Signs and Symptoms of Heart Attacks (and How to Respond)

Heart attacks are the leading cause of death for both men and women, with over 600,000 people dying from heart disease in 2017. Here’s what to do before having a cardiac event:
1) Call 911 if you have chest pain or shortness of breath that lasts more than 30 minutes;2) Get someone else to call 911 while you wait;3) If your symptoms worsen or they last longer than one hour, go immediately to an emergency room (ER).

The “how to prevent heart attack” is a symptom of a heart attack. If you are experiencing any of these signs, call 911 immediately.

Note from the editor: This is a guest post by Charles Patterson, a Marine Corps veteran and paramedic.

Consider the following scenario: you’re waiting in line at an airport ticket desk to travel on a well-deserved vacation with your wife. The kids are safe with your parents, you turned off the stove before leaving the home, and you even remembered to bring your toothbrush. The guy in front of you suddenly holds his chest, shouts out in agony, loses his carry-on, and falls to his hands and knees, having been disputing with the ticket clerk over the weight of his baggage. “Bill?! Bill!” his wife yells, desperately yelling. What’s the matter?! Bill!” You see the man’s face has become pale and he appears afraid as he rolls over to a sitting posture against the ticket desk. He stops replying to his wife and slumps over while you’re watching.

So, what exactly happened? Your wife is looking at you with a Do something! expression on her face, and you want to help, but you have no idea what occurred or what to do. “Call 911!” someone yells, and you fumble for your phone, afraid of what to say if you do dial.

Bill recently had a heart attack. Years of overeating, limited physical exercise, unwillingness to take his blood pressure meds, and the on-and-off chest symptoms he’d been neglecting for the last six months culminated in a single event that might have killed him.

The actors and places change, and the reasons and outcomes differ, yet a drama identical to this plays out in people’s hearts every day, all over the globe.

Every year, almost 800,000 individuals in the United States suffer from a heart attack, with males accounting for the bulk of these cases. Patients with heart problems are more likely to have a heart attack. With more than 600,000 fatalities each year due to heart attacks and strokes, heart disease (a phrase that encompasses various illnesses) is one of the major causes of mortality in the United States.

With rates like these, you or someone you know is quite likely to have had or will have a heart attack. Although a heart attack may cause abrupt cardiac arrest, in which the heart stops beating, the majority of heart attacks are treatable. The good news is that with little training, you can identify the signs, symptoms, and risk factors of a heart attack, as well as what to do if you or someone close to you suffers from one.

The Physiology of a Heart Attack Physiology of a Heart Attack Physiology of a Heart Attack

A heart attack may happen in a variety of ways, but the majority occur as a consequence of a clot forming in the coronary arteries. Patients who suffer a heart attack are likely to have some kind of coronary artery disease, most often atherosclerosis (plaque accumulation along the walls of the coronary arteries). Under extreme pressure, these plaque deposits might rupture or break off. When they burst, the blood is exposed to the necrotic core of the plaque, causing a clot to develop. Blood flow to the rest of the heart is diminished as the clot forms and plugs the artery, and it may finally halt. As a consequence, oxygen is unable to reach the remainder of the heart, causing tissue to die.

 

Ischemic tissue is tissue that is becoming oxygen-depleted. This is known as cardiac ischemia in the heart. When tissue is deprived of oxygen for an extended period of time, it gets irreversibly damaged and is referred to be infarcted. A myocardial infarction is a permanent tissue death of the heart muscle, which literally means “death of heart muscle.”

The capacity of the heart to pump blood is impaired when a portion of the heart muscle is injured or dies. Imagine experiencing a lifelong arm injury that stops you from doing as many bicep curls as you once did. The extent of heart muscle damage is determined by a number of variables, including the location of the clot in the coronary arteries and the length of time the patient goes without therapy.

While many heart attacks may not result in death, the damage they inflict can have long-term consequences that can lead to more heart issues or raise the risk of future heart attacks and other illnesses.

Following a heart attack, you may experience:

  • Heart failure due to congestive heart failure (a progressive condition where the heart no longer pumps efficiently)
  • Heart beats that are irregular and may be deadly
  • Stroke risk is higher.
  • There will be more heart attacks.

