How do you decide when it is time to seek emergency medical help?

As a pacemaker or ICD patient how do you decide when to go to the Emergency Room/Accident & Emergency department of your nearest hospital?  What are the red flags for you personally with your heart condition?

I think this is an important question because we all have different levels of tolerance to symptoms like chest pain, an arrhythmia, feelings of breathlessness, instability and near loss of consciousness.  Some of us may even wonder if we have had a stroke after experiencing confusion or noticing extra brain fog.

I recently received a private message from a member asking me how do I know when it’s time to go to the Emergency Room for a heart rhythm disturbance like Atrial Fibrillation?  I thought I would share my answer with you in case it helps:- 

Hello X:  According to my doctors, the decision when to seek help will depend on our symptoms and how well we are tolerating them.  For example, during a “symptomatic” episode of AF I can experience chest pain (pressure type pain, mid central chest);  weakness (feeling unstable as though I might collapse);  being aware of rapid palpitations and  breathlessness.  These would be my red flags. 

My advice to you is that whenever you feel in trouble and unable to tolerate your symptoms, you should seek medical help.  “Don’t delay this until you learn what is normal for you during an arrhythmia like AF".

So go and get all those checks in the emergency room if you need to where they can rule out any significant events like a stroke or heart attack and hopefully give you the all clear.  Sometimes, by the time I reach A&E my AF has stopped and my symptoms have eased but because of my original symptoms I will not be wasting precious resources in getting checked out and in any event doctors will know that I need better treatment for my arrhythmias in the future, so my visit will never be a waste of time. 

I hope some of you will share with us any symptoms that would make you seek help or any experiences you have had in the past.  Thank you and stay safe everyone 



by AgentX86 - 2023-01-08 20:06:43

My gauge wouldn't be how uncomfortable I was, rather "Have I been here before and what was the outcome?"  If it's a new symptom and it's troubling, I'll get it checked out (rarely).  If the last time I went to the ER they found absolutely nothing, I may go again if it comes back again soon but the longer between episodes, the less likely I am to go again.  OTOH, if it's completely new, there is much higher chance I'll go but probably not immediately. I'm not much for hanging around the ER for hours (and hours).

There are some symptoms where there isn't much thought, like my near syncope or stroke symptoms (not been there, fortunately). The syncope didn't take more than a half a minute to decide but I didn't go to the nearest hospital, rather to the one where my cardiologist and EP are affiliated (Midtown Atlanta ~40mi).

Aside: It was a Friday night and I spent four hours in the waiting room with fifty people all hacking (to put it nicely)  from the flu (2018 was a really bad year for the flu). After I got into the room, I was admitted to the hospital in minutes.  Someone finally read the charts.


by Old male - 2023-01-08 21:05:28

Entering my 25th year with cardiac issues.  Bypass surgery, 2 heart attacks, stents, defibrillator, Afib.  Would like to believe I have experienced enough to know when to seek help but sure other surprises may be lurking.                    

Occasionally there are sensations, short pains, tightness, etc.  Usually just take Nitro and it goes away.  As for SOB, which has rarely but sometimes awakened me, I know it's time for Lasix.

My 2nd and last heart attack started with what I thought was indigestion that quickly changed to feeling like a hand was inside my chest squeezing my heart.

As for what lead to having an ICD, three episodes of vision loss as if I had closed my eyes for about a second.  Tests discovered V-TAC.

Realizing this may be more info than you asked for Gemita.  Anything unusual, whether experienced before or not could prompt seeking medical advice.  Would have to decide if it can wait for doctor appointment or go to ER.  

