Chest Pain: Causes, Symptoms & When to Seek Care

What Are the Different Types of Chest Pain?

Chest pain can feel different depending on its cause. The main types include pressing or squeezing pain (often cardiac), sharp stabbing pain (often musculoskeletal or respiratory), cramping pain, and pain that radiates to the back, arms, or neck. Understanding the type of pain helps determine if it requires emergency care.

Chest pain manifests in various ways, and the character of the pain provides important clues about its underlying cause. Healthcare providers use the quality, location, duration, and associated symptoms of chest pain to determine the urgency of care needed and guide diagnostic testing. While not every type of chest pain is immediately dangerous, certain patterns warrant emergency evaluation.

The chest contains multiple organ systems, including the heart, lungs, esophagus, and the musculoskeletal structures of the chest wall. Pain can originate from any of these sources, and sometimes pain from other areas (like the upper abdomen) can be felt in the chest. This complexity is why chest pain requires careful evaluation rather than self-diagnosis.

Research published in the European Heart Journal shows that the character of chest pain is one of the most important factors in determining cardiac risk. However, it's important to understand that atypical presentations are common, especially in women, elderly patients, and those with diabetes. What matters most is recognizing warning signs that require immediate medical attention.

Pressing or Squeezing Pain

This type of pain feels like a heavy weight or pressure on the chest. Patients often describe it as "an elephant sitting on my chest" or a tight band around the chest. This pressing quality is classically associated with cardiac causes, particularly angina pectoris and heart attack (myocardial infarction).

When the heart muscle doesn't receive enough oxygen-rich blood due to narrowed or blocked coronary arteries, it generates pain signals that are typically perceived as pressure rather than sharp pain. This pain often radiates to the left arm, neck, jaw, or back. It may be triggered by physical exertion or emotional stress and typically improves with rest (in the case of stable angina).

Sharp or Stabbing Pain

Sharp, stabbing chest pain that worsens with breathing or movement is more commonly associated with musculoskeletal causes, pleurisy (inflammation of the lung lining), or pericarditis (inflammation of the heart's outer lining). While this type of pain can be quite severe and frightening, it is less likely to indicate an acute heart attack.

Musculoskeletal chest pain often can be reproduced by pressing on the chest wall or by specific movements. It may follow unusual physical activity, coughing, or minor trauma. Pleuritic pain specifically worsens with deep breathing and may be accompanied by a dry cough.

Cramping Pain

Intense, cramping chest pain can have various causes. It may be related to esophageal spasm (painful contractions of the esophagus that can mimic heart pain), coronary artery spasm (Prinzmetal's angina), or muscular causes. This type of pain often comes in waves and may be associated with eating or occur at rest.

Radiating Pain

Pain that spreads from the chest to other areas of the body—particularly the left arm, neck, jaw, shoulder, or back—is a concerning feature that increases the likelihood of cardiac origin. According to ESC guidelines, radiation of chest pain is one of the key features of typical angina. However, pain can also radiate from non-cardiac sources, so this feature alone doesn't confirm a heart problem.

When Should You Call Emergency Services for Chest Pain?

Call emergency services immediately if you have severe, pressing or cramping chest pain lasting more than 15 minutes, unexplained chest discomfort with shortness of breath, cold sweats, nausea, or irregular heartbeat. These could be signs of a heart attack requiring immediate treatment.

Knowing when chest pain requires emergency care versus when it can wait for a scheduled appointment is crucial. While most chest pain is not immediately life-threatening, certain patterns indicate potentially serious conditions that require rapid diagnosis and treatment. Time is particularly critical in heart attacks, where early treatment can prevent permanent heart damage and save lives.

The "time is muscle" principle in cardiology emphasizes that every minute of delayed treatment during a heart attack results in more heart muscle damage. Modern treatments like primary angioplasty (PCI) can open blocked arteries and restore blood flow, but their effectiveness decreases with delay. This is why recognizing emergency warning signs is so important.

Emergency medical services should be called rather than driving yourself to the hospital. Paramedics can begin treatment en route, including ECG monitoring, aspirin administration, and in some regions, transmission of ECG data to the hospital for faster treatment upon arrival.