Fatal heart attacks injure the heart to the point that it stops beating. Sudden cardiac arrest is the medical term for this. Surprisingly, the great majority of persons who have abrupt cardiac arrest — up to 90% — do not survive. A heart may sometimes be shocked back to a regular beat if found soon. However, the chances of this happening are very slim, and many of those who do survive are unable to return to regular life.

Factors that Increase Your Chances of Having a Heart Attack

While anybody of any age might have a heart attack as a result of congenital cardiac problems, drug usage, or other circumstances, there are several characteristics that enhance the chance of a heart attack. Because the majority of heart attacks are caused by underlying heart disease, the risk factors for a heart attack are largely the same as for heart disease.

Some of these variables are under our control, whether via dietary modifications or medication given by a doctor. These are some of them:

  • Blood pressure that is too high (hypertension)
  • Cholesterol levels are high.
  • Unhealthy eating habits
  • Obesity
  • Stress
  • A sedentary way of life
  • Smoking
  • Use of illegal drugs
  • Diabetes that is uncontrolled

With these things in place, decreasing your risk of a heart attack may be as easy (I said easy!) as eating well and exercising frequently. Consult your doctor about drugs and lifestyle changes that may help you minimize your chance of developing these conditions. In the event of uncontrolled diabetes, sticking to your insulin or medicine regimen, eating a nutritious food, and seeing your doctor on a regular basis might reduce your chance of developing frequent complications.

Some risk factors are uncontrollable, such as:

  • Men are more likely than women to suffer from heart attacks.
  • Age: As we become older, our chances of acquiring coronary artery disease and so suffering a heart attack increase. Heart attacks become more common in males after the age of 45 (55 for women), and the average age of a first heart attack is 66. (age 70 for women).
  • People who have a family history of heart disease or heart attacks are more likely to acquire such illnesses themselves. This might be due to genetics, but it could also be due to common environmental variables or acquired habits like drinking, bad nutrition, drug use, or increased stress levels.
  • Race: Certain ethnic groups, such as African-Americans and Native Americans/Alaskan Natives, have a greater frequency and incidence of heart disease, its risk factors, and related disorders than others.

Thyroid and adrenal gland abnormalities, among other medical issues, may raise the risk of heart disease. It’s important to speak with your doctor about your specific risk factors, underlying medical issues, and what you can do to live a healthy lifestyle.

 

Visit the American Heart Association’s website to learn more about risk factors and measures you may take.

How Do You Know If You’re Having a Heart Attack?

The hallmark symptom of a heart attack is chest discomfort, which may manifest in a number of ways. Around 70% of heart attack sufferers report chest discomfort (you probably assumed it would be 100%!). This pain generally originates in the center or left side of the chest and may or may not extend to the left arm, neck, jaw, or back between the shoulder blades. Pressure, tightness, heaviness, or “as if someone is sitting on my chest” are all common descriptions of chest discomfort.

Other common signs and symptoms are:

  • Sweating that is both sudden and excessive
  • Skin that is cool and clammy
  • Pale in appearance
  • Breathing problems or shortness of breath
  • Reflux of acid
  • Abdominal discomfort in the upper middle (“epigastric”)
  • nauseous (with or without vomiting)
  • Syncope is a term that refers to a (fainting or passing out)
  • Lightheadedness, weakness, or faintness
  • Anxiety, irritation, or a restless feeling
  • a feeling of impending disaster

Despite the fact that chest discomfort is the most common symptom of a heart attack, many individuals do not feel any pain at all. Women, diabetics, those with neuropathy, and the elderly are more prone to have a “silent” heart attack, which is one that occurs without chest discomfort.

The problem with a silent heart attack is that the symptoms you’re experiencing might be similar to those of other ailments, or they could be so vague that you don’t feel the need to seek medical attention. While you may rationalize your acid reflux and upper stomach discomfort as “probably my meal disagreeing with me,” you should never be reluctant to seek medical assistance if anything doesn’t feel right.

Men, in particular, have a proclivity for putting off or ignoring health difficulties. We tend to dismiss our symptoms, ignore them till they go gone, or create explanations and denials for them. Don’t put things off, and don’t be obstinate. It’s critical to act quickly; you need to go to a hospital in approximately 60 minutes or fewer to avoid severe, irreparable cardiac damage. “Time is life,” or “time is muscle,” as we like to say. 

Is It a Heart Attack or a Stroke? Or Is There Something Else?

