The center of your chest feels like it’s being clamped in a vice, and tightly squeezed. You’re short of breath. Sweat drenches your clothing. Nausea grips you, as does a premonition of doom. The pain from your chest radiates into your arms and jaw. You’re scared and know you need immediate medical attention. When a friend calls 911 you’re instantly grateful. Waiting in a chair by the front door, panting slightly, you hope the paramedics will get there in time.

This is what a heart attack can feel like.

But is a heart attack the only thing this could be? Is this the only way a heart attack can feel? Should you drive yourself to the hospital or call 911? How is a heart attack diagnosed? What exactly is a heart attack? What’s going to happen next?

You’re filled with questions.

This article will answer many, if not all, of them.

Why should you read this? What are my credentials?

I’m an Emergency Physician — an “ER Doc” — who spent 37 years in the medical field before retiring in mid-2020. About a third of those years were spent in the private sector directly caring for patients, many of whom were having heart attacks. The other two-thirds of my career was in the academic/university sector, still caring for patients but also researching, writing, and teaching. In particular, I taught medical students and young doctors in training, teaching them how to be better doctors.

I’ve cared for hundreds of patients with heart attacks and many thousands more with symptoms suggesting a heart attack that turned out to be something else. Also, I’ve cared for many people whose symptoms were unlike the classic description above, but still, it turned out that they too were having heart attacks.

What is a heart attack?

Let’s break down “myocardial infarction,” the precise medical term for “heart attack.”

Myo = muscle (made up of cells)

Cardial = referring to the heart

Infarction = death

Putting this all together, a heart attack or myocardial infarction is the “death of cells that make up heart muscle.”

How common are heart attacks?

Roughly 1,000,000 to 1,500,000 Americans have heart attacks each year. About one-third of these individuals die.

How does a heart attack usually happen?

The heart is a muscle made up of cells. Just like other muscles, the heart’s muscle cells depend on a steady supply of oxygen from the bloodstream to live and function properly. And just like other muscles, open blood vessels are necessary for the heart’s muscle cells to receive blood and oxygen. When one of these blood vessels is blocked, heart muscle cells die. Heart muscle cell death is a heart attack or myocardial infarction.

A blood clot in an already-narrowed blood vessel that supplies heart muscle is the usual cause of a heart attack.

What happens in the United States and in many places in the world when you go to the hospital concerned that you’re having a heart attack?

You see someone just like me, an ER Doc. If it’s a heart attack, a cardiologist — a heart specialist — will be involved in your care, slightly later. But, you’re generally met in your hospital’s Emergency Department by an Emergency Physician who can immediately begin treatment, potentially save your life and diagnose your condition.

Why should you call 911, the paramedics, when you think you’re having a heart attack?

Paramedics too can immediately begin treatment and potentially save your life. They cannot diagnose your condition with absolute certainty but they can do an important first test — an EKG (or ECG) — and monitor your condition. They can intervene with certain helpful treatments and begin life-saving measures if they are called for. Paramedics can also go “lights-and-sirens,” getting you to the hospital quickly and in the safest way possible.

Some other helpful tips: remain as calm as possible, have someone stay with you, call 911 without delay, chew and swallow an aspirin, sit or recline quietly, do not panic.

What is an EKG (ECG)

An electrocardiogram (EKG/ECG) is a “heart wave tracing,” a record of the heart’s electrical activity. This recording gives doctors and others in healthcare a tremendous amount of useful information. Often, but not always, a heart attack can be immediately diagnosed by the EKG’s distinctly abnormal pattern indicating that heart muscle damage has occurred.

Why do I write “often, but not always” above?

An EKG is a useful test and frequently a helpful one, providing lots of relevant information, but IT IS NOT A PERFECT TEST. There are no perfect tests in medicine. In other words, a person’s EKG can be normal and they’ll still be having a heart attack. Also, someone’s EKG can be abnormal and it does NOT signal that they’re having a heart attack.

