Definition

It’s the middle of the night or maybe the beginning of a busy workday when you suddenly feel pain in your chest. You try to ignore it at first, but your chest pain has you scared and worried. Could you be having a heart attack? Should you go to the emergency room?

Chest pain is one of the most common reasons people call for emergency medical help. Every year emergency room doctors evaluate and treat millions of people for chest pain.

Fortunately, chest pain doesn’t always signal a heart attack. Often chest pain is unrelated to any heart problem. But even if the chest pain you experience has nothing to do with your cardiovascular system, the problem may still be important  and worth the time spent in an emergency room to have your chest pain evaluated.

Symptoms

The characteristics of chest pain vary depending on what may be the cause. Chest pain symptoms may include:

Cardiac causes

• Heart attack. A heart attack can cause pressure, fullness or a crushing pain in your chest that lasts more than a few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms, especially your left arm. Other signs and symptoms may include shortness of breath, sweating, dizziness and nausea. All, some or none of these may accompany your chest pain.
• Angina. Restricted blood flow to your heart can cause recurrent episodes of chest pain  angina pectoris, or angina. Angina (pronounced an-JI-nuh or AN-juh-nuh) is often described as a pressure or tightness in the chest. It’s usually brought on by physical or emotional stress. The pain usually goes away within minutes after you stop the stressful activity.
• Pericarditis. Inflammation of the sac surrounding your heart (pericarditis) causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick.
• Aortic dissection. In this condition, the inner layers of the main artery leading from your heart (aorta) separate, forcing blood between them. Symptoms are sudden and tearing chest and back pain.
• Coronary artery spasm. Coronary spasm can cause varying degrees of chest discomfort. In coronary spasm, arteries that supply blood to your heart go into spasm, temporarily closing down blood flow to your heart. It can occur with activity or at rest. A spasm may even wake you from sleep.

Noncardiac causes

• Heartburn. Heartburn is a painful, burning sensation behind your breastbone (sternum). Often this feeling is accompanied by a sour taste and the sensation of food re-entering your mouth (regurgitation). Heartburn-related chest pain usually follows a meal and may last for hours. Signs and symptoms occur more frequently when you bend forward at the waist or lie down. Pain can also occur when you swallow.
• Panic attack. Symptoms of a panic attack include intense fear accompanied by chest pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath.
• Pleurisy. Symptoms of pleurisy, an inflammation of the membrane that lines your chest cavity, include sharp, localized chest pain that’s made worse when you inhale or cough.
• Costochondritis. In this condition, the cartilage of your rib cage becomes inflamed. The pain from costochondritis may occur suddenly and be intense, leading you to assume you’re having a heart attack. Yet the location of the pain is different. Costochondritis causes your chest to hurt when you push on your sternum or on the ribs near your sternum. Heart attack pain is usually more widespread, and the chest wall usually isn’t tender.
• Pulmonary embolism. This condition involves blockage of a lung artery. Symptoms can include sudden, sharp chest pain that begins or worsens with a deep breath or cough. Other symptoms can include shortness of breath, rapid heartbeat, anxiety and faintness.
• Sore muscles. Muscle-related chest pain tends to come on when you twist side to side or when you raise your arms, and can occur in conditions such as fibromyalgia.
• Injured ribs or pinched nerves. Symptoms of a bruised rib, broken rib or a pinched nerve can be chest pain that tends to be localized and sharp.
• Espophageal spasms. This disorder of the esophagus, the tube that runs from your throat to your stomach, can make swallowing difficult and even painful. The muscles that normally move food down the esophagus are uncoordinated, resulting in painful muscle spasms.
• Achalasia. In this swallowing disorder, the valve in the lower esophagus doesn’t open properly to allow food to enter your stomach. Instead, food backs up into your esophagus, causing pain.
• Shingles. Symptoms of this reactivation of the same virus that causes chickenpox include pain and a band of blisters from your back around to your chest wall. The sharp, burning pain may begin several hours to a day or so before blisters appear.
• Gallbladder or pancreas problems. Symptoms can include acute abdominal pain that radiates to your chest.

