Chest Pain: Causes and When It Is an Emergency

When to worry about chest pain

There is no reliable way to tell at home whether chest pain is from your heart. Doctors in the ER cannot tell either without an ECG and blood tests. Call 911 or your local emergency number, rather than driving, if your chest pain has any of the emergency features above. Paramedics can start treatment on the way.

If a heart attack is possible and you are not allergic to aspirin, the dispatcher may advise chewing one regular 325 mg aspirin or four 81 mg low-dose tablets. Do not take aspirin if you are allergic, have been told not to, or have a bleeding problem.

Heart attack symptoms in women, older adults and people with diabetes

Women are more likely than men to have a heart attack with less typical symptoms: breathlessness, nausea, back or jaw pain, unusual tiredness, indigestion-like discomfort, or lightheadedness, sometimes with little or no chest pain. Older adults and people with diabetes may also have muted or unusual symptoms.

Causes of chest pain

Heart and blood vessels

• Heart attack: a blocked coronary artery. Typically pressure, squeezing or heaviness in the center or left of the chest lasting over 15 minutes, often with sweating, nausea and breathlessness.
• Angina: temporary lack of blood flow to the heart muscle. Similar pressure that comes on with exertion, cold or stress and eases within minutes of rest. New or worsening angina (unstable angina) needs emergency care.
• Pericarditis: inflammation of the sac around the heart. Sharp pain, worse lying down or breathing in, better sitting forward, often after a viral illness.
• Myocarditis: inflammation of the heart muscle, often after a viral illness, with chest pain, palpitations and breathlessness.
• Aortic dissection: a tear in the wall of the main artery. Sudden, severe, tearing pain going to the back. Rare but life-threatening.

Lungs

• Pulmonary embolism: a clot in the lung arteries. Sudden sharp pain worse on breathing in, breathlessness, fast heart rate, sometimes coughing blood. Risk is higher after surgery, long journeys, with cancer, pregnancy or estrogen pills.
• Pneumonia and pleurisy: sharp pain on breathing with fever and cough.
• Collapsed lung (pneumothorax): sudden one-sided sharp pain and breathlessness, often in tall, thin young men or people with lung disease.
• Asthma and COPD: chest tightness with wheeze.

Digestive system

• Acid reflux and GERD: burning behind the breastbone after meals or lying down, with a sour taste.
• Esophageal spasm: squeezing pain that can mimic angina, sometimes with trouble swallowing.
• Gallbladder and pancreas problems: upper belly pain that can spread to the chest or back.
• Peptic ulcers: gnawing upper belly or lower chest pain.

Muscles, bones and nerves

• Muscle strain: pain after exercise, lifting or heavy coughing, worse with movement.
• Costochondritis: inflammation where the ribs join the breastbone. Sharp or aching pain that is tender to press.
• Rib fracture or bruising: after a fall or blow, very painful with breathing.
• Shingles: burning, one-sided band of pain, followed by a blistering rash.
• Neck or upper back problems: pain referred to the chest.

Anxiety and panic

Panic attacks cause chest tightness or sharp pain with a racing heart, fast breathing, tingling, shaking and a sense of doom, peaking within 10 minutes. They are very common, but panic is a diagnosis made only after heart problems are excluded, especially in a first episode.

Chest pain by type and location

Location is less helpful than people expect. Left-sided chest pain can come from the heart but is equally often muscular, from the stomach or anxiety. Heart pain is often central or diffuse rather than pinpoint. For stabbing pain in particular, see sharp chest pain.

How doctors evaluate chest pain

In the ER, you will have:

1. An ECG within 10 minutes of arrival, looking for heart attack patterns and rhythm problems.
2. Troponin blood test: a marker of heart muscle damage, often repeated after 1 to 3 hours.
3. Chest X-ray: for pneumonia, collapsed lung and heart size.
4. Other tests as needed: D-dimer and CT pulmonary angiogram for suspected clot; CT of the aorta for dissection; echocardiogram for pericarditis or heart function.

If urgent causes are ruled out but heart disease is still possible, follow-up tests include an exercise stress test, a stress echocardiogram, or a CT coronary angiogram.

Treatment and what you can do

Treatment depends on the cause:

• Heart attack: emergency procedures to reopen the artery (angioplasty and stent), blood thinners and long-term heart medicines.
• Angina: nitroglycerin for attacks, medicines to protect the heart, and sometimes stents or bypass surgery.
• Pulmonary embolism: anticoagulant (blood-thinning) medicine.
• Reflux: antacids, acid-reducing medicine and avoiding late, large meals.
• Muscle and costochondritis pain: rest from aggravating activities, heat or ice, and acetaminophen (paracetamol) or ibuprofen at the label dose.
• Panic attacks: slow breathing, cognitive behavioral therapy and sometimes medicines.

To lower your risk of heart-related chest pain: stop smoking, control blood pressure, cholesterol and blood sugar, stay active and keep a healthy weight.

Frequently asked questions

How do I know if chest pain is serious?

Chest pain is more likely serious if it feels like pressure or squeezing, lasts more than a few minutes, spreads to the arm, jaw or back, or comes with breathlessness, sweating, nausea or fainting. Sudden sharp pain with breathlessness is also serious. When in doubt, call 911.

What does heart-related chest pain feel like?

Heart pain is usually a pressure, heaviness, squeezing or tightness, often in the center of the chest, that may spread to the arms, neck, jaw or back. It typically lasts minutes rather than seconds and may come with exertion. It is rarely a pinpoint pain you can press on.

Can anxiety cause chest pain?

Yes. Anxiety and panic attacks cause chest tightness or sharp pain with a fast heartbeat, rapid breathing, tingling and dizziness. Because these symptoms overlap with heart problems, a first episode should be checked by a doctor before assuming it is anxiety.

Is left-sided chest pain always the heart?

No. Left-sided pain is often caused by muscle strain, costochondritis, acid reflux, lung problems or anxiety. The heart sits in the center of the chest, and heart pain is often central or spread out. Any chest pain with warning signs still needs emergency assessment.

How long does chest pain from a heart attack last?

Heart attack pain usually lasts more than 15 minutes and may come and go. Angina usually lasts 2 to 10 minutes and eases with rest. Never wait to see whether pain passes if it has heart attack features. Faster treatment saves heart muscle.

What should I do while waiting for an ambulance?

Stop all activity and sit or lie in a comfortable position. Open the front door so responders can get in. If advised by the dispatcher and you are not allergic, chew an aspirin. Take your own prescribed nitroglycerin if you have it. If the person collapses and is not breathing normally, start CPR.