Physician judgment and interpretation of the information an EKG provides figures heavily into decisions that are made about whether or not an individual is having a heart attack.

Also, other tests, including x-rays, laboratory investigations, CT scans and more can be, and often are, done to help determine what is really going on.

Again, an EKG is an important test in someone suspected of having a heart attack, but it is just one test among many that can and will be done. It’s interpretation in context is critically important. The information provided by an EKG is NOT perfect. To repeat, a normal EKG does NOT mean no heart attack, and an abnormal EKG does NOT necessarily mean a heart attack has occurred.

What other tests are immediately done to diagnose a heart attack?

In addition to the EKG, a blood test measuring troponin is done. This substance, a so-called “biochemical marker,” is released into the bloodstream when heart muscle cells die. Troponin testing is often done several times even in the Emergency Department.

The combination of an abnormal EKG, particularly one that that is abnormal in a very specific way, and an elevated troponin level, usually provides enough information to diagnose a heart attack.

What else can feel like a heart attack

This is not a complete list by any means, but other medical problems with similar or overlapping symptoms can be: pulmonary embolism (blood clot in the lungs), heart muscle inflammation or infection, aortic dissection (tearing of the large artery that exits the heart and supplies blood to the rest of the body), infection or inflammation of the heart’s covering membrane, diseases of the esophagus (muscular tube connecting the mouth with the stomach), and MANY others.

Hospitalization — yes/no?

Again, physician judgment, a variety of tests, and even some days in the hospital to allow further evaluation may be required to determine whether or not a heart attack has occurred. If one has occurred, determining its extent (size and location) and assessing its immediate aftereffects should occur in the hospital. Hospitalization will also allow for other tests to be done, if required, if a heart attack is NOT the diagnosis or not the only diagnosis.

Therapy for heart attacks starts in the Emergency Department and continues in the hospital. This may include surgery to bypass blocked blood vessels, medications and other treatments to open blocked blood vessels, medications to limit a heart attack’s size and severity, medications to treat associated medical conditions, and more.

Do all heart attacks feel like the description above?

The short answer … no!

That is a fairly classic or “textbook” description. Many people including women, diabetics, the elderly, and those with certain other conditions may experience a wide variety of other symptoms, or almost no symptoms at all. “Silent” heart attacks can and do occur. These are heart attacks without any symptoms at all or perhaps no symptoms that patients can remember.

By way of example, I’ve seen elderly patients with behavioral changes who turned out to be having heart attacks, women with shortness of breath only, diabetics with what seemed like indigestion or upper abdominal pain, and MANY others.

Bottom line — if you are concerned about a set of symptoms, even including mild chest discomfort, mild breathlessness, skipped heartbeats, a feeling of “indigestion” and others, seek medical attention. Let medical professionals decide if it’s a heart attack or something else

Do only old people have heart attacks?

Again, the short answer is NO!

People of any age, including teenagers and twenty-somethings, can have heart attacks. I’ve seen this happen.

Even infants and children can have them, rarely, but they do occur.

Heart attacks do become increasingly common as age increases.

What can you do now to help prevent a heart attack?

There are a variety of conditions and so-called risk factors that lead to narrowing of the heart’s blood vessels (the “coronary” blood vessels) leading to a heart attack.

Some of these include advancing age, smoking, overweight and obesity, diabetes, a family history of coronary artery disease, elevated cholesterol, high blood pressure, and more.

Some of these conditions and risk factors are under your control and some are not.

Smoking is known to be a significant risk factor for heart attack and is completely under one’s control. So, if you smoke, quit!

Avoid weight gain if possible. Seek to lose weight if you’re overweight.

Obtain treatment for other conditions that lead to coronary artery disease and heart attack.

Bottom line — heart health, heart attack risk, and strategies to avoid heart attacks are complex, long-term issues best discussed with your primary healthcare provider.