Causes

Chest pain has many possible causes, all of which deserve medical attention. The causes of chest pain fall into two major categories  cardiac and noncardiac causes.

Cardiac causes

• Heart attack. A heart attack is a result of a blood clot that’s blocking blood flow to your heart muscle.
• Angina. Atherosclerotic plaques, containing cholesterol and other substances, can build up in the arteries that carry blood to your heart, narrowing them and temporarily restricting blood flow to your heart, especially during times of exertion. Restricted blood flow to your heart can cause recurrent episodes of chest pain  angina pectoris, or angina (pronounced an-JI-nuh or AN-juh-nuh).
• Other cardiac causes. Other problems that can cause chest pain include inflammation of the sac surrounding your heart (pericarditis), a short-lived condition often related to a viral infection.A rare, life-threatening condition called aortic dissection involves the main artery leading from your heart your aorta. If the inner layers of this blood vessel separate, forcing blood flow between them, the result is sudden and tearing chest and back pain. Aortic dissection can result from a sharp blow to your chest or develop as a complication of uncontrolled high blood pressure.Coronary spasm, also known as Prinzmetal’s angina, can cause varying degrees of chest discomfort. In coronary spasm, coronary arteries  arteries that supply blood to the heart  go into spasm, temporarily closing down blood flow to the heart. Spasm of the coronary arteries may occur spontaneously or be triggered by a stimulant, such as nicotine or caffeine. Coronary artery spasm, which tends to cause episodes of chest pain, can occur with activity or at rest. It may coexist with coronary artery disease  a buildup of plaques in the coronary arteries.Other possible heart-related conditions that can cause chest pain are metabolic syndrome and endothelial dysfunction.

Noncardiac causes
Many conditions unrelated to your heart can cause chest pain. These include:

• Heartburn. Stomach acid that washes up from your stomach into the tube (esophagus) that runs from your throat to your stomach can cause heartburn  a painful, burning sensation behind your breastbone (sternum).
• Panic attack. If you experience periods of intense fear accompanied by chest pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath, you may be experiencing a panic attack  a form of anxiety.
• Pleurisy. This sharp, localized chest pain that’s made worse when you inhale or cough occurs when the membrane that lines your chest cavity and covers your lungs becomes inflamed. Pleurisy may result from a wide variety of underlying conditions, including pneumonia and, rarely, autoimmune conditions, such as lupus. An autoimmune disease is one in which your body’s immune system mistakenly attacks healthy tissue.
• Costochondritis. In this condition  also known as Tietze’s syndrome  the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed. The result is chest pain when you push on your sternum or on the ribs near your sternum.
• Pulmonary embolism. This cause of chest pain occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue. It’s rare for this life-threatening condition to occur without preceding risk factors, such as recent surgery or immobilization.
• Other lung conditions. A collapsed lung (pneumothorax), high blood pressure in the arteries carrying blood to the lungs (pulmonary hypertension) and asthma also can produce chest pain.
• Sore muscles. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
• Injured ribs or pinched nerves. A bruised or broken rib, as well as a pinched nerve, can cause chest pain.
• Swallowing disorders. Disorders of the esophagus, the tube that runs from your throat to your stomach, can make swallowing difficult and even painful. One type is esophageal spasm, a condition that affects a small group of people with chest pain. When people with this condition swallow, the muscles that normally move food down the esophagus are uncoordinated. This results in painful muscle spasms.Another swallowing disorder that also affects a small group of people with chest pain is achalasia (ak-uh-LA-zhuh). In this condition, the valve in the lower esophagus doesn’t open properly to allow food to enter your stomach. Instead, food backs up into the esophagus, causing pain.
• Shingles. This infection of the nerves caused by the chickenpox virus can produce pain and a band of blisters from your back around to your chest wall.
• Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder (cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.
• Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of the body can cause chest pain.

Chest pain isn’t always caused by heart problems. But, because you can’t always determine the cause yourself, don’t delay in seeking medical attention.

When to seek medical advice

Pain in your chest can be severe. It can be difficult to interpret. The cause of the pain could be something as simple as heartburn or as serious as a heart attack.

