomfort travelling into the neck, jaw, back or upper abdomen
The pain may be severe, but it does not have to be. Some people describe discomfort rather than pain.
LESS OBVIOUS WARNING SIGNS
Other symptoms can include:
- breathlessness
- sweating or cold, clammy skin
- nausea or vomiting
- dizziness, light-headedness or feeling faint
- sudden weakness or overwhelming tiredness
- anxiety, fear or a strong sense that something is wrong
- discomfort in the jaw, back, shoulders, arms or upper abdomen
- sudden collapse
The person may have several symptoms or only one. Symptoms can also come and go.
OLDER PEOPLE AND PEOPLE WITH DIABETES
The NHS notes that a heart attack without obvious symptoms—a “silent” myocardial infarction—is more common in older people and people with diabetes.
That does not mean every vague symptom is a heart attack, or that chest discomfort is unimportant. It means that the absence of severe chest pain must not be used to dismiss a sudden, unexplained change.
In somebody who communicates differently, possible clues may include:
- becoming suddenly pale, sweaty or distressed
- stopping an activity or meal without explanation
- clutching or rubbing the chest, arm, jaw or upper abdomen
- unexpected breathlessness at rest
- new agitation, withdrawal or unusual quietness
- repeatedly saying they feel unwell, frightened or “not right”
- a sudden and unexplained reduction in mobility or alertness
These signs have many possible causes. Staff should avoid labelling them as indigestion, anxiety or ageing without appropriate assessment.
CALL 999 IMMEDIATELY
If you suspect a heart attack, call 999 for an ambulance. Tell the call handler that you suspect a heart attack and describe the symptoms.
Do not:
- wait for severe chest pain to appear
- wait to see whether the symptoms settle
- call NHS 111 instead when a heart attack is suspected
- drive the person to hospital yourself
- leave them alone
- delay the emergency call while taking observations or completing paperwork
The ambulance service can begin assessment and treatment on the way to hospital and can respond if the person deteriorates.
WHILE WAITING FOR THE AMBULANCE
Help the person stop what they are doing and rest in a comfortable position. Many people find a supported, semi-sitting position easier than lying flat.
Then:
- reassure them and keep the environment calm
- loosen restrictive clothing if necessary
- stay with them and watch for deterioration
- follow the 999 call handler’s instructions
- arrange access for the ambulance team
- gather the current medicines list, allergies, care information and emergency treatment plan
- ask somebody to bring the AED if one is available nearby
Do not give food or drink unless the emergency call handler advises otherwise.
ASPIRIN AND PRESCRIBED GTN
UK guidance recommends a single 300 mg dose of aspirin, chewed, for suspected acute coronary syndrome unless there is clear evidence of aspirin allergy.
In a social-care setting, follow your first-aid training, organisational procedure and the 999 call handler’s instructions. The emergency call must come first. Aspirin must never delay calling 999 and should only be offered when the person is conscious and able to chew and swallow safely.
The 300 mg emergency dose is not the same as assuming that somebody’s usual low-dose aspirin is sufficient.
If the person has their own prescribed glyceryl trinitrate—GTN—support its use only in accordance with the prescription, care plan, staff training and emergency advice. Do not use somebody else’s medicine.
IF THE PERSON BECOMES UNRESPONSIVE
Check breathing immediately.
If they are not breathing normally:
- Make sure 999 has been called.
- Start CPR immediately.
- Send somebody for an AED and use it as soon as it arrives.
- Continue following the call handler’s instructions until help takes over.
Agonal gasps are not normal breathing. If you are unsure, tell the call handler exactly what you can see and hear.
If the person is unresponsive but breathing normally, follow the call handler’s instructions, maintain their airway and continue monitoring.
GIVE A USEFUL HANDOVER
Emergency documentation must never delay the call, but accurate information helps the ambulance team.
Be ready to give:
- the exact symptoms and the person’s own description
- the time symptoms began or the last time they appeared well
- whether symptoms were sudden, intermittent or worsening
- relevant diagnoses, including heart disease and diabetes
- current medicines and allergies
- any prescribed GTN or aspirin taken, including dose and time
- observations if these were obtained by trained staff without delaying help
- the person’s normal baseline and any communication needs
SBARD can help organise the handover:
Situation — State that a heart attack is suspected and describe the immediate symptoms.
Background — Give relevant diagnoses, medicines, allergies, previous angina or heart attack and the person’s normal baseline.
Assessment — Explain what changed, when it began, associated symptoms and any observations already obtained.
Recommendation — State that 999 has been called and identify any immediate support needed.
Decision — Record the emergency advice, action taken, ambulance outcome and subsequent care arrangements.
Do not allow the structure of SBARD to slow an emergency call. The situation can be stated in one clear sentence first.
HEART ATTACK OR ANGINA?
Someone with diagnosed angina may have an individual plan for chest pain and prescribed GTN. Follow that plan, but remain alert to symptoms that are different, more severe, occur at rest or do not respond as expected.
If you suspect a heart attack, or are uncertain whether the symptoms are angina or a heart attack, call 999. Do not allow previous indigestion, anxiety or angina to create false reassurance.
THE PRACTICAL MESSAGE
Not every heart attack begins with dramatic pain or collapse.
If somebody develops possible heart-attack symptoms, call 999 immediately, help them rest, follow emergency instructions and be ready to begin CPR and use an AED if they become unresponsive and stop breathing normally.
Do not wait for the “classic” picture. Early action can save heart muscle—and lives.
For me, if I had hesitated whilst alone, I may not have been here to write this article and do the job I love.
Safe Skills Training provides practical first-aid, clinical-skills and patient-safety training for adult-social-care teams and other workplaces. To discuss training for your organisation, visit www.safeskillstraining.com.
GUIDANCE AND FURTHER INFORMATION
World Heart Federation: World Heart Day
https://world-heart-federation.org/world-heart-day/
NHS: Heart attack
https://www.nhs.uk/conditions/heart-attack/
NHS: Coronary heart disease symptoms
https://www.nhs.uk/conditions/coronary-heart-disease/symptoms/
NHS: When to call 999
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-call-999/
NICE: Recent-onset chest pain of suspected cardiac origin
https://www.nice.org.uk/guidance/cg95/chapter/recommendations
Resuscitation Council UK: The ABCDE approach
https://www.resus.org.uk/library/abcde-approach