I honesty don't know (until it happens)

by TLee - 2023-01-08 21:15:34

I was asking myself this very question just the other day--had sort of a "should I or shouldn't I" moment. Here's the story: 

Walking my dog, we came to the ravine down from my house--steep hill with woods & a creek at the bottom. I have an arthritic hip that says no to the hill, but I have been known to drop the leash & allow her to explore. She is a very good, very smart dog & keeps me in sight, always coming back when called. Until she didn't. Something caught her attention in the woods, and with a guilty glance at me she was off. I called, but eventually had to stumble down the hill & thrash my way through the underbrush. She finally turned up, and with a few choice words from me we made our way up the hill. I had been in such a panic, which then became anger, and along with the physical exertion I was uncomfortably short of breath. Once I felt I could walk back home I noticed that I had significant pain in the left side of my chest. Uh-oh. Was it anxiety? Muscle pain from catching my breath? Minor heart flip-flop? Major heart flip-flop? I did what I think I tend to do in most cases, I waited. I figured it would either get better or it would get worse, and obviously it did get better, because I'm not writing this from the hospital. The thing is, I don't think I considered that it could have gotten much worse very quickly. I am very interested in seeing the replies to your question! 

Call the doctor first

by Lavender - 2023-01-08 21:50:39

I always call the dr's emergency number first. I get a call back. I make sure while I am waiting for the call back to take my blood pressure and pulse as well as pulse oximeter oxygen reading -so I can give the doctor more info. 

Only three times did they actually advise me to go to the emergency department of the hospital. Twice it was due to sudden high blood pressure and once it was due to a 33 second heart pause prior to receiving my pacemaker. 

There is always a long wait at the ER. I am also concerned about exposure to other germs in the waiting room there. Ugh. 

I let my pcp make the call as to whether my situation is a life threatening situation or whether I can wait and see him when his office opens. 

ER Visits

by Marybird - 2023-01-08 23:09:19

One of the things that I have seen happen in ERs here is that patients complaining of chest pain or other possibly heart-related issues, or symptoms and signs of stroke are given priority over other patients and will be triaged and seen as soon as possible. I've gone to the ER twice over the years, the first time was when an episode of SVT that had my heart rate stuck around 200 BPM. I waited for about 2 hrs for it to stop, then went to the ER, which was so crowded people were sitting on the floor. Presented myself to the triage nurse, who looked at me, checked my vital signs and yelled for help. Several nurses, etc came out with a wheelchair, one put in an IV site on the fly as we wheeled past all those waiting patients, and the treatment started from there. Earned me an overnight admission and more testing.

The second time was about 14 years later, tachycardia lasting a number of hours. Went to the ER, they called it A-Flutter, though it stopped just after I got settled in an ER cubicle. I'd have gone home at that point, but the ER doc insisted I be admitted overnight and see a cardiologist. 

These days I'd consider a visit to the ER as a last resort measure, ( unless there is trauma involved)  but that is me. I've had many more arrhythmia/tachycardia incidents over the years, am more familiar with how those go, and know that these will sooner or later ( usually sooner) stop. So I will wait them out, perhaps take an extra metoprolol tablet ( as suggested by my cardiologist) in the event a tachy/arrhythmia is particularly bothersome. At this point I am not sure how long I would let it last before I went to the ER, but such an event would also be recorded on my remote pacemaker monitor, and if the heart rate is 140 or more, the clinic personnel would receive an alert about it. I'd follow their instructions.

I occasionally get mild left sided chest pains that don't last that long. They remind me of the "stitches" one can get in the side from running a long way, I associate those with the A-fib I or other tachycardias I get sometimes. If these continued for a long time, left me short of breath or I felt I would pass out, I'd make a trip to the ER. 

For signs or symptoms that might be caused by a stroke or even a TIA, I'd get myself to the ER ( well, have my husband take me or call an ambulance, one shouldn't be driving under those conditions) as time is of the essence in diagnosing stroke soon enough to treat it and prevent the brain damage associated with stroke. 

And, I reluctantly went to our local ER on Christmas Eve after I took a tumble down three steps, smashed my head into the garage door, my knee into the concrete driveway, and my hip and surrounding area into a 3 lb coffee can I was carrying ( the coffee can kept my hip from hitting the edge of the last step, or the edge of the concrete driveway, thank goodness, otherwise, I believe I'd have broken my hip). smashing one side of the can. I went to the ER mainly to check on the large goose egg and bruising mainly on my forehead, since I take Eliquis I have been told head injuries should be checked to make sure there is no subdural bleeding. There wasn't, and no broken bones either. I felt kind of silly going to the ER, but knew I should do it. 