If you experience unexplained and persistent chest pain or a feeling of pressure or tightness in your chest particularly if it’s accompanied by other signs and symptoms, such as shortness of breath, sweating, nausea, dizziness or pain that radiates beyond your chest to one or both of your arms or your neck  seek emergency medical care immediately. If you are having a heart attack, rapid treatment can dramatically reduce the amount of damage to your heart muscle and prevent long-term complications.

Every minute is crucial if you are in the midst of a heart attack. A trip to the emergency room could save your life  or bring you peace of mind if nothing is seriously wrong with your health.

Tests and diagnosis

At the emergency room or chest pain center  some large hospitals designate areas just for the evaluation of chest pain  you’ll probably have your blood pressure, pulse and temperature checked right away. In addition, the doctor will ask you questions about your chest pain:

• Where is the pain located?
• How would you describe the pain?
• Do you have other signs and symptoms along with the pain?

Chest pain doesn’t always signal a heart attack. But that’s what emergency room doctors will test for first because it’s potentially the most immediate threat to your life. They may also check for life-threatening lung conditions  such as pulmonary embolism, aortic dissection or a collapsed lung (pneumothorax)  that can cause chest pain.

Tests you may have to determine the cause of your chest pain include:

• Electrocardiogram (ECG). This test can help doctors diagnose a heart attack as well as other heart problems. It records the electrical activity of your heart through electrodes attached to your skin. Heart rate and rhythm and the electrical impulses going through your heart are recorded as waves displayed on a monitor or printed on paper. Because injured heart muscle doesn’t conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.
• Stress tests. These measure how your heart and blood vessels respond to exertion, which may indicate if your pain is related to your heart. 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. Stress tests may be combined with imaging of the heart using ultrasound (echocardiography) or radioactive material (nuclear scan).
• Blood tests. Your doctor may order blood tests to check for increased levels of certain enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these 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. Doctors can also use a chest X-ray to check for tumors in the chest.
• Nuclear scan. This test helps doctors diagnose cardiac causes of chest pain, such as a narrowed heart artery. Trace amounts of radioactive material, such as thallium or sestamibi, are injected into your bloodstream. Special cameras can detect the radioactive material as it flows through your heart and lungs.
• 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 catheter  a long, thin tube that’s fed through an artery, usually in your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-ray and video.
• Electron beam computerized tomography (EBCT). This procedure, also called an ultrafast CT scan, scans your arteries for signs of calcium, which indicates that atherosclerotic plaques along with calcium may be accumulating and blocking arteries supplying your heart.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses magnetic fields and radio waves to create cross-sectional images of your body.
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors identify heart problems.
• Endoscopy. In this test a thin, flexible instrument attached to a camera is passed down your throat, allowing doctors to view your esophagus and stomach and check for gastroesophageal problems that can cause chest pain.

Many types of chest pain may at first seem related to heart problems. But often, after careful evaluation, doctors can distinguish the symptoms of noncardiac chest pain from the pain caused by a heart condition.

Treatments and drugs

Cardiac causes
If it appears that heart problems are the cause of your chest pain, your doctor may give you medications such as:

• Aspirin. Aspirin inhibits blood clotting, helping to maintain blood flow through narrowed heart arteries. When taken during a heart attack, aspirin can significantly decrease death rates. You may be asked to chew the aspirin to hasten its absorption. Aspirin is recommended for most people who have had a heart attack.
• Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that’s blocking blood flow to your heart. The earlier you receive a thrombolytic drug after a heart attack, the greater the chance you will survive and lessen the damage to your heart.
• Nitroglycerin. This medication for treating angina temporarily widens narrowed blood vessels, improving blood flow to and from your heart.
• Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications help limit the amount of damage during a heart attack and prevent a second heart attack.
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs allow blood to flow from your heart more easily. Your doctor may prescribe ACE inhibitors or ARBs if you’ve had a moderate to severe heart attack that has reduced your heart’s pumping capacity. These drugs also lower blood pressure and may prevent a second heart attack.
• Calcium channel blockers. When treating coronary artery spasm, doctors sometimes use heart medications such as calcium channel blockers to relax the coronary arteries and prevent spasm.
• Ranolazine (Ranexa). This is a relatively new drug for treating chronic angina. It’s used only when other anti-anginal drugs haven’t worked because it can cause a heart problem known as QT prolongation, which can increase your risk of heart rhythm problems. It should be used with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.

