Patient guide

Read this first

If you have chest pain or pressure right now, severe breathlessness, fainting, or a very fast and irregular heartbeat with worse symptoms, this guide is not for you. Call 115 (Iran’s emergency number) and do not wait for an appointment. The full list is in the guide “When to seek urgent care”.

Why do documents matter?

A heart doctor reaches a decision by putting several things together: history, examination, ECG and sometimes an echo or a test. For coronary heart disease the NHS says the doctor asks about your medical and family history and lifestyle. So the more complete this information is, the more precise the visit can be. Earlier documents also help avoid repeating a test that has already been done, or let a new result be compared with an old one. The doctor decides this.

What should you bring?

• The referral letter, if another doctor sent you, with the reason for the referral.
• Results and images of earlier echos and ECGs. The NHS also says, about results, that if you hear nothing after a few weeks you should contact the doctor who referred you. Bring all of them, on paper or digital.
• Blood test reports and any other test related to the heart, such as an angiogram or an exercise test.
• A list of all your medicines, including prescribed, over-the-counter and herbal ones. It is best to bring the boxes or leaflets (for palpitations and valve disease the NHS also says to bring your medicines with you).
• Your history of illnesses and operations, especially high blood pressure, diabetes, high cholesterol, kidney disease, an overactive thyroid and anaemia.
• A blood pressure diary if you measure at home (see the guide “Measuring blood pressure at home”).
• A palpitations note if you have one (see the guide “Tracking palpitations”).

What should you write down?

Before the visit, write down answers to these questions for yourself:

• What is the symptom? Pain, pressure, breathlessness, palpitations, dizziness, swollen legs?
• When did it start? Was it sudden or gradual?
• What brings it on? Activity, stairs, excitement, cold, food, lying down?
• How long does it last and what eases it? Rest, a change of position, a medicine? For example, about angina the NHS says an attack usually lasts less than 10 minutes and eases with a few minutes of rest.
• What else comes with it? Sweating, nausea, dizziness, breathlessness?
• Family history: a heart attack or angina in close relatives (the NHS gives under 60 as an example), high blood pressure, irregular heartbeat or sudden death in the family.
• Habits: cigarettes, waterpipe, alcohol, caffeine, exercise.
• Medicines: the names, and when each is taken.

You do not need to know everything exactly. “I don’t know” is also an answer.

What can you ask the doctor?

• What is my problem likely to be, and what else could it be?
• What test do I need, and why?
• When will the result be ready, and where and how will I get it?
• What should I do and not do until then?
• Which signs should I treat as warning signs, and what should I do if they happen?
• Will my medicines change? (Only a doctor decides on a change of medicine.)
• When is the next follow-up?

After the visit

Collect the test results and ask what they show. The NHS says to ask if anything is unclear. If you hear nothing after a few weeks, get in touch. Keep the results in one folder so they are ready next time.

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.

The first point

If you have a warning sign, such as chest pain or pressure, severe breathlessness or fainting, do not wait for an echo. Call 115 (Iran’s emergency number). This guide is for someone who has been asked to have an echo and has no urgent sign.

The most important rule: follow the instructions of the centre doing the test. Cleveland Clinic says preparation differs by type of echo and the centre tells you what to do.

Before a standard echo (on the chest)

The NHS says:

• You can usually eat and drink as normal on the day.
• Wear clothes that are easy to take off from the top half. You take off your top and put on a gown.
• If you wish, you can ask for a companion or a trained person to be in the room.

The source says nothing about stopping medicines before a standard echo. Cleveland Clinic says to stop medicines only if a doctor tells you to. Do not stop your medicines on your own.

Echo through the food pipe (TOE)

The NHS says you may be asked not to eat or drink for some hours; you are given the exact instructions. The throat is numbed with a spray and, if you wish, a sedative can be given. A sedative does not put you to sleep but makes you very drowsy, and someone needs to take you home by car or taxi, because you must not drive for 24 hours. Your throat may be sore for a day or two.

Exercise (stress) echo

Cleveland Clinic says to wear comfortable clothes and shoes. You may be asked not to have caffeine, alcohol, tobacco or food for some time before the echo. During exercise, symptoms such as chest pain or breathlessness may come on; if they do, tell the staff at that moment. If you cannot walk on a treadmill or pedal, the NHS says you may be given a medicine that has an effect on the heart similar to exercise. The centre doing the test and the doctor decide this.

