What is chest pain

Chest pain is any sort of pain felt in your upper body, from your jaw down to the bottom of your ribs. Because it can be a sign of a heart attack, it’s safest to consider chest pain as heart-related, until proven otherwise!

People having a heart attack may have just one of these symptoms, or a combination of them. They can come on suddenly or develop over minutes and get progressively worse. Symptoms usually last for at least 10 minutes.

Warning signs of a heart attack could include:

• discomfort or pain in the center of your chest – a heaviness, tightness or pressure, like an elephant sitting on your chest, or a belt tightening around your chest, or a bad case of indigestion
• discomfort in the arms, shoulder, neck, jaw or back
• other problems such as:
• a choking feeling in your throat
• your arms feeling heavy or useless
• feeling short of breath
• feeling nauseated
• having a cold sweat
• feeling dizzy or light-headed.

Chest pain symptoms can range from a mild sensation, to a severe pain. All chest pain is considered to be heart-related until proven otherwise.

Heart attacks are more common in older people than younger people, but they can occur in people of any age.

Other causes of chest pain

There can be many other causes, including:

• Other heart problems, such as angina
• Panic attacks
• Digestive problems, such as heartburn or esophagus disorders
• Sore muscles
• Lung diseases, such as pneumonia, pleurisy, or pulmonary embolism
• Costochondritis – an inflammation of joints in your chest

Some of these problems can be serious. Get immediate medical care if you have chest pain that does not go away, crushing pain or pressure in the chest, or chest pain along with nausea, sweating, dizziness or shortness of breath. Treatment depends on the cause of the pain.

Chest pain Symptoms

Chest pain can cause many different sensations depending on what’s triggering the symptom. Often, the cause has nothing to do with your heart — though there’s no easy way to tell without seeing a doctor.

Heart-related chest pain

Although chest pain is often associated with heart disease, many people with heart disease say they experience a vague discomfort that isn’t necessarily identified as pain. In general, chest discomfort related to a heart attack or another heart problem may be described by or associated with one or more of the following:

• Pressure, fullness, burning or tightness in your chest
• Crushing or searing pain that radiates to your back, neck, jaw, shoulders, and one or both arms
• Pain that lasts more than a few minutes, gets worse with activity, goes away and comes back, or varies in intensity
• Shortness of breath
• Cold sweats
• Dizziness or weakness
• Nausea or vomiting

Other types of chest pain

It can be difficult to distinguish heart-related chest pain from other types of chest pain. However, chest pain that is less likely due to a heart problem is more often associated with:

• A sour taste or a sensation of food re-entering your mouth
• Trouble swallowing
• Pain that gets better or worse when you change your body position
• Pain that intensifies when you breathe deeply or cough
• Tenderness when you push on your chest
• Pain that is persistently present for many hours

The classic symptoms of heartburn — a painful, burning sensation behind your breastbone — can be caused by problems with your heart or your stomach.

Causes of chest pain

Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction (heart attack) ¹.

Cardiac disease is the leading cause of death in the United States, yet only 1.5 percent of patients presenting to a primary care office with chest pain will have unstable angina or an acute myocardial infarction (heart attack) ².

The most common causes of chest pain in the primary care population include ²:

1. Chest wall pain (20 percent);
2. Reflux esophagitis (13 percent);
3. Costochondritis (13 percent).

Although in practice, costochondritis is often included in the chest wall pain category. Other considerations include pulmonary (e.g., pneumonia, pulmonary embolism), gastrointestinal (e.g., gastroesophageal reflux disease [GERD]), and psychological (e.g., anxiety, panic disorder) etiologies, and cardiovascular disorders (e.g., acute congestive heart failure, acute thoracic aortic dissection). Table 1 lists the differential diagnosis of chest pain.

