What Happens During a Heart Attack?
A heart attack (myocardial infarction) occurs when blood flow to part of the heart muscle is blocked, usually by a blood clot in a coronary artery. Without oxygen-rich blood, heart muscle begins dying within minutes, causing permanent damage unless blood flow is quickly restored.
Most heart attacks result from coronary artery disease—the gradual buildup of cholesterol plaque inside coronary arteries that supply blood to the heart muscle. When a plaque ruptures or cracks, the body responds by forming a blood clot at that site. If the clot grows large enough to completely block the artery, it cuts off blood supply to the section of heart muscle fed by that artery. Heart muscle cells deprived of oxygen begin to die within 20-30 minutes. The longer the blockage remains, the more heart muscle dies. Dead heart tissue cannot contract, conduct electrical impulses, or regenerate.
Time is critical—the phrase 'time is muscle' emphasizes that every minute counts. Treatment within 90 minutes of symptom onset (door-to-balloon time for angioplasty, or door-to-needle time for clot-busting drugs) can prevent most permanent heart damage. After 6-12 hours, damage becomes extensive and permanent. This is why recognizing symptoms immediately and calling 911 without delay is so crucial. About 47% of sudden cardiac deaths occur outside a hospital, suggesting many people delay seeking care or don't recognize symptoms until it's too late.
What Are the Classic Heart Attack Symptoms?
The most common symptom is uncomfortable chest pressure, squeezing, fullness, or pain lasting more than a few minutes. This is often accompanied by shortness of breath, cold sweat, nausea, lightheadedness, or pain radiating to arms, back, neck, jaw, or stomach.
Chest discomfort is the most frequent heart attack symptom in both men and women, reported in about 90% of cases. This isn't always severe pain—many people describe it as pressure, tightness, heaviness, or squeezing rather than sharp pain. It's typically located in the center or left side of the chest and lasts more than a few minutes (usually at least 15-20 minutes). The discomfort may come and go in waves. Some people say it feels like an elephant sitting on their chest, a tight band around their chest, or severe heartburn that doesn't respond to antacids.
Additional symptoms often occur with chest discomfort: Pain or discomfort may radiate to one or both arms (especially the left arm), shoulders, back, neck, jaw, or upper stomach. Shortness of breath may occur with or without chest discomfort—some people feel like they can't catch their breath even while resting. Breaking out in a cold sweat is common. Nausea, vomiting, or feeling like you have severe indigestion can occur. Lightheadedness or sudden dizziness may make you feel like you might faint. An overwhelming sense of anxiety or feeling of impending doom is also common. Unusual fatigue, especially if it comes on suddenly, can be a warning sign.
How Do Symptoms Differ in Women, Older Adults, and People With Diabetes?
Women, older adults, and people with diabetes are more likely to experience atypical symptoms including unusual fatigue, shortness of breath, nausea, back pain, or jaw pain without classic chest pain. These groups often delay seeking treatment because symptoms seem less urgent.
Women experience heart attacks differently than men in important ways. While most women do have chest pain or discomfort, they're significantly more likely than men to have other symptoms instead of or in addition to chest pain: unusual or extreme fatigue that may start days or weeks before the heart attack; shortness of breath without chest pain; nausea or vomiting; back pain or pain between shoulder blades; jaw pain or throat discomfort; cold sweat; lightheadedness; or pressure in the upper back. Women are also more likely to attribute symptoms to stress, flu, indigestion, or anxiety rather than recognizing a heart attack, leading to dangerous delays in seeking treatment. On average, women wait 54 minutes longer than men before calling for help.
Older adults (over age 75) and people with diabetes often have reduced pain sensation and may not feel typical chest pain. They're more likely to experience 'silent' heart attacks or present with confusion, sudden weakness, or falls. Diabetic neuropathy (nerve damage) can mask pain signals. These groups may experience: unexplained sudden fatigue or weakness; new or worsening shortness of breath; confusion or altered mental status; falls or dizziness; or subtle changes in functional ability. Because symptoms are less obvious, heart attacks in these populations are often discovered later through ECG changes, elevated cardiac enzymes, or imaging. Unfortunately, delayed recognition means delayed treatment and worse outcomes. Anyone in these groups with new or unexplained symptoms should seek immediate medical evaluation.
What Should You Do If You Think You're Having a Heart Attack?
Call 911 immediately—don't wait more than 5 minutes. Sit down, chew an aspirin if not allergic, and wait for paramedics. Never drive yourself to the hospital. Emergency responders can start life-saving treatment immediately and alert the hospital for faster care.