It’s worth noting that any of the symptoms described above might be signals of something else. These symptoms may indicate various causes of shock, pulmonary embolisms (clots in the blood arteries of the lungs), aortic aneurysms (ballooning of a portion of the aorta in the chest cavity or belly), abnormal heart rhythms, certain thyroid problems, and more. Whether you’re not sure if you’re having a heart attack, get medical assistance. Whether or whether you have a heart attack, they are all significant disorders that may be deadly if not treated promptly.

A coronary artery that is partly blocked owing to plaque development is one disease that may cause symptoms that feel like a heart attack. The heart is unable to get enough oxygen as a result of this partial obstruction, and you may have chest discomfort or other symptoms. Angina is the medical term for this condition. Angina is most often associated with physical effort or stress, when the heart’s need for oxygen rises, although it may also happen at rest. With time and rest, the pain or symptoms may or may not go away. Angina is a symptom of underlying heart disease and a warning sign of a heart attack, but it is not a heart attack.

 

The difference between angina and a heart attack cannot be established without a doctor’s assessment and testing, just as a broken bone cannot be detected without an x-ray. If you’re experiencing chest discomfort or any of the other symptoms listed above, don’t dismiss it as “simply” angina. Again, err on the side of caution and get assistance.

What Should You Do If You Have a Heart Attack?

It’s critical to respond swiftly while keeping cool if you or someone you love is experiencing a heart attack. The first and most essential stage in what the American Heart Association refers to as the “Chain of Survival” is an informed bystander who detects when someone may be experiencing a heart attack. The additional links in the chain of survival cannot be activated unless a bystander or a patient recognizes the signs and decides to act.

  • CALL 911 PRIOR TO DOING ANYTHING ELSE (or your local emergency number). Make careful to provide the dispatcher your location and as much information as you can about the patient so that EMS can find them. Consider sending another person (if available) as a guide to wait for EMS if you’re in a huge structure like a retail, warehouse, or office building. Other details regarding the patient and their health will be requested by the dispatcher. Stay with the patient and provide this information while being calm, and stay on the line until EMS comes.
  • Place the patient in a comfortable posture. While it is widely accepted that the best position for someone in shock or with shock-like symptoms is to lie down on their back with their feet elevated, a person having a heart attack may have difficulty breathing and may have fluid in their lungs (a condition known as pulmonary edema), making breathing difficult. Sitting up straight may help to some extent. Place the patient in the most comfortable posture for them.
  • If aspirin is available, provide it. Give aspirin to the patient if they are awake and cognizant enough to follow recommendations and swallow safely. 162-325 mg (2-4 baby aspirin or 1 full strength aspirin) chewed and swallowed is a common advice. Chewing before ingesting enhances absorption and allows the medicine to operate more quickly. Although aspirin is often referred to be a blood thinner, it is really an anti-platelet drug. Aspirin inhibits clotting by causing platelets in the blood to become less adherent to each other. Before you provide aspirin to a patient, be sure they aren’t allergic to it! (It’s a good idea to carry some aspirin in your personal first-aid box for occasions like these!)

These first measures may make a big difference in whether or not you survive a heart attack. The most crucial step, if nothing else, is to contact 911 right away to activate emergency assistance.

The patient may have gone into cardiac arrest if they become unresponsive. Don’t assume they’ve passed out and attempt CPR; they might have just passed out or fallen unconscious. First:

 

  • Check for attentiveness by shaking the patient’s shoulder and asking, “Hey buddy, are you all right?” “Can you hear what I’m saying?” Address them by name if you know their name.
  • If the patient is still unconscious, lie them down on the floor and check for a carotid pulse (the one in the neck).
  • Look for signs of breathing by “seeing, listening, and feeling.” Look towards the patient’s chest with your face over the patient’s lips. Look for the patient’s chest to rise and fall, listen for breath noises from the patient’s nose and mouth, and feel for their breath on your face while you check their pulse.
  • If you can feel a pulse and they seem to be breathing properly, don’t start CPR right away; instead, keep an eye on their heart rate and breathing until EMS comes.