Table 1. Differential Diagnosis of Chest Pain

Diagnosis	Clinical findings
Acute myocardial infarction	Chest pain radiates to both arms
	Third heart sound on auscultation
	Hypotension
Chest wall pain	At least two of the following findings: localized muscle tension; stinging pain; pain reproducible by palpation; absence of cough
Gastroesophageal reflux disease	Burning retrosternal pain, acid regurgitation, sour or bitter taste in the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms
Panic disorder/anxiety state	Single question: In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?
Pericarditis	Clinical triad of pleuritic chest pain (increases with inspiration or when reclining, and is lessened by leaning forward), pericardial friction rub, and electrocardiographic changes (diffuse ST segment elevation and PR interval depression without T wave inversion)
Pneumonia	Egophony
	Dullness to percussion
	Fever
	Clinical impression
Heart failure	Pulmonary edema on chest radiography
	Clinical impression/judgment
	History of heart failure
	History of acute myocardial infarction
Pulmonary embolism	High pretest probability based on Wells criteria
	Moderate pretest probability based on Wells criteria
	Low pretest probability based on Wells criteria
Acute thoracic aortic dissection	Acute chest or back pain and a pulse differential in the upper extremities

[Sources ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶]

• Chest pain has many possible causes, all of which need medical attention.

Heart-related causes

Examples of heart-related causes of chest pain include:

• Heart attack. A heart attack results from blocked blood flow, often from a blood clot, to your heart muscle.
• Angina. Angina is the term for chest pain caused by poor blood flow to the heart. This is often caused by the buildup of thick plaques on the inner walls of the arteries that carry blood to your heart. These plaques narrow the arteries and restrict the heart’s blood supply, particularly during exertion.
• Aortic dissection. This life-threatening condition involves the main artery leading from your heart (aorta). If the inner layers of this blood vessel separate, blood is forced between the layers and can cause the aorta to rupture.
• Pericarditis. This is the inflammation of the sac surrounding your heart. It usually causes sharp pain that gets worse when you breathe in or when you lie down.

Digestive causes

Chest pain can be caused by disorders of the digestive system, including:

• Heartburn. This painful, burning sensation behind your breastbone occurs when stomach acid washes up from your stomach into the tube that connects your throat to your stomach (esophagus).
• Swallowing disorders. Disorders of the esophagus can make swallowing difficult and even painful.
• Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder or pancreas can cause abdominal pain that radiates to your chest.

Muscle and bone causes

Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall, including:

• Costochondritis. In this condition, the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed and painful.
• Sore muscles. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
• Injured ribs. A bruised or broken rib can cause chest pain.

Lung-related causes

Many lung disorders can cause chest pain, including:

• Pulmonary embolism. This occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue.
• Pleurisy. If the membrane that covers your lungs becomes inflamed, it can cause chest pain that worsens when you inhale or cough.
• Collapsed lung. The chest pain associated with a collapsed lung typically begins suddenly and can last for hours, and is generally associated with shortness of breath. A collapsed lung occurs when air leaks into the space between the lung and the ribs.
• Pulmonary hypertension. This condition occurs when you have high blood pressure in the arteries carrying blood to the lungs, which can produce chest pain.

Other causes

Chest pain can also be caused by:

• Panic attack. If you have periods of intense fear accompanied by chest pain, a rapid heartbeat, rapid breathing, profuse sweating, shortness of breath, nausea, dizziness and a fear of dying, you may be experiencing a panic attack.
• Shingles. Caused by a reactivation of the chickenpox virus, shingles can produce pain and a band of blisters from your back around to your chest wall.

Initial Evaluation of a Chest Pain

Algorithmic approaches to the diagnosis and workup of the patient presenting with chest pain in the primary care setting have not been specifically studied. Differentiating ischemic from nonischemic causes often is difficult and patients with chest pain with an ischemic cause often appear well. As such, the initial diagnostic approach should always consider a cardiac etiology for the chest pain, unless other causes are apparent ¹⁷.

The first decision point for most physicians is whether or not the chest pain is caused by coronary ischemia (coronary heart disease) ¹⁷. Acute coronary syndrome is a constellation of clinical findings that suggests acute myocardial ischemia encompassing unstable angina and acute myocardial infarction (heart attack).

