Chest pain is a very common complaint. Pain may be sharp or dull, although some people with a chest disorder describe their sensation as discomfort, tightness, pressure, gas, burning, or aching. Sometimes people also have pain in the back, neck, jaw, upper part of the abdomen, or arm. Other symptoms, such as nausea, cough, or difficulty breathing, may be present depending on the cause of the chest pain.
Many people are well aware that chest pain is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other people, including many with serious disease, minimize or ignore its warnings.
Causes of Chest Pain
Many disorders cause chest pain or discomfort. Not all of these disorders involve the heart. Chest pain may also be caused by disorders of the digestive system, lungs, muscles, nerves, or bones.
Overall, the most common causes of chest pain are
Disorders of the ribs, rib cartilage, chest muscles (musculoskeletal chest wall pain), or nerves in the chest
Inflammation of the membrane that covers the heart (pericarditis Overview of Pericardial Disease Pericardial disease affects the pericardium, which is the flexible two-layered sac that envelops the heart. The pericardium helps keep the heart in position, helps prevent the heart from overfilling... read more )
Digestive disorders (such as esophageal reflux Gastroesophageal Reflux Disease (GERD) In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom... read more or spasm Esophageal Spasm Esophageal spasm is a disorder of the rhythmic waves of muscular contractions (peristalsis) of the esophagus. The cause of this disorder is not known. Symptoms include chest pain and difficulty... read more , ulcer disease Peptic Ulcer Disease A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more , or gallstones Gallstones Gallstones are collections of solid material (predominantly crystals of cholesterol) in the gallbladder. The liver can secrete too much cholesterol, which is carried with bile to the gallbladder... read more )
Heart attack or angina (acute coronary syndromes Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount... read more and stable angina Angina Angina is temporary chest pain or a sensation of pressure that occurs while the heart muscle is not receiving enough oxygen. A person with angina usually has discomfort or pressure beneath the... read more )
Undiagnosed causes that go away on their own
Acute coronary syndromes Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount... read more (heart attack or unstable angina) involve a sudden blockage of an artery in the heart (coronary artery) that cuts off the blood supply to an area of the heart muscle. If some of the heart muscle dies because it does not get enough blood, that effect is termed a heart attack (myocardial infarction). In stable angina Angina Angina is temporary chest pain or a sensation of pressure that occurs while the heart muscle is not receiving enough oxygen. A person with angina usually has discomfort or pressure beneath the... read more , long-term narrowing of a coronary artery (for example by atherosclerosis Atherosclerosis Atherosclerosis is a condition in which patchy deposits of fatty material (atheromas or atherosclerotic plaques) develop in the walls of medium-sized and large arteries, leading to reduced or... read more ) limits blood flow through that artery. This limited blood flow causes chest pain when people exert themselves.
Some causes of chest pain are immediately life threatening but, except for heart attack or unstable angina, are less common:
Heart attack or unstable angina
A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax Tension Pneumothorax Tension pneumothorax occurs when air accumulates between the chest wall and the lung and increases pressure in the chest, reducing the amount of blood returned to the heart. Symptoms include... read more )
Other causes range from serious, potential threats to disorders that are simply uncomfortable.
Evaluation of Chest Pain
People with chest pain should be evaluated by a doctor. The following information can help people decide when evaluation is needed and help them know what to expect during the evaluation.
In people with chest pain or discomfort, certain symptoms and characteristics are cause for concern. They include
Crushing or squeezing pain
Shortness of breath
Nausea or vomiting
Pain in the back, neck, jaw, upper abdomen, or one of the shoulders or arms
Light-headedness or fainting
Sensation of rapid or irregular heartbeat
When to see a doctor
Although not all causes of chest pain are serious, because some causes are life threatening, the following people should seek care in an emergency department right away:
Those with new chest pain (within several days)
Those who have a warning sign
Those who suspect that a heart attack is occurring (for example, because symptoms resemble a previous heart attack)
These people should call emergency services (911) or be taken to an emergency department as quickly as possible. People should not try to drive themselves to the hospital.
Chest pain that lasts for seconds (less than 30 seconds) is rarely caused by a heart disorder. People with very brief chest pain need to see a doctor, but emergency services are usually not needed.
People who have had chest pain for a longer time (a week or more) should see a doctor as soon as possible, but they do not need to go to the hospital unless they develop warning signs or the pain has steadily been getting worse or coming more often, in which case they should go to the hospital right away.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of the chest pain and the tests that may need to be done.
However, symptoms due to dangerous and not dangerous chest disorders overlap and vary greatly. For example, although a typical heart attack causes dull, crushing chest pain, some people with a heart attack have only mild chest discomfort or complain only of indigestion or arm or shoulder pain (referred pain—see figure ). On the other hand, people with indigestion may simply have an upset stomach, and those with shoulder pain may have only sore muscles. Similarly, although the chest is tender when touched in people with musculoskeletal chest wall pain, the chest can also be tender in people who are having a heart attack. Thus, doctors usually do tests on people with chest pain.
For adults with sudden chest pain, tests are done to rule out dangerous causes. For most people, initial tests include
Measurement of oxygen levels with a sensor placed on a finger (pulse oximetry)
If symptoms suggest an acute coronary syndrome (heart attack or unstable angina) or if no other cause is clear (particularly in people who are at high risk), doctors usually measure levels of substances that indicate heart damage (cardiac markers) in the blood (at least two separate times over a few hours) and do repeated ECGs Electrocardiography Electrocardiography (ECG) is a quick, simple, painless procedure in which the heart’s electrical impulses are amplified and recorded. This record, the electrocardiogram (also known as an ECG)... read more .
If these tests do not show an acute coronary syndrome, doctors often then do a stress test Stress Testing Stressing the heart (by exercise or by use of stimulant drugs to make the heart beat faster and more forcibly) can help identify coronary artery disease. In coronary artery disease, blood flow... read more or CT angiography before people go home or within a few days. However, if a newer cardiac marker, called high sensitivity troponin, is used and that test does not show evidence of heart damage, further testing may not be required. For a stress test, ECG or an imaging test (such as echocardiography Echocardiography and Other Ultrasound Procedures Ultrasonography uses high-frequency (ultrasound) waves bounced off internal structures to produce a moving image. It uses no x-rays. Ultrasonography of the heart (echocardiography) is one of... read more ) is done during exercise (often on a treadmill) or after a drug is given to make the heart beat fast or increase blood flow through the coronary arteries (such as dipyridamole).
If pulmonary embolism is suspected, CT angiography (CT with intravenous contrast) of the lungs or a lung scan Chest Imaging Chest imaging studies include X-rays Computed tomography (CT) CT angiography Magnetic resonance imaging (MRI) read more is done. If pulmonary embolism is considered only somewhat possible, a blood test to detect clots (D-dimer test) is often done. If this test is negative, pulmonary embolism is unlikely, but if the test is positive, other tests, such as ultrasonography of the legs or CT angiography, are often done.
In people who have had chest pain for a long time, immediate threats to life are unlikely. Most doctors initially do only a chest x-ray and then do other tests based on the person's symptoms and examination findings.
Treatment of Chest Pain
Specific identified disorders are treated. If the cause is not clearly benign, people are usually admitted to the hospital or an observation unit for heart monitoring and more extensive evaluation. Pain is treated with acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), or opioids as needed until a diagnosis is made.
Chest pain may be caused by serious life-threatening disorders, so people with new chest pain (within a few days) should get immediate medical attention.
The symptoms of life-threatening and non–life-threatening disorders overlap, so testing is usually needed to determine a cause.