If you can’t feel the patient’s pulse and they’re not breathing, they’ve gone into cardiac arrest. The greatest chance for this patient right now is to start CPR and provide an AED shock (AED). If an AED is accessible, the emergency dispatcher may walk you through the procedures to start “hands-only” CPR and use an AED. To administer a shock safely and efficiently, an AED delivers easy-to-follow voice or visual instructions. If a patient slips into cardiac arrest, immediately initiating CPR and administering an AED shock might mean the difference between life and death. Next, we’ll go further into this.

AEDs and CPR

CPR is a life-saving procedure.

If you’ve never done CPR before, you should know that it’s not at all what it’s presented in movies and television. In movies, we frequently see someone giving a few soft pats or gentle presses on the patient’s chest (or, in the worst cases, their stomach), or a single grandiose thump of the chest, and the patient suddenly and dramatically returning to full consciousness with a huge gasp and a “Whoa, what happened?!?” CPR does not operate like this in real life, and the patient does not mysteriously come back to life.

CPR is used to keep a person alive until they can be sent to a hospital for further treatment. CPR physically forces the heart to pump blood to the body, supplying oxygen to the brain and other essential organs, until the heart can be jumpstarted with an electric shock from an AED or by EMS or hospital personnel using modern cardiac monitors and medicines like adrenaline (epinephrine). Even if the heart is returned to a normal rhythm using these devices and medicines, the patient may not regain consciousness soon or at all. Unfortunately, the vast majority of cardiac arrests that occur outside of the hospital are deadly. We provide a cardiac arrest patient the greatest chance of survival by doing high-quality CPR and administering an early shock from an AED.

If you’re with someone who’s had a heart attack, the emergency dispatcher may tell you to administer CPR until the EMTs or paramedics come. Bystanders are now advised to administer “hands-only CPR,” which is different from standard CPR in that it does not entail “mouth-to-mouth” or other ways of breathing for the patient, but merely chest compressions. 

 

Everyone should get CPR (and AED) instruction. Hands-on training to assist you learn the mechanics of CPR and feel the proper pace and depth of compressions is invaluable and cannot be replaced by viewing a video or reading instructions online. Knowing how to do CPR on a dummy can help you gain confidence and remain cool in the case of an emergency.How to perform hands-only CPR.

Hands-only CPR for an adult is mainly conducted as follows, for informational reasons only:

  • Kneel down by the patient’s side.
  • In the middle of the patient’s sternum, place the heel of your dominant hand’s palm. The second hand should be interlocked on top of the first.
  • Begin squeezing the chest with your body weight while holding your arms fully extended and bending forward so your shoulders are above your hands. Bend your arms instead of compressing using your arm power.
  • Compress the chest at a pace of 100-120 compressions per minute to a depth of at least two inches. While performing CPR, I was taught to sing the Bee Gees’ “Stayin’ Alive” refrain to get a sense of the acceptable rate (albeit I’ve never had the Bee Gees jump into my head or felt like singing in the midst of an actual CPR episode).

Untrained people’s efforts at CPR often fail because the depth and pace of compressions are insufficient. People are concerned about injuring the patient by pressing too hard on the chest. At the risk of seeming harsh, if you’re administering CPR, the patient is already dead; completely squeezing the chest will not harm them.

Don’t stop doing hands-only CPR after you’ve started! Until EMS comes, keep squeezing the chest. Consider switching compressions with another bystander every couple of minutes so you can keep providing efficient compressions; proper CPR will exhaust you, and your compressions will become slower and shallower as you become weary. Do not give up! If you must take a break, keep it to 10 seconds or less.

Using an AED (Automated External Defibrillator)

Remember, CPR is used to extend life until an AED or EMS can administer a shock. Use an AED as soon as one becomes available.

AEDs are provided in many public buildings and workplaces in the case of an emergency. Every state has some kind of AED rule or regulation, and some states mandate them in certain places like health and fitness clubs. You may have seen placards that read “AED HERE” or something like in public places to warn the public to the presence of these devices. They may also come with trauma shears to remove clothes so that AED pads may be placed, protective barrier devices to provide mouth-to-mouth respirations during CPR, and even a razor to shave the chest (if there is excessive hair, which prevents the pads from sticking properly). Check with your employer to see whether an AED is accessible in the event of an emergency, and keep an eye out for them when doing errands.