ER visits

by AgentX86 - 2023-01-09 01:19:22

I sure haven't gotten the royal treatment when showing up at ERs.  Last summer ('21) I had an auto accident. I was taken by ambulance to the ER and sat there for five hours before even being checked in. Note that I'm on an anticoagulant, have the pacemaker, as well as the right hand "isn't supposed to go that way", as the EMT said.

I should have had a CT and x-ray immediately but had to sit there with the ambulance crew from midnight until 5:00AM.  The EMTs can't leave until the patient is checked into the ER. That's one ambulance and crew out of comission for pretty much a shift, as well as not even checking me for a brain bleed or compromised leads.


ER....gee whiz

by Daedalus - 2023-01-09 02:00:01

Reading the stories of lengthy ER waits, I guess I've been lucky.  15 minutes was my longest wait and that was for an attack of diverticulitis in Nov. 2020 during heavy Covid days.  Went 3 times early last year for my first 3 AFib attacks (had never heard of it before and thought it was a heart attack during the first one) and basically got right in each time. Had three more non-ER episodes since.   In July I waited an hour, then drove to ER with my wife. As I parked the car, the AFib stopped.  Went back home.  When it hit in November I waited and 90 minutes later it stopped.  Then a few evenings ago another sudden attack and again I waited.  Ended after two hours.  Interesting that it stopped right around the moment that the pacemaker auto-check kicked in for about 30 seconds. 

With the experience from these events I feel more confident about how to deal with it.  It's uncomfortable and somewhat stressing, of course, but now my plan is to wait it out.  Don't have an ER visit time line yet, but guessing if it hasn't stopped in ~ 4 hours, I'll go check in.  My cardiologist suggested I take an extra Sotalol if needed, but so far haven't had to.  

Keep the input coming.  I'm learning a lot here. 

When to seek help? A difficult question to answer

by Gemita - 2023-01-09 03:25:48

Thank you AgentX86, Angry Sparrow, Old male, TLee, Lavender, Marybird, Daedalus for your helpful comments.  

When I last experienced difficult symptoms, particularly the chest pain and breathlessness, I did initially see my GP and she organised an immediate referral to A&E for some checks.  I was hoping I could get away with just a few extra blood tests to look at electrolytes or look for any infection.  

Many hospitals have a rapid access chest pain clinic and our nearest one does.  When I reached A&E, I had a very pleasant experience (unusual I know) and was quickly seen.  Doctors there accepted that while arrhythmias can come and go quickly as can any symptoms associated with an arrhythmia, they said that any significant chest pain during an arrhythmia should be assessed. My tests were mostly fine and my chest pain gradually eased on cessation of my AF.  I was kept in hospital overnight for observation. I will be seeing my EP next week for advice and hopefully better control of any future “symptomatic” AF episodes.

When I first started my AF journey, I was always told by my consultant and general doctor to seek emergency help if I felt I was in trouble (for example experiencing a high heart rate which couldn't be controlled).    Like most of you, I have learnt over the years how my arrhythmias behave and can usually tell from my symptoms alone if I need help but it takes time to build confidence and to recognise the symptoms that could spell trouble and to distinguish them from those symptoms that might be perfectly normal with an irregular rhythm like AF.  A newly diagnosed patient can perhaps be forgiven for running to ER/A&E at the earliest opportunity and will need time to accept any symptoms that might be normal for them during an arrhythmia like AF and to learn how best to control these symtoms as well as any anxiety that they will almost certainly experience too.  And fear can be a major factor in keeping our symptoms going.

I’m with AgentX86 on this

by Lavender - 2023-01-09 09:11:09

I was sent directly from my pcp to the ER and they called ahead to report fear of impending stroke or aortic aneurysm when my blood pressure went to 200/100 with center upper stomach pain.