Echo with contrast

Sometimes a small amount of liquid is injected into a vein in the arm to make the picture clearer. The NHS says you may be asked to stay for up to 30 minutes so any reaction can be checked. Cleveland Clinic says an allergic reaction can happen; tell the staff if you have a history of allergy.

What happens during a standard echo?

The NHS gives this order:

1. You take off your top and put on a gown.
2. You lie on a couch. A few stickers on your chest monitor your heartbeat.
3. Gel is put on your chest or on the probe.
4. The sonographer moves the probe gently over your chest. The machine makes a loud whooshing sound.

The BHF says the gel is cold and sticky and you may feel the pressure of the probe. A standard echo does not hurt, and the BHF says it has no risks or side effects.

How long does it take?

The sources do not give the same figure: the NHS gives about 30 to 40 minutes for a standard echo, Cleveland Clinic usually 40 to 60 minutes, and the BHF from 15 minutes to an hour. An echo through the food pipe takes about 30 minutes (BHF) and up to 90 minutes (Cleveland Clinic), and afterwards you may stay for 30 minutes to be checked. Ask the centre for the total time.

After the echo

• After a standard echo you can usually go straight back to your activities (BHF: most people go home after the scan).
• The result: sometimes the doctor talks to you on the same day and sometimes there is a separate appointment. If you hear nothing after a few weeks, contact the referring doctor (NHS).
• Find out who the result is sent to and how you get it.

What should you bring?

• The referral letter and an ID card
• Results of earlier echos and ECGs
• Your medicine list
• For an echo with a sedative: someone to take you home

When to seek urgent care

If any of these happens before or after the echo, call 115 (Iran’s emergency number) and do not wait:

• Sudden chest pain or pressure that does not go away, or pain that spreads to the arm, jaw, neck, back or belly
• Severe breathlessness, fainting, cold sweat with nausea or dizziness
• Sudden weakness on one side of the face or body, or trouble speaking

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.

Read this first

Measuring blood pressure at home is for follow-up and to help the doctor, not for spotting danger signs. If you have sudden chest pain or pressure, severe breathlessness, weakness on one side of the body or trouble speaking, do not measure your pressure; call 115 (Iran’s emergency number). Do not waste time on a measurement.

Why measure at home?

The NHS and the WHO both say high blood pressure usually has no symptoms and the only way to know is to measure it. If a reading at a clinic was high, the NHS says you may be asked to check your pressure at home for a few days or wear a portable 24-hour monitor. The WHO says automatic home devices can be used for self-measurement, but an assessment by a healthcare professional still matters.

The device

• The NHS says your doctor or nurse may lend you a device and show you how to use it, or you can buy one yourself. Follow the instructions that come with the device.
• Blood Pressure UK suggests asking your doctor or nurse to confirm that your device is validated and accurate, and taking the device to an appointment so the cuff and your method can be checked.

Before measuring

Blood Pressure UK says:

• For at least 30 minutes before measuring, do not eat, smoke, have coffee or tea, or exercise.
• Go to the toilet before measuring.
• Wear loose clothing with sleeves that roll up easily.
• Sit and rest for 5 minutes in a quiet place.

How to sit

• Back supported, both feet on the floor, legs not crossed.
• Arm resting on a firm surface, relaxed and level with the heart.
• Do not talk or move.
• The cuff goes directly on the skin of the upper arm, about 2 cm above the elbow (Blood Pressure UK). The NHS also says to roll up your sleeve and rest your arm on a table.
• At the start measure both arms, and from then on use the arm that gave the higher reading (Blood Pressure UK).

How many times, and when?

The sources differ a little in detail, so your own doctor’s instructions come first:

• NHS: measure once, write down the number, wait 1 minute and measure again. Usually one session in the morning and one in the evening. The doctor or nurse says how many days to continue.
• Blood Pressure UK: two or three readings in each session, 1 to 2 minutes apart. If the first reading is much higher than the rest, set it aside, measure once more and take the average. At the start, measure morning and evening for seven days and ignore the readings from the first day. After that the doctor or nurse may suggest measuring once every one to two weeks.
• Always measure at set times so the numbers can be compared.

Recording the numbers

Write the numbers exactly as you see them on the screen and do not round them (Blood Pressure UK). Write the date, time, arm and how you were feeling next to each. Record them on paper, on your phone or in the device’s own memory, and bring them to the appointment.

What do the numbers say?

Each measurement has two numbers, for example 130/80. The first (systolic) is the pressure when the heart pumps and the second (diastolic) is the lowest pressure between beats (NHS).