 

Despite the many manufacturers and versions of AEDs, the procedure for utilizing one is almost universal:

  • To begin, switch on the AED. With auditory or video-guided prompts, the gadget will start giving instructions. Because the instructions differ significantly across models, pay attention to the prompts.
  • The pads should be placed on the patient’s bare chest. Yes, this also applies to women. If the patient’s chest is damp or moist, dry it before putting the pads on. The pads are usually maintained in a container with a picture of where each pad should be placed. One pad will be put on the chest below the collar bone and to the right (the patient’s right!) of the sternum. The second one will go beneath the left pectoral/breast. If you have another bystander nearby, place the pads on them while they administer CPR. Stop only when the gadget tells you to.
  • While the AED examines the electrical rhythm of the patient’s heart, it will instruct you to halt CPR and not to touch the patient. If a shockable rhythm is identified, the AED will display a message that says “shock recommended” and begin charging.
  • The AED will advise you to give a shock by pushing a button on the device, while reminding you to keep far of the patient (humans are excellent conductors of electricity).
  • Ascertain that no one is touching the patient before administering the shock. Even if you’re not in direct touch with the patient, be wary of items like metal near the patient or puddles of water that might transmit the voltage to you.
  • The AED will advise you to resume CPR after you’ve administered the shock. With sustained auditory and/or visual guidance, the AED will repeat the stages of analysis, charging, and shock delivery after two minutes of CPR. Until EMS comes, this will continue in cycles of CPR and shocks.

A short search on YouTube yields multiple videos from the American Heart Association and the American Red Cross that illustrate these techniques for reference, but nothing substitutes real-world experience in how to use an AED, just as nothing replaces hands-on instruction in CPR. You may never be required to utilize these talents, but if you are, you will be grateful for the training.

The American Heart Association offers a variety of training alternatives for everyone from first responders to regular citizens, including certification if it is necessary for a job. Full First Aid, CPR, and AED training are available, but you may also obtain instruction only for the hands-only CPR we mentioned. Similar training is available via the American Red Cross. Both of these organizations provide online, in-person, or hybrid courses as well as supplemental training resources to meet your specific requirements.

What to Expect From EMS and Hospitalization

So far, we’ve spoken about what causes heart attacks, how to lower your chance of having one, and what to look for and do if you see someone suffering a heart attack. What many people don’t know is what to anticipate after they’re in an ambulance or at the hospital. It’s easy for things to seem chaotic in these high-stress, emotionally charged circumstances. It could assist you in gaining a better grasp of what’s going on.

 

2-6 EMS personnel may arrive, depending on where you reside and the resources available. In certain places, EMS resources are restricted, and you may only get two EMTs. Other fire agencies react with an ambulance and a fire engine that can transport up to six paramedics. Regardless, during a heart attack, each member of these teams has a distinct job to perform. These responsibilities and processes may differ somewhat depending on responder certification and whether or not the patient is aware. In both a paramedic-staffed ambulance and an emergency hospital, the processes I explain are extremely similar. Most of these processes are done at the same time, depending on the scenario.

One of the responders will converse to the patient about their symptoms, medical history, prescription drugs, and other information while the procedures are being performed. They’ll try to get the same information from a family member or bystander if the patient is asleep.

A 12-lead EKG is conducted after vital indicators such as blood pressure, heart rate, and oxygen percentage are taken. An EKG includes sticking a lot of stickers (electrodes) on the patient’s chest, arms, and legs and connecting them to cables. These cables link to a sophisticated cardiac monitor that can read the electrical signal from the heart and display it in 12 various ways (leads). The 12-lead can reveal the indicators of a heart attack as well as where section of the heart is impacted. (Because a 12-lead may identify abnormal cardiac rhythms and a variety of other diseases outside a heart attack, they’re often employed in EMS and hospital settings for more than simply suspicion of a heart attack.)

When EMS comes, if the patient is in cardiac arrest, they will take over CPR and link the patient to their heart monitor, which features an enhanced form of an AED. On the drive to the hospital, they’ll keep doing CPR and administering shocks, as well as taking the other actions listed below.

Depending on how much more oxygen the patient need, they may be given supplemental oxygen via a nasal cannula (the little tube shown under the nose that wraps around the ears) or a non-rebreather (a mask that covers the nose and mouth with a bag connected to the bottom).