I got there and was told to have a seat in the waiting room. It was totally packed with people-most had IV poles and many were in wheelchairs. 

An hour went by and no one came to triage me. I went up to the receptionist and told them one side of my head was pounding. They said it would be soon. Another hour, I was taken to triage and it was determined they'd do a CT scan of the abdomen and they would call my cellphone with results. In another area, an IV was started, blood was taken, and I was sent back to the waiting room.  

About four hours later, I got the CT scan and was returned to the waiting room. At no time was  my blood pressure retaken and I was in my street clothes the whole time. 

Another hour or two and the ER dr called my cellphone saying the scan and bloodwork were normal and I was told I would be sent home. No suggestions given. I still had head pain and stomach pain. 

Another half hour, I was taken back to discharge. I reminded them that no one had taken my blood pressure and I still had an IV line started. This gal left to get someone who could remove the IV and take my blood pressure because I refused to leave until they took it. 

Another half hour, a hurried nurse came in, I handed her the IV which had fallen out of my arm. My blood pressure was high but she advised me to go home and take it later-maybe I was just stressed. Ya think?!?

 I left. Found out a few days later from my pcp it was a reaction to the bivalent covid vaccine. 

Other ER visits have been discouraging with being sent home feeling just like I felt when sent in. I don't go often but the few times I did-it was exhausting and a long long wait. 

I will not go to the ER unless my pcp insists. I do think that people are using the emergency room like a doctor visit for things that could be treatable in a regular physician office setting. It jams up when true emergencies are happening. 

time to seek help

by new to pace.... - 2023-01-09 09:47:52

I have found out that many use the ER( in the US) who do not have regular doctors.

new to pace 

Off to the ER?

by Gotrhythm - 2023-01-09 12:56:37

I'm glad  you've raised this question. It's an important one without an easy answer.

As we can see from the above post, the question has two parts. (I'm narrowing the question to heart issues--otherwise we could fill a book.)

1. What are the heart symptoms that indicate that death or disability will result if not treated quickly?

2. What are our expectations of prompt, effective treatment, based on past experience?

In the past six months I have become more aquainted with ERs than I ever wanted to be. I have concluded that they are places to stay away from. If you have to go, then the time to go is between 8 and 10 AM.


For peace of mind or when in doubt I would always go to A&E/ER

by Gemita - 2023-01-09 15:49:20

Gotrhythm, yes the question is an important one and difficult to answer because it so depends on a patient’s overall health too, not only on their heart condition for which they might seek emergency help.  Thank you for challenging us with a couple of important questions.  As I sit here in normal sinus rhythm it is easy to answer these:-

1.  An arrhythmia, for example, that is out of control could result in a serious situation very quickly for the patient and in a worst case scenario with other acute symptoms, could lead to heart failure, stroke or even sudden cardiac death. I would rather err on the side of caution every time when in any doubt and seek urgent medical help if my symptoms or my husband's symptoms suggest that we are in trouble. 

My arrhythmia started with frightening speed one day while out on public transport.  I had multiple episodes of syncope due to an exceedingly high heart rate.  I thought I was experiencing mini strokes too. The decision to go to A&E/ER was clear cut and essential for my well being.  I still cannot believe how severe my arrhythmias were on that day, or how quickly my symptoms deteriorated.  I would have absolutely no hesitation to recommend A&E/ER to anyone who experienced similar symptoms.

2.  When my arrhythmias have been out of control I have always received prompt, effective treatment at A&E and so has my husband for his heart failure.  We are always fast tracked if we present with chest pain or chest discomfort.

When to go to the ER

by Aberdeen - 2023-01-09 18:52:25

I went to the ER or (Accident and Emergency)in Scotland when I woke up and collapsed on to the floor. I saw flashing lights and my wardrobes were like an elevator. Then I seemed all right but my heart rate was over 100. This seemed abnormal.

At the ER after tests they discovered that my dual lead pacemaker had caused LVSD and I had to have a CRT pacemaker.