• Angina has been described as deep, poorly localized chest or arm discomfort (pain or pressure) that is reproducibly associated with physical exertion or emotional stress and is relieved promptly with rest or sublingual nitroglycerin ¹⁸.
• Unstable angina is defined as angina at rest, new-onset angina, or angina that has become more severe or longer in duration ¹⁹.
• Acute myocardial infarction (heart attack) is defined as ST segment changes (elevation or depression) on electrocardiography (ECG) and positive laboratory markers of myocardial necrosis (e.g., troponin I) ¹⁸

In office and ambulatory settings, the clinical impression is, in most cases, shaped by the presenting symptoms, physical examination, and initial ECG, combined with the patient’s risk of acute coronary syndrome ¹⁷.

The initial goal is to determine if the patient needs to be referred for further testing (e.g., troponin I or stress testing, coronary angiography) to rule in or out a potentially catastrophic acute coronary syndrome and acute myocardial infarction (heart attack). One recent meta-analysis concluded that the history and physical examination were mostly not helpful in diagnosing acute coronary syndrome or acute myocardial infarction (heart attack) in patients presenting with chest pain, especially in a low prevalence setting ²⁰.

Although individual characteristics may not rule in or out a diagnosis, a combination of signs and symptoms may increase diagnostic accuracy. Characteristics traditionally associated with increased likelihood of acute myocardial infarction (heart attack) include male sex plus age older than 60 years; diaphoresis (sweating); pain that radiates to the shoulder, neck, arm, or jaw; and a history of angina or acute myocardial infarction (heart attack) ²¹. Predictability may be influenced by patient description of their symptoms. Patients often do not use the term pain to describe their symptoms, but frequently use other terms like discomfort, tightness, squeezing, or indigestion ¹⁷.

Other clinical features that increase the likelihood of myocardial infarction (heart attack) in patients with acute chest pain include pain that radiates to both arms, a third heart sound on auscultation and hypotension. Clinical features that decrease the likelihood of acute myocardial infarction (heart attack) include pleuritic chest pain, sharp or stabbing chest pain and chest pain reproduced by palpation ⁴.

The presence or absence of comorbidities, such as diabetes mellitus, tobacco use, hyperlipidemia, or hypertension, as cardiac risk factors weakly predict acute coronary syndrome in patients older than 40 years ²²; however, evaluating for presence or absence of comorbidities is still an important component of the initial assessment.

One recently developed and validated clinical decision rule (Table 2) outlines five items that best predict coronary artery disease as the cause of chest pain ²³:

• age/sex (55 years or older in men or 65 years or older in women);
• known coronary artery disease, occlusive vascular disease, or cerebrovascular disease;
• pain that is worse during exercise;
• pain not reproducible by palpation; and
• patient assumption that the pain is of cardiac origin.

Table 2. Validated Clinical Decision Rule to Predict Coronary Artery Disease as a Cause of Chest Pain

Component	Points
Age/sex: men 55 years or older, women 65 years or older	1
Known vascular disease (coronary artery disease, occlusive vascular disease, cerebrovascular disease)	1
Pain worse with exercise	1
Pain not elicited with palpation	1
Patient assumes pain is of cardiac origin	1

Score	Positive likelihood ratio	Negative likelihood ratio
0 to 1 point	1.09	0.00
2 to 3 points	1.83	0.03
4 to 5 points	4.52	0.16

---

[Source ²³]

Among those with none or one of these clinical factors, only 1 percent had coronary artery disease, whereas 63 percent of the patients with four or five of the factors had coronary artery disease ²³. The study results suggest that patients with chest pain and four or five of these factors require urgent workup. Physicians should consider applying a validated clinical decision rule to predict heart disease as a cause of chest pain ²³.

Twelve-lead ECG is typically the test of choice in the initial evaluation of patients with chest pain ²⁴. ST segment changes (elevation or depression), new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversion increase the likelihood of acute coronary syndrome or acute myocardial infarction (heart attack) ⁴. Concern based on the clinical impression (history, physical examination, risk factors, and 12-lead ECG) often will influence the physician’s decision regarding whether to refer the patient to a higher level of care (emergency department or hospital) for further workup and treatment, or to look for other possible diagnoses for the chest pain ¹⁷.

Chest pain diagnosis in the emergency room

Emergency room doctors will test for myocardial infarction (heart attack) first because it’s potentially the most immediate threat to your life. They may also check for life-threatening lung conditions — such as a collapsed lung or a clot in your lung.