The NHS says high blood pressure usually means 140/90 or more when measured by a healthcare professional, or 135/85 or more at home. The WHO gives 140/90 or more on two different days for a diagnosis. So:

• One high number is not a diagnosis. This is why the sources stress preparation so much: resting, no coffee or smoking before measuring, and sitting correctly. Measure again with the correct method.
• A low or ordinary number is not a reason to ignore other symptoms. If you have chest pain or breathlessness, do not look at the pressure number; get help.

What not to do with home readings

• Do not cut down, increase or stop a medicine because of your own home reading. Medicine decisions are the doctor’s job.
• Do not use a home reading in place of seeing a doctor.
• Do not take one bad reading as a reason for great worry or for dropping your follow-up.

When to seek urgent care

The WHO says very high pressure, usually 180/120 or more, can cause a severe headache, chest pain, dizziness, breathlessness, nausea, vomiting, changes in vision, confusion, ringing in the ears, nosebleeds or an irregular heartbeat, and needs urgent care.

Call 115 (Iran’s emergency number) if the reading is very high and you have any of these signs, or if you have sudden chest pain, severe breathlessness, weakness on one side of the face or body, trouble speaking or sudden blurred vision. Do not drive yourself.

If you often have headaches or blurred vision, or chest pain that comes and goes (NHS), do not put off the appointment; see a doctor as soon as you can.

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.

Read this first

If your palpitations come with chest pain, breathlessness or feeling faint right now, do not write notes; call 115 (Iran’s emergency number). The NHS also says to call the emergency services in this case and not to drive yourself. The note is for palpitations that come and go and have no warning signs.

Why keep a record?

The NHS says palpitations are common and usually harmless, but they have different causes: from lack of sleep, stress and caffeine to a rhythm problem, anaemia, an overactive thyroid or valve disease. To find the cause the doctor first asks what you feel and when, and an ECG records only that one moment. If the palpitations come and go, they may not be happening when you get to the clinic. Your note gives a picture from outside the clinic.

Please note: the sources give no particular advice about keeping a diary. This is our own practical suggestion and does not replace an examination and an ECG.

What should you write down?

Each time:

• Date and time, and how long it lasted (a few seconds, minutes, longer)
• How it felt: fast and racing? Irregular, with skipped or extra beats? Pounding or thumping? Fluttering? (The NHS lists these same patterns)
• Start and end: did it start suddenly and stop suddenly, or gradually?
• What you were doing: resting, exercising, climbing stairs, sleeping, after a meal, lying down, under stress
• Possible triggers: coffee and tea, energy drinks, alcohol, smoking, lack of sleep, stress, a new medicine. The NHS lists these.
• Signs that came with it: chest pain, breathlessness, dizziness, feeling faint, cold sweat, weakness
• If you counted your pulse: the number, and whether it was regular or irregular. (The NHS describes AF with an irregular pulse and a heart rate over 100 beats a minute, but taking your pulse at home does not replace an ECG.)

An example line

12 Aban (Iranian calendar), 10:30 pm. I was sitting watching television. Fast, sudden beating, about five minutes. It stopped suddenly. I had had coffee in the afternoon and had slept little. No dizziness or pain.

Helping yourself

The NHS says if the palpitations do not have a medical cause, staying away from triggers such as stress, smoking, caffeine and alcohol may help. For AF it also lists too little sleep, dehydration and spicy food among the triggers. Some medicines may cause palpitations (the NHS says to check the leaflet), but do not stop your own medicine without a doctor’s advice. If you suspect a medicine, only tell your doctor or pharmacist.

What does the doctor do with your note?

The note helps the doctor decide which checks are needed. The NHS lists these checks for palpitations and AF: an ECG, sometimes a portable ECG that stays with you for 24 to 48 hours and up to 7 days, an echo, a plain chest X-ray and blood tests. Which of these you need is for the doctor to say.

When to make an appointment

The NHS says to see a doctor if:

• The palpitations keep happening or have become more frequent
• They last more than a few minutes
• You have heart disease
• There is a heart problem in the family

When to seek urgent care

Call 115 (Iran’s emergency number) and do not drive yourself if:

• The palpitations do not stop, or come with chest pain, breathlessness or feeling faint
• You have a fast or irregular heartbeat and suddenly get cold sweat, nausea, fainting, dizziness, a severe headache, weakness or numbness on one side of the face or body, blurred or lost vision, confusion or trouble speaking
• You have fainted, especially during exercise or when lying down (NHS)

If the palpitations came with these signs and then stopped, still contact a doctor without delay and do not wait for an appointment.

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.