I am paced 100% of the time and my usual resting heart rate is 60-70 . If at any time it  increased to over 100 I would go again especially if I had experienced unusual symptoms.🤞I don't experience anything like it again!



by Gemita - 2023-01-10 03:15:41

Aberdeen, hope all well your end.  Thank you for your contribution.  Clearly you had an emergency situation to deal with, with a falling ejection fraction and your syncope event, so the decision to attend A&E was the only one possible.  You clearly needed urgent assistance.  

My sister attended A&E just over a year ago now when she had tachycardia and they discovered an ejection fraction (EF) of only 16%, so dangerously low, but even so they only treated her with medication because of her poor general health.  Her EF today is much better at around 45%.  However if she hadn’t presented to A&E for her tachycardia symptoms which were not apparently life threatening at the time, she would not have received timely treatment for her heart failure and the outcome could have been so very different, so this is why we should always listen to our bodies and seek emergency help whenever our symptoms suggest we may need it. 

How each one of us with a heart condition will decide when the time is right to seek emergency help should ideally be based on our symptoms.  If these are severe or intolerable, then seek advice from whatever source.  Your life may well depend on it. 

Lavender and New to Pace

by Gemita - 2023-01-10 03:43:30

Lavender, your treatment in ER was truly appalling and I can understand your reluctance to go back there. I think though with our hearts, we will soon get to know what is serious and when we need to call for help.  

Hubby being 84 with multiple complex health problems can get into trouble very quickly and I have had to learn what symptoms to look out for.  I usually get it right and try not to attend A&E without good reason.   With so many conditions, so many meds, failing organs (heart/kidneys), I don’t know how to manage this all the time, so we are frequent A&E visitors unfortunately.  Anyway he hates going there also and would rather I nurse him back to health, but sometimes this just isn’t possible.

New to Pace, yes I am aware also here in the UK that the Emergency department is used by those who do not have a regular GP or who cannot get a service from their own GP.  At the same time, our GPs are now pushing us towards emergency services because they cannot manage so many patients with chronic health conditions.  The situation is dire over here.  I appreciate emergency departments should be used only for emergencies, but clearly this is no longer the case.

ER visits

by Aberdeen - 2023-01-10 05:50:41

Thank you Gemita. I have been feeling very well since April 2022🤞

In July 2021when my heart rate increased to 115 (due to food poisoning) I went to Accident and emergency (ER) . I left it quite a few hours as I realised what I had eaten was causing it but I had a vice like pain in my chest which was not improving.

I was treated promptly and well. I don't know how quickly you would be treated now given the crisis in the NHS.

Low BP

by Persephone - 2023-01-10 20:09:25

Gemita - I know from your previous posts that you are well familiar with this issue - there is no lower threshold for BP that warrants an ER trip, as far as I can tell, but guidelines exist. Falls related to lightheadness and risk of sustaining injuries may necessitate medical intervention.


by Gemita - 2023-01-11 05:58:45

Hello Persephone,

Thank you for your valuable contribution.  I agree with your statement generally, although it would very much depend on any deteriorating symptoms which could lead to a state of "shock" if not quickly corrected.  I hope one day a pacemaker will be able to support our blood pressure as well as our heart rate although pacemakers may already help with certain conditions like orthostatic hypotension where a patient might have episodes of AV Block.

In my experience chronic “stable” low blood pressure can often be managed by increasing my fluids and lying down when I feel weak and would not warrant a trip to ER.  However, “volatile” blood pressure is quite another matter entirely and may well need intervention.  Some of my triggers for volatile blood pressure are most definitely my arrhythmias like AF which can still intermittently occur at extremely high heart rates despite beta blocker treatment. 

As you may know I also have documented evidence of swallowing problems which can cause Swallow Syncope which is a vasovagal condition.  My oesophageal motility problems are a definite trigger for all my arrhythmias, so a complex picture. 

As I have said throughout this thread, I will always seek help when I am unable to control my symptoms and when my body tells me I may be in trouble.  I certainly recognise the signs now.

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