Immediate tests

Some of the first tests your doctor may order include:

• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn’t conduct electrical impulses normally, the ECG may show that you have had or are having a heart attack.
  Blood tests. Your doctor may order blood tests to check for increased levels of certain proteins or enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these proteins or enzymes to leak, over a period of hours, into your blood.
• Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs and the size and shape of your heart and major blood vessels. A chest X-ray can also reveal lung problems such as pneumonia or a collapsed lung.
• Computerized tomography (CT scan). CT scans can spot a blood clot in your lung (pulmonary embolism) or make sure you’re not having aortic dissection.

Follow-up testing

Depending upon the results from these initial tests, you may need follow-up testing, which may include:

• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart in motion. A small device may be passed down your throat to obtain better views of different parts of your heart.
• Computerized tomography (CT scan). Different types of CT scans can be used to check your heart arteries for blockages. A CT coronary angiogram can also be done with dye to check your heart and lung arteries for blockages and other problems.
• Stress tests. These measure how your heart and blood vessels respond to exertion, which may indicate if your chest pain is heart-related. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise.
• Coronary catheterization (angiogram). This test helps doctors identify individual arteries to your heart that may be narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that’s fed through an artery, either through your wrist or your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-rays and video.

Other Causes of Chest Pain

If the initial evaluation indicates that a cardiac cause of acute coronary syndrome is less likely, other noncardiac causes of chest pain should be considered. Understanding that there are common conditions that often occur, with the clinical impression, will help lead to a correct diagnosis.

Chest wall pain, reflux esophagitis, and costochondritis are the most common causes of chest pain in the primary care population.

Chest wall pain

One prospective cohort study identified four clinical factors that predict a final diagnosis of chest wall pain in patients presenting to the primary care office with chest pain: localized muscle tension, stinging pain, pain reproducible by palpation, and the absence of a cough. Having at least two of these findings had a 77 percent positive predictive value for chest wall pain, and having none or one had an 82 percent negative predictive value ⁵.

Costochondritis

Often considered a subset of chest wall pain, costochondritis is a self-limited condition characterized by pain reproducible by palpation in the parasternal/costochondral joints. It is sometimes called Tietze syndrome, which is distinguished from costochondritis by the presence of swelling over the affected joints ²⁵. Costochondritis is a clinical diagnosis and does not require specific diagnostic testing in the absence of concomitant cardiopulmonary symptoms or risk factors ²⁶.

GERD

Classic symptoms of GERD include a burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth ⁶. No useful physical examination maneuvers exist to assist in establishing the diagnosis, and there is no standard test to rule it in or out. However, a one-week trial of a high-dose proton pump inhibitor is modestly sensitive and specific for GERD ⁷.

Panic disorder and anxiety state

Panic disorder and anxiety state are common. One in four persons with a panic attack will have chest pain and shortness of breath ²⁷. Yet, concomitant panic disorder and chest pain are often not recognized, leading to more testing, follow-up, and higher costs of care ²⁸. Panic may cause chest pain and vice versa ²⁷. Several validated brief questionnaires are used to diagnose panic disorder and anxiety state. One question (In the past four weeks, have you had an anxiety attack [suddenly feeling fear or panic]?) is sensitive (93 percent) and modestly specific (78 percent) in detecting panic disorder ⁸.

Less Common, but Important, Diagnostic Considerations

Pericarditis

Pericarditis is the clinical triad of pleuritic chest pain, pericardial friction rub, and diffuse electrocardiographic ST-T wave changes ⁹. ECG usually demonstrates diffuse ST segment elevation and PR interval depression without T wave inversion. Acute pericarditis should be considered in patients presenting with new-onset chest pain that increases with inspiration or when reclining, and is lessened by leaning forward ¹⁰.

Pneumonia

Community-acquired pneumonia is a cause of chest pain and respiratory symptoms in the outpatient setting. Common symptoms include fever, chills, productive cough, and pleuritic chest pain ²⁹. Fever, egophony heard during auscultation of the lungs, and dullness to percussion of the posterior thorax are suggestive of pneumonia ¹¹. Clinical impression is modestly useful for ruling in or out pneumonia ¹¹. The test of choice for diagnosing pneumonia is chest radiography ¹², although it has been more recently recommended that it be performed only if other diagnoses are being considered in the uncomplicated outpatient setting ³⁰.