When to Seek Non-Emergency Medical Care

Not all chest pain requires emergency services. You should schedule an appointment with your healthcare provider if you experience chest pain that is brief (lasting seconds to minutes), reproducible with movement or pressure, clearly related to eating, or that you've had before and been evaluated for.

However, if you're uncertain about the cause of your chest pain or it's a new symptom for you, it's always better to err on the side of caution and seek medical evaluation sooner rather than later. Your healthcare provider can help determine whether further testing is needed.

What Causes Chest Pain?

Chest pain has many causes including muscle strain and tension (most common), anxiety and psychological stress, acid reflux (GERD), angina pectoris, heart attack, pericarditis, pulmonary embolism, and aortic dissection. While most cases are non-cardiac, ruling out serious heart conditions is essential.

The causes of chest pain range from benign to life-threatening, which is why proper evaluation is important. Studies show that among patients presenting to emergency departments with chest pain, approximately 15-25% have an acute coronary syndrome (heart attack or unstable angina), while the majority have non-cardiac causes. Understanding the different causes helps recognize patterns that require urgent attention.

The chest wall, heart, lungs, esophagus, and even upper abdominal organs can all generate pain perceived in the chest. Additionally, psychological factors can cause or amplify chest pain through muscle tension and heightened pain perception. A comprehensive approach considers all these possibilities.

Musculoskeletal Causes

Muscle strain and inflammation are among the most common causes of chest pain. The chest wall contains numerous muscles, joints, and cartilages that can become strained, inflamed, or injured. Various tension states in the chest muscles can cause pain and lead to inflammation. This tension can cause cramping pains or tingling that radiates to the back, neck, and shoulders.

Common triggers include unusual physical activity, heavy lifting, prolonged coughing, or repetitive movements. The pain is typically sharp, worsens with movement or pressure on the affected area, and improves with rest and anti-inflammatory medications. Tietze's syndrome, an inflammation of the costochondral joints (where ribs meet the breastbone), causes localized tenderness and swelling that can mimic cardiac pain.

Age-related changes in the cervical spine can also cause severe pain when pressure develops on nerves that extend from between the vertebrae to the arms and chest. This can mimic heart pain but typically follows a dermatomal pattern and is associated with neck movement.

Psychological Causes

Muscle tension is common in connection with worry, anxiety, and depression. This can cause heart palpitations, chest pressure, and shortness of breath. Prolonged psychological stress can lead to muscle inflammation in the chest wall and other muscles, creating a cycle of pain and anxiety that can be difficult to break.

Panic attacks can cause intense chest pain, rapid heartbeat, shortness of breath, and a feeling of impending doom that closely mimics a heart attack. While not physically dangerous, these episodes are genuinely distressing and the pain is real. Distinguishing panic attacks from cardiac events often requires medical evaluation, especially if it's the first occurrence.

Cardiac Causes

Angina pectoris (stable angina) occurs when one or more coronary arteries become narrowed due to atherosclerosis. The narrowed vessels cannot deliver enough blood to meet the heart's demands during exertion, causing chest pain that typically improves with rest. Angina is a warning sign of underlying coronary artery disease that requires medical management.

A heart attack (myocardial infarction) occurs when a coronary artery becomes completely blocked, usually by a blood clot forming on top of an atherosclerotic plaque. This causes oxygen deprivation to part of the heart muscle, which can be permanently damaged if blood flow isn't restored quickly. Heart attack pain is typically more severe and prolonged than angina and doesn't improve with rest.

Pericarditis (inflammation of the sac surrounding the heart) can develop from viral infections, and you may also have myocarditis (heart muscle inflammation) simultaneously. The viral infection usually means you have symptoms of flu or sore throat at the same time. But sometimes you can have isolated inflammation of the pericardium or heart muscle. Pericarditis pain is typically sharp, worsens with breathing or lying down, and improves with sitting forward.

Cardiomyopathy (heart muscle disease) or enlargement of the heart can also cause chest pain. The disease occurs because the heart muscle grows abnormally. A common cause is high blood pressure.

Pulmonary Causes

Pulmonary embolism occurs when blood clots form in the veins (blood vessels that return blood to the heart) and a portion or entire clot breaks loose and travels through the bloodstream to the lungs' blood vessels. These clots often form in the legs but can develop in other parts of the body. Risk factors include surgery, prolonged immobility, cancer, and certain inherited conditions.