What this guide is not

This guide gives no drug names, no doses, and does not say which medicine is right for you. The decision to start, change or stop any medicine is for your own doctor. Here are only principles on which reliable sources agree.

If you have chest pain or pressure, severe breathlessness or fainting right now, do not read this guide; call 115 (Iran’s emergency number).

Rule one: do not stop on your own

On the page for one heart medicine, the NHS says not to stop it without talking to your doctor, because your condition may get worse. If it is to be stopped, it is usually done gradually and with a doctor’s guidance. The advice is to keep taking it until a doctor says otherwise.

About blood pressure medicines the WHO says to take them as directed, not to skip them, not to share them with others, and to keep your medical appointments. For heart failure the NHS also says to take your medicines as directed.

If for any reason you cannot take a medicine (it ran out, it has side effects, it is costly, you keep forgetting), contact your doctor or pharmacist before stopping. A doctor or pharmacist can help.

Medicines and stages of treatment

Most heart conditions are treated with a mix of lifestyle change and medicine. A few examples of what the sources say:

• High blood pressure: the NHS says there are different medicines and the choice among them depends on the pressure reading, age and other factors. Most are taken once a day and sometimes more than one medicine is needed.
• Angina: the NHS says medicines are used to stop an attack, to make attacks less likely, and to lower the risk of a heart attack and stroke. Ask your doctor how to use them and where to keep them.
• Atrial fibrillation: the NHS says there are medicines to control the heart rate and rhythm, and medicines to lower the risk of clots and stroke. Only a doctor prescribes these medicines.
• Heart failure: the NHS lists several groups of medicines; some remove extra fluid, some widen the blood vessels and some slow the heartbeat.
• After a heart attack: the NHS says long-term medicines may be needed.

The names and amounts of these medicines are not given in the list above. Ask your doctor about your own medicine.

If you miss a dose

The right answer depends on the medicine, so there is no single rule to give here. Ask your doctor or pharmacist in advance what to do if you miss a dose of each of your medicines, and write it next to your medicine list. Do not take extra to make up for a missed dose unless they tell you to.

What to tell your doctor and pharmacist

• All the medicines you take: prescribed, over-the-counter, herbal and supplements
• Allergies and earlier side effects
• Pregnancy or plans for pregnancy, or breastfeeding
• Any new symptom after starting a medicine (dizziness, weakness, cough, swelling, palpitations)
• If you are not taking a medicine, or are taking less of it, even if you feel embarrassed. A doctor needs to know in order to help you.

What can you do yourself?

• Keep your medicine list up to date and with you. For emergencies the NHS also says to take your medicines with you.
• Take enough supply when you travel (NHS, in the angina section).
• Get medicines on a doctor’s or pharmacist’s advice and from a reliable source.
• Do not take anyone else’s medicine and do not give yours to others (WHO).
• In heart failure, weigh yourself regularly, as the NHS says. Ask your own care team how often and what change is worrying.
• Do not give up the non-drug care: stopping smoking, a balanced diet, activity, less alcohol (NHS).

When to seek urgent care

Call 115 (Iran’s emergency number) and do not wait for an appointment if, after taking a medicine or with no link to a medicine, you have:

• Sudden chest pain or pressure that does not go away (if you have angina and it does not stop with rest and your prescribed medicine)
• Severe breathlessness, or pale, bluish or grey lips or skin
• Fainting
• Sudden weakness on one side of the face or body, or trouble speaking

For new symptoms that are not urgent but began after starting a medicine, contact your doctor or pharmacist as soon as you can. Do not stop the medicine on your own.

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.

Rule one

If you think something serious is wrong, do not wait. In Iran the emergency number is 115. Do not make an appointment and do not wait to see if it gets better. About heart attack the WHO says not to wait to see whether the symptoms pass, because “time lost is heart muscle lost”.

The NHS and MedlinePlus both say not to drive yourself in these situations. Call 115 and follow the phone instructions of the call handler.

Heart attack

Call 115 if:

• You have chest pain or discomfort that is sudden and does not go away: squeezing, pressure, heaviness or burning, or a feeling like indigestion
• The pain spreads to the left or right arm, shoulder, neck, jaw, back or belly
• Chest pain comes with cold sweat, nausea or vomiting, dizziness or breathlessness
• Your lips or skin have turned pale, bluish or grey (on darker skin this is easier to see on the palms)
• You have severe breathlessness: gasping, feeling choked or unable to speak
• Someone has collapsed and is not responding normally

MedlinePlus says heart attack pain usually lasts more than 20 minutes and may not go away with complete rest, and may come back. This does not mean waiting 20 minutes; call from the very first moment.