Heart attack treatments
If it’s clear you’re having a heart attack, you may be treated with clot-busting drugs or undergo a surgical procedure such as:

• Angioplasty. In this procedure, doctors insert a catheter with a special balloon into a blocked coronary artery. The balloon is inflated to open up the artery and restore blood flow to your heart. Many people will go straight from the emergency room to the catheterization laboratory to have angioplasty performed as quickly as possible.
• Stenting. A stent is like a scaffold inside the artery to prop it open after it has been opened with angioplasty.
• Coronary bypass surgery. This procedure creates an alternative route for blood to go around a blocked coronary artery.

If it’s clear you’re experiencing a pulmonary embolism, you’ll likely be treated with emergency blood-thinning medications. Aortic dissection, also an emergency, may require surgery. Other heart and lung conditions can be treated initially in the emergency room.

Doctors usually treat angina chest pain caused by restricted blood flow to the heart  with medication, angioplasty or coronary bypass surgery. For people who don’t respond to or who aren’t candidates for these standard treatments, an alternative treatment called enhanced external counterpulsation (EECP) may be available for the treatment of chronic angina.

Most of the time, chest pain isn’t related to emergency heart or lung problems. If doctors determine you’re out of immediate danger, evaluation and treatment may shift to an outpatient setting. You may be referred to your own physician or a specialist for further evaluation.

Noncardiac causes
Treatments for noncardiac causes of chest pain depend on the type of problem. These problems and their treatments include:

• Heartburn. If your symptoms suggest heartburn, you’ll likely need to take an over-the-counter or prescription-strength stomach acid blocker or antacid in the emergency room. Most episodes of heartburn are isolated events caused by overeating or by eating fatty foods.If you experience frequent heartburn (at least one episode a week), your doctor or a doctor who specializes in stomach and intestinal problems (gastroenterologist), may ask you to undergo more tests. Left untreated, chronic, frequent heartburn can occasionally lead to scarring and narrowing of your esophagus. Treatment for chronic heartburn may include dietary modifications, antacids, acid blockers or other prescription medications and, in some cases, surgery.
• Panic attack. This anxiety-related cause of chest pain can be treated with prescription anti-anxiety medications, relaxation techniques and counseling to find out what may be triggering your attacks. Panic attacks are often mistaken for heart attacks, and many people are seen in emergency rooms for this problem. But once your condition is diagnosed, you can be referred for treatment to help you gain control over these attacks.
• Pleurisy. This inflammation of the pleura, the membrane that lines your chest cavity and covers your lungs, may result from a variety of conditions, including pneumonia and, rarely, autoimmune conditions such as lupus. Your doctor will want to identify and treat the underlying disease that caused pleurisy. Over-the-counter pain relievers can help minimize the pain until the inflammation subsides.
• Costochondritis. Treatment for this inflammation of the cartilage of your rib cage is generally rest, heat and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others).
• Sore muscles, injured ribs or pinched nerves. Chest pain from injured ribs, pinched nerves and sore chest muscles improves with time and self-care measures recommended by your doctor.
• Swallowing disorders. These disorders have many causes, which can usually be treated with medications, minor surgery or endoscopic techniques. You’ll probably be referred to a gastroenterologist for evaluation and treatment.
• Shingles. Treatment with acyclovir (Zovirax) or a similar antiviral medication is best started as quickly as possible, preferably within 24 hours from the onset of pain or burning, and before the appearance of blisters. Doctors use other treatments, such as analgesics and antihistamines, to control symptoms such as pain and itching.
• Gallbladder or pancreas problems. You may need surgery to treat an inflamed gallbladder or pancreas that’s causing pain to radiate from your abdomen into your chest.

Chest pain can be one of the most difficult symptoms to interpret. But spending a few hours in the ER having your chest pain evaluated can bring you peace of mind, and may even save your life.