Pneumothorax (collapsed lung from burst air sacs) is most common in older adults with lung diseases that cause enlarged air sacs. However, ruptures can also occur in younger people, usually during sports activities. This causes sudden, sharp chest pain and shortness of breath.

Pleurisy (inflammation of the lung lining) often results from viral infections but can sometimes be caused by pneumonia or certain allergic diseases. The hallmark is sharp pain that worsens with breathing.

Vascular Causes

Aortic dissection is a rare but life-threatening condition where the wall of the aorta (the main artery from the heart) tears. One cause is atherosclerosis, but it can also result from a congenital weakness in the vessel wall. The pain is typically sudden, severe, and described as "tearing," often radiating to the back. This is a surgical emergency.

Gastrointestinal Causes

Gastroesophageal reflux disease (GERD) occurs when stomach acid leaks into the esophagus, causing inflammation and spasm. The esophageal lining reacts with inflammation and cramping. This can cause chest pain that closely mimics cardiac pain, often described as burning or pressure behind the breastbone.

Peptic ulcers in the stomach or duodenum can cause upper abdominal pain that may be perceived as chest pain. Gallstones can also cause referred pain to the chest, particularly after fatty meals.

Other Causes

Shingles (herpes zoster) is caused by the same virus as chickenpox and appears as a painful rash along a nerve distribution. Before the rash appears, it can cause chest pain that may be confusing diagnostically. Once the characteristic blistering rash appears, the diagnosis becomes clear.

What Tests Are Done for Chest Pain?

Common tests for chest pain include ECG (electrocardiogram) to check heart rhythm and detect heart damage, blood tests for cardiac enzymes (troponin), chest X-ray, echocardiogram (heart ultrasound), stress testing, and coronary angiography. The specific tests depend on your symptoms and risk factors.

When you see a doctor for chest pain, they will start by taking a detailed history about your symptoms and any previous medical conditions. How you're feeling psychologically is also important for the doctor's assessment, which is why you may also be asked about your relationships and daily activities. The doctor then performs a physical examination and listens to your heart.

The goal of testing is to determine whether the chest pain has a cardiac cause and, if so, how serious it is. Testing also helps rule out other dangerous conditions and identify the actual cause so appropriate treatment can begin. The extent of testing depends on your symptoms, risk factors, and initial findings.

ECG and Stress Testing

An ECG (electrocardiogram) is often the first test performed to assess heart function. An ECG can show if you've had a heart attack, among other things. It also shows if the heart has oxygen deprivation, which is a clear sign of angina. Rhythm disturbances that can cause chest pain are also visible on ECG.

A stress test (exercise ECG) records the ECG before, during, and after exertion on a treadmill or exercise bike. This helps detect coronary artery disease that may not be apparent at rest. Sometimes a CT coronary angiography (CT scan of the heart's coronary arteries) is done instead of a stress test, particularly in patients who cannot exercise adequately.

Echocardiography

An echocardiogram (heart ultrasound) can show if the amount of fluid in the pericardium has increased, which may indicate pericarditis. The examination can also reveal abnormalities in heart valves or heart muscle function. It's non-invasive and provides valuable information about heart structure and function.

Blood Tests

Cardiac biomarkers, particularly troponin, can detect heart muscle damage. Elevated troponin levels indicate that heart cells have been damaged, as occurs in a heart attack. Modern high-sensitivity troponin tests can detect very small amounts of heart damage and are central to the diagnosis of acute coronary syndromes.

Other blood tests may include complete blood count, kidney function, and inflammatory markers depending on the suspected diagnosis.

Coronary Angiography

Through coronary angiography, the doctor can see if you have narrowings in the blood vessels that can cause angina. A catheter is inserted through an artery (usually in the wrist or groin), contrast dye is injected, and X-ray images show the coronary arteries in detail. This is the gold standard for diagnosing coronary artery disease.

If significant blockages are found during angiography, they can often be treated immediately with angioplasty and stent placement (percutaneous coronary intervention, or PCI).