If aspirin hasn’t been administered before, another medicine called nitroglycerin may be given to the patient. Nitroglycerin, sometimes known as “nitro,” dilates blood vessels and may open up the damaged coronary arteries, allowing more blood to flow past the blockage. Depending on the patient’s vital signs, nitroglycerin may or may not be administered. Patients may be given nitro for specific cardiac issues, and although they may take it as advised, you should not give it to them. Nitro may be beneficial, but under the wrong circumstances, it might really make things worse. These conditions are recognized by EMS and hospital personnel.

 

At least one, but typically two, IVs will be started (intravenous access). Responders may provide drugs such as morphine straight into the bloodstream by inserting an IV. Morphine relieves pain rapidly, which lowers the patient’s tension and reduces the heart’s workload. If your blood pressure is too low, you may be given fluids to raise it. Other medicines, such as adrenaline, will be administered via the IV if the patient is in cardiac arrest (Motley Crüe, anyone?).

If a patient is in cardiac arrest, some EMS companies and hospitals will instead initiate a “IO.” Intraosseous access (IO) refers to a needle inserted into a bone that allows drugs or fluids to reach the bloodstream through the bone marrow. When the heart isn’t pumping blood, this works almost as rapidly as an IV (the difference is largely invisible) and may be quicker and simpler to start. An IO begins with a little handheld drill, which may seem brutal to family members watching, but it is a quick procedure that helps to recall that the unconscious patient cannot feel it.

Initially, the patient’s artificial respiration will be provided via a football-shaped bag that is linked to a face mask and pressed to give air. However, this manner of breathing isn’t ideal, and some air will unavoidably seep outside the mask or end up in the stomach rather than the lungs. Varying EMS agencies have different restrictions, however paramedics will do an endotracheal intubation if it is approved.

Endotracheal intubation is inserting a tiny tube directly into the trachea, enabling all air provided from the bag to reach the lungs directly. Witnessing it might be terrifying for family members or onlookers, but it is more effective at supplying much-needed oxygen. It is also safer for the patient in the long run since it maintains the airway open and avoids vomit, blood, or other secretions from entering the airway. It efficiently isolates the lungs from any air that isn’t oxygen-rich.

Blood tests will be conducted after the patient has been stabilized in the hospital to search for various enzymes and hormones generated by the heart during a heart attack. The patient will be sent to a cardiac catheterization lab (also known as a “cath lab”), where a doctor may conduct a number of minimally invasive procedures guided by modern imaging to improve blood flow to the coronary arteries and insert stents or balloons to keep these vessels open. They’ll then be sent to the intensive care unit (ICU). Not all patients need a trip to the cath lab; some may require more invasive treatments, while others may be sent directly to the ICU. There are just too many variables and possible outcomes to mention here.

You should also be prepared for the potential that the patient may not be able to leave the emergency department despite your best efforts. While not all heart attacks are deadly, many are, and most individuals who fall into cardiac arrest will die if they are not resuscitated.

 

This is not a situation that any of us wants to find ourselves in. However, armed with some information and guidance from your doctor, you may take actions to lower your personal risk of heart disease and heart attacks, as well as urge people you care about to do so. Don’t put it off any longer. Schedule an appointment with your doctor and enroll in a CPR course. You can make a difference and maybe save the life of someone you care about by understanding what to look for, maintaining your calm, and performing a few easy measures.

This is not a situation that any of us wants to find ourselves in. However, armed with some information and guidance from your doctor, you may take actions to lower your personal risk of heart disease and heart attacks, as well as urge people you care about to do so. Don’t put it off any longer. Schedule an appointment with your doctor and enroll in a CPR course. You can make a difference and maybe save the life of someone you care about by understanding what to look for, maintaining your calm, and performing a few easy measures.

Charles Patterson is the father of five gorgeous children and the spouse of a lovely woman. Charles discovered his real calling as a paramedic after serving in the Marine Corps as a linguist and receiving a degree in Music Production following his release. He likes cycling, mountain biking, shooting firearms, frisbee golf with his family, and playing guitar when the job and duties are done.

 

 

The “what is the first aid treatment for heart attack” is a question that has been asked many times. The symptoms of a heart attack are not always easy to spot and can be difficult to diagnose. The best way to respond would be to call an ambulance or emergency services as soon as possible.

Related Tags

  • how to stop a heart attack in 30 seconds
  • pre heart attack symptoms male
  • pre heart attack symptoms female
  • heart attack emergency treatment at home
  • 6 signs of heart attack a month before