Heart failure

Most patients with heart failure present with dyspnea (shortness of breath) on exertion, although some will have chest pain ¹³. A history of heart failure or acute myocardial infarction (heart attack) best predicts the presence of heart failure ¹³. Clinical impression/judgment is predictive of heart failure, as is pulmonary edema on chest radiography ¹³.

Acute thoracic aortic dissection

Patients with acute thoracic aortic dissection may present with chest or back pain ³¹. History and physical examination are only modestly useful for ruling in or out the condition; acute chest or back pain and a pulse differential in the upper extremities modestly increase the likelihood of an acute thoracic aortic dissection ¹⁶.

Pulmonary embolism

Diagnosing pulmonary embolism in the office based on signs and symptoms is difficult because of its highly variable presentation. Although dyspnea, tachycardia, and/or chest pain are present in 97 percent of those diagnosed with pulmonary embolism (Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190–195.()), there is no single clinical feature that effectively rules it in or out ³². The physician can estimate the patient’s likelihood of pulmonary embolism by using a validated clinical decision rule, such as the Wells criteria (Table 3), to determine if further testing should be performed (e.g., d-dimer assay, ventilation-perfusion scan, helical computed tomography of the pulmonary arteries) ¹⁴.

Table 3. Wells Clinical Prediction Rule for Pulmonary Embolism

Component	Points
Clinical signs of DVT (asymmetric leg swelling, palpable calf pain)	3
Diagnosis of PE is more likely than an alternative diagnosis	3
Heart rate greater than 100 beats per minute	1.5
Previous diagnosis of DVT or PE	1.5
Bed rest immobilization or surgery within the past four weeks	1.5
Hemoptysis	1
Malignancy within the past six months	1

Points	Risk of PE	Probability of PE (%)
0 to 1 point	Low	1.3
2 to 6 points	Moderate	16
Greater than 6 points	High	41

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[Source ¹⁴]

Chest Pain Treatment

Treatment varies depending on what’s causing your chest pain.

Medications

Drugs used to treat some of the most common causes of chest pain include:

• Artery relaxers. Nitroglycerin — usually taken as a tablet under the tongue — relaxes heart arteries, so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels.
• Aspirin. If doctors suspect that your chest pain is related to your heart, you’ll likely be given aspirin.
• Thrombolytic drugs. If you are having a heart attack, you may receive these clot-busting drugs. These work to dissolve the clot that is blocking blood from reaching your heart muscle.
• Blood thinners. If you have a clot in an artery feeding your heart or lungs, you’ll be given drugs that inhibit blood clotting to prevent the formation of more clots.
• Acid-suppressing medications. If your chest pain is caused by stomach acid splashing into your esophagus, the doctor may suggest medications that reduce the amount of acid in your stomach.
• Antidepressants. If you’re experiencing panic attacks, your doctor may prescribe antidepressants to help control your symptoms. Psychological therapy, such as cognitive behavioral therapy, also might be recommended.

Surgical and other procedures

Procedures to treat some of the most dangerous causes of chest pain include:

• Angioplasty and stent placement. If your chest pain is caused by a blockage in an artery feeding your heart, your doctor will insert a catheter with a balloon on the end into a large blood vessel in your groin, and thread it up to the blockage. Your doctor will inflate the balloon tip to widen the artery, then deflate and remove the catheter. In most cases, a small wire mesh tube (stent) is placed on the outside of the balloon tip of the catheter. When expanded, the stent locks into place to keep the artery open.
• Bypass surgery. During this procedure, surgeons take a blood vessel from another part of your body and use it to create an alternative route for blood to go around the blocked artery.
• Dissection repair. You may need emergency surgery to repair an aortic dissection — a life-threatening condition in which the artery that carries blood from your heart to the rest of your body ruptures.
• Lung reinflation. If you have a collapsed lung, doctors may insert a tube in your chest to reinflate the lung.

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