Lung Investigations

Your lungs are examined with chest X-ray if the doctor suspects pleurisy or if you have air in the pleural space due to ruptured lung air sacs. If there is suspicion of a pulmonary embolism, one of the following investigations may be needed:

• CT pulmonary angiography - the primary test for diagnosing pulmonary embolism
• Ultrasound of leg veins - to look for deep vein thrombosis
• D-dimer blood test - elevated levels suggest blood clotting
• V/Q scan (ventilation-perfusion scintigraphy) - used when CT is contraindicated

Additional investigations may be needed depending on what the doctor suspects you have.

How Is Chest Pain Treated?

Treatment depends on the underlying cause. Temporary muscle inflammation typically doesn't require treatment. Heart conditions may require medications (aspirin, nitroglycerin, blood thinners), interventional procedures (angioplasty, stenting), or surgery. Emergency treatment for heart attack focuses on rapidly restoring blood flow to the heart.

The treatment of chest pain is entirely dependent on its underlying cause. A temporary muscle inflammation usually doesn't need treatment and resolves on its own with rest and time. Anti-inflammatory medications and heat or ice application may provide symptomatic relief. However, certain heart and lung diseases may require treatment with surgery or interventional procedures.

For chest pain with psychological components, addressing the underlying anxiety or stress is important. This may involve counseling, stress management techniques, or in some cases, medication for anxiety or depression. The pain from psychological causes is real and deserves treatment, even though it's not dangerous.

Emergency Treatment for Heart Attack

If a heart attack is suspected or confirmed, treatment focuses on rapidly restoring blood flow to the heart muscle. Time is critical—the faster treatment begins, the more heart muscle can be saved. Initial treatment typically includes:

• Aspirin to prevent further clot formation
• Antiplatelet medications (like clopidogrel or ticagrelor)
• Anticoagulants (blood thinners) to prevent clot extension
• Nitroglycerin to dilate blood vessels and reduce heart workload
• Pain relief (often morphine)
• Oxygen if blood oxygen levels are low

The definitive treatment for most heart attacks is primary PCI (angioplasty with stenting), where a catheter is used to open the blocked artery and a stent is placed to keep it open. This should ideally be performed within 90-120 minutes of arrival at the hospital. When PCI is not available quickly enough, thrombolytic therapy (clot-dissolving medication) may be used.

Treatment for Angina

Stable angina is managed with medications to reduce symptoms and prevent heart attacks, along with lifestyle modifications. Medications may include:

• Nitroglycerin for acute symptom relief
• Beta-blockers to reduce heart rate and blood pressure
• Calcium channel blockers to reduce heart workload
• Aspirin and statins to reduce cardiovascular risk

If medications don't adequately control symptoms or if testing shows significant coronary artery disease, revascularization (PCI or bypass surgery) may be recommended.

Treatment for Other Causes

Other causes of chest pain have their own specific treatments:

• Pericarditis: Anti-inflammatory medications (NSAIDs, colchicine), sometimes steroids
• Pulmonary embolism: Anticoagulation therapy, sometimes thrombolysis or intervention
• GERD: Proton pump inhibitors, lifestyle modifications
• Musculoskeletal pain: Rest, anti-inflammatory medications, physical therapy
• Anxiety-related pain: Counseling, stress management, sometimes medications

How Can You Prevent Chest Pain from Cardiac Causes?

Preventing cardiac-related chest pain involves managing cardiovascular risk factors: maintaining healthy blood pressure and cholesterol, not smoking, regular physical activity, healthy diet, maintaining a healthy weight, managing diabetes, and limiting alcohol. These measures reduce the risk of developing coronary artery disease.

While not all chest pain can be prevented, cardiac causes—which are the most dangerous—are largely preventable through lifestyle modifications and management of risk factors. Coronary artery disease develops over decades, and addressing risk factors early can significantly reduce the chance of heart attacks and angina later in life.

The major modifiable risk factors for coronary artery disease are:

• High blood pressure: Regular monitoring and treatment if elevated
• High cholesterol: Diet modifications and medication if needed
• Smoking: Complete cessation is essential
• Diabetes: Good blood sugar control
• Obesity: Maintaining a healthy weight
• Physical inactivity: Regular moderate exercise
• Unhealthy diet: Mediterranean-style diet is cardioprotective

If you have known coronary artery disease, taking prescribed medications consistently, attending regular follow-up appointments, and recognizing when symptoms change are all important for preventing chest pain episodes and heart attacks.

Frequently Asked Questions About Chest Pain