The single most important action is calling 911 without delay. Don't wait to see if symptoms improve. Don't call your doctor first. Don't have a family member drive you unless there's absolutely no alternative. Paramedics can begin treatment the moment they arrive, giving you medications, performing an ECG, and transmitting results to the hospital so the cardiac team is ready when you arrive. Patients who arrive by ambulance receive treatment faster than those who arrive by car. While waiting: Sit or lie down in a comfortable position and try to stay calm. Chew one regular-strength aspirin (325 mg) or four baby aspirins (81 mg each) unless you're allergic to aspirin or your doctor has told you not to take it. Aspirin helps prevent further blood clotting. Loosen any tight clothing.
If you've been prescribed nitroglycerin for angina, take it as directed (usually one tablet under the tongue). You can repeat every 5 minutes up to three doses total, but still call 911 immediately—nitroglycerin may relieve angina but won't stop a heart attack. Don't eat or drink anything (you may need emergency procedures). If you become unconscious and someone is with you, they should start CPR immediately and use an AED (automated external defibrillator) if available. Don't try to drive yourself or have someone drive you—about 20% of people who drive themselves to the hospital during a heart attack experience cardiac arrest along the way. Arriving by ambulance reduces time to treatment by an average of 1-2 hours, which can make the difference between full recovery and permanent disability or death.
What Are the Warning Signs Before a Heart Attack?
Many people experience warning signs days or weeks before a heart attack including new or worsening chest discomfort with exertion (angina), unusual fatigue, shortness of breath, or sleep disturbances. Recognizing and acting on these warnings can prevent a full heart attack.
About 50% of heart attack patients report experiencing warning symptoms in the days or weeks beforehand, particularly unusual fatigue (71% of women), sleep disturbances (48% of women), and anxiety. New or worsening angina (chest discomfort with physical activity or stress that goes away with rest) is a major warning sign. You might notice: chest discomfort triggered by exertion, stress, cold weather, or heavy meals; shortness of breath with activities that didn't previously cause it; unusual fatigue that seems out of proportion to your activity level; or indigestion-like discomfort that comes and goes. If you experience new, changing, or worsening symptoms, contact your doctor immediately—don't wait for a scheduled appointment.
Unstable angina is a particularly serious warning sign. This is chest pain that occurs at rest, lasts longer than stable angina, is more severe than usual, or isn't relieved by nitroglycerin or rest. Unstable angina means a coronary artery is severely narrowed or partially blocked—you're at very high risk for a complete heart attack within hours or days. Treat unstable angina as a medical emergency requiring immediate hospitalization. Other high-risk warning signs include crescendo angina (chest pain that's rapidly increasing in frequency, severity, or duration), new angina in someone with multiple risk factors, or angina occurring for the first time at rest. These patterns require emergency evaluation, typically including hospitalization, cardiac catheterization, and possibly angioplasty or bypass surgery to prevent a full heart attack.
How Can You Prevent a Heart Attack?
Prevention focuses on controlling risk factors: don't smoke, maintain healthy blood pressure and cholesterol, exercise regularly, eat a heart-healthy diet, maintain healthy weight, manage diabetes, limit alcohol, and manage stress. Know your family history and discuss prevention strategies with your doctor.
Major modifiable risk factors account for about 90% of heart attack risk: Smoking is the single most preventable cause—smokers have 2-4 times the heart attack risk of nonsmokers, but risk drops by 50% within one year of quitting. High blood pressure damages arteries over time; keep blood pressure below 130/80 mmHg through lifestyle changes and medication if needed. High cholesterol leads to plaque buildup; manage through diet, exercise, and statins if indicated. Physical inactivity doubles heart attack risk—aim for at least 150 minutes of moderate exercise weekly. Obesity, especially abdominal obesity, increases risk through multiple mechanisms; losing even 5-10% of body weight provides significant benefits. Diabetes dramatically increases cardiovascular risk; keep hemoglobin A1c below 7% through diet, exercise, and medication.
Dietary approaches proven to reduce heart attack risk include the Mediterranean diet (emphasizing vegetables, fruits, whole grains, fish, olive oil, and moderate wine), the DASH diet (similar to Mediterranean but emphasizing low-fat dairy and limiting alcohol), and simply eating more plant-based foods while limiting red meat, processed foods, and added sugars. Stress management through meditation, yoga, or counseling may reduce risk, particularly for people with anxiety or depression. Know your family history—having a first-degree relative (parent or sibling) who had a heart attack before age 55 (men) or 65 (women) significantly increases your risk and may warrant earlier or more aggressive preventive treatment. If you have multiple risk factors, your doctor may recommend aspirin for prevention (though this is no longer routinely recommended for people without existing cardiovascular disease) or other medications. Regular checkups allow early detection and treatment of risk factors before they cause a heart attack.