Less typical signs: women, older people, people with diabetes

Not everyone starts with severe, classic chest pain. The WHO says women, older people and people with diabetes more often have unusual signs. MedlinePlus also says these groups may have little or no chest pain and feel breathlessness, tiredness or weakness instead.

• In women, according to womenshealth.gov and the WHO: pain in the back, neck or jaw, nausea and vomiting or indigestion, sudden unusual tiredness, unfamiliar dizziness, severe breathlessness and cold sweat. Women are more likely than men to have several signs together and not only chest pain.
• In older people, according to the WHO and MedlinePlus: breathlessness, tiredness, weakness, indigestion-like discomfort or jaw and back pain, without marked chest pain.
• In people with diabetes, according to the WHO and the BHF: nerve damage from diabetes may lessen or dull the pain, and a silent heart attack can even happen and be found later on examination.

The practical point: if you have sudden unusual tiredness, breathlessness for no reason, indigestion-like discomfort or back and jaw pain and you do not know the cause, especially if you are a woman, older or have diabetes, do not play it down; call 115. The WHO also says not to wait to see whether the symptoms pass.

If angina has been diagnosed

The NHS says if you have been diagnosed with angina before and the pain does not stop with rest and your prescribed medicine, call the emergency services. Your own doctor has told you what your treatment should be; this guide gives no medicine instructions.

Stroke

The NHS sums up four signs as FAST:

• Face: one side of the face has drooped and it is hard to smile
• Arms: you cannot lift both arms fully
• Speech: your words are slurred or you seem confused
• Time: call 115 right now

Other signs: weakness or numbness on one side of the body, blurred vision or loss of sight in one or both eyes, trouble speaking or finding words, confusion and forgetfulness, dizziness or falling, and a severe headache. The WHO treats suddenness as important.

The NHS says even if the signs are brief and go away, if they started in the last 24 hours you should still get help straight away. The signs may fade and you may feel well, but you should not wait. Do not drive yourself.

Severe breathlessness

Call 115 if the breathlessness is severe: gasping, feeling choked, or you cannot speak. The same applies if your lips or skin have turned pale, bluish or grey with it (NHS, on heart failure and heart attack).

If you have heart failure and have breathlessness when lying down or during everyday tasks, a cough with pink frothy phlegm, or sudden weight gain, the NHS says to get medical help without delay and not to leave it for your next appointment. If severe breathlessness comes with any of these, call 115.

Fainting

The NHS gives a list for urgent calls. Call 115 if someone:

• Is not breathing or does not wake up within a minute
• Has not fully recovered, or has trouble speaking or moving
• Has chest pain or palpitations, shaking or an irregular heartbeat
• Fainted during exercise or while lying down
• Is badly injured or has had a seizure

The NHS says even a faint without these signs should be looked at by a doctor.

A very fast or irregular heartbeat

For palpitations and atrial fibrillation, the NHS says to call 115 if you have a fast or irregular heartbeat and:

• You have chest pain, breathlessness, cold sweat, nausea or vomiting
• You have fainted, are dizzy or have fallen
• You have a severe headache, weakness or numbness in the face or body, blurred or lost vision, confusion or trouble speaking
• The palpitations do not stop

If the palpitations came with these signs and then stopped, still contact a doctor without delay (NHS).

Very high blood pressure

The WHO says very high pressure, usually 180/120 or more, can cause a severe headache, chest pain, dizziness, breathlessness, nausea, vomiting, changes in vision, confusion, ringing in the ears or an irregular heartbeat, and needs urgent care. If the number is very high and comes with these signs, call 115.

What should we do until help arrives?

• Do not drive yourself. Call 115 and follow the call handler’s instructions.
• Sit quietly or lie down. The NHS says to sit on the floor with knees bent and back supported, or on a chair if that is not possible.
• Have the medicines you take, or a list of them, ready to give to the medical staff.
• Keep checking the person’s response and breathing. If they are not responding and not breathing, CPR is needed; 115 will give instructions.
• Ask the 115 call handler about taking any medicine at that moment. This guide gives no medicine instructions.

And if I am not sure?

Signs such as repeated palpitations, swollen legs or a high number on a home blood pressure reading also need to be checked and should not be ignored for long; see a doctor as soon as you can. But if you suspect your symptom is on the list above, do not hesitate: call 115 and explain the situation.

Symptoms and treatment plans differ from patient to patient. Talk to a doctor about your own situation.