Chest pain is a very common reason people seek medical care. 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.
Common causes
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 lungs (pleuritis)
Inflammation of the membrane that covers the heart (pericarditis)
Digestive disorders (such as esophageal reflux or esophageal spasm, ulcer disease, or gallstones)
Heart attack or angina (acute coronary syndromes and stable angina)
Undiagnosed causes that go away on their own
Acute coronary syndromes (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, long-term narrowing of a coronary artery (for example by atherosclerosis) limits blood flow through that artery. This limited blood flow causes chest pain when people exert themselves.
Life-threatening causes
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 tear in the wall of the aorta (thoracic aortic dissection)
A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax)
Blockage of an artery to the lungs by a blood clot (pulmonary embolism)
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.
Warning signs
In people with chest pain or discomfort, certain symptoms and characteristics are cause for concern. They include
Crushing or squeezing pain
Shortness of breath
Sweating
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
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 should go to the hospital right away if they develop warning signs or the pain has steadily been getting worse or coming more often.
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 can cause dull, aching, squeezing, or crushing chest pain, some people with a heart attack have only mild chest discomfort or indigestion or arm or shoulder pain (referred pain—see figure What Is Referred Pain). 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.
Some Causes and Features of Chest Pain
Causes | Common Features* | Tests† |
|---|---|---|
Heart disorders | ||
Heart attack (myocardial infarction) or unstable angina | Immediately life threatening Dull, aching, squeezing, or crushing pain, sometimes sudden that
Sometimes shortness of breath or nausea Pain that occurs during exertion and is relieved by rest (angina pectoris) Certain abnormal heart sounds, heard through a stethoscope Often warning signs‡ | ECG, done several times over a period of time Blood tests to measure substances that indicate heart damage (cardiac biomarkers) If ECG and cardiac biomarker levels are normal, often CT of heart arteries or a stress test If ECG or cardiac biomarker levels are abnormal, heart catheterization |
Thoracic aortic dissection (a tear in the wall of the part of aorta in the chest) | Immediately life threatening Sudden, tearing pain that spreads to or starts in the middle of the back Sometimes light-headedness, stroke, or pain, coldness, or numbness in a leg (indicating inadequate blood flow to the leg) Sometimes a pulse or blood pressure in one limb that differs from that in the other limb Usually in people who are over 55 years and have a history of high blood pressure Warning signs‡ | Chest x-ray studies An imaging study of the aorta
|
Pericarditis (inflammation of the membrane around the heart) | Potentially life threatening Sharp pain that
An abnormal heart sound, heard through a stethoscope | ECG Echocardiography (ultrasound study of the heart) Sometimes MRI study |
Digestive tract disorders | ||
Immediately life threatening Sudden, severe pain immediately after vomiting or after a medical procedure involving the esophagus (such as endoscopy of the esophagus and stomach or transesophageal echocardiography) Several warning signs‡ | Chest x-ray studies X-ray studies of the esophagus taken after the person swallows water-soluble contrast (esophagography) | |
Pancreatitis (inflammation of the pancreas) | Potentially life threatening Severe, constant pain that
Vomiting Upper abdominal tenderness Sometimes shock Often in people who abuse alcohol or who have gallstones | Blood tests to measure an enzyme (lipase) produced by the pancreas Sometimes CT scans of the abdomen |
Recurring, vague discomfort that
Often in people who smoke, drink alcohol, or do both Often no warning signs‡ | A doctor's examination Sometimes endoscopy | |
Gastroesophageal reflux (GERD)§ | Typically, recurring, burning pain that
| A doctor's examination Sometimes endoscopy |
Gallbladder and bile duct disorders (biliary tract disease)§ | Recurring discomfort that
| Ultrasound study of the gallbladder Sometimes hepatobiliary scan (HIDA) |
Swallowing disorders in which there is abnormal movement (propulsion) of food through the esophagus§ | Pain that
Usually difficulty swallowing | Sometimes x-ray studies of the upper digestive tract after barium is given by mouth (barium swallow) A test to determine whether contractions in the digestive tract are normal (esophageal manometry) |
Lung disorders | ||
Pulmonary embolism (blockage of an artery in the lungs by a blood clot) | Immediately life threatening Often sharp pain when breathing in, shortness of breath, rapid breathing, and a rapid heart rate Sometimes mild fever, coughing up blood, or shock More likely in people with risk factors for pulmonary embolism (such as previous blood clots, recent surgery especially surgery on the legs, prolonged bed rest, a cast or splint on a leg, older age, smoking, or cancer) | CT angiography or nuclear scanning of the lungs Sometimes a blood test to detect blood clots (D-dimer test) |
Tension pneumothorax (a collapsed lung with a high-pressure buildup of air in the chest) | Immediately life threatening Significant shortness of breath Low blood pressure, swollen neck veins, and weak breath sounds on one side, heard through a stethoscope Typically occurs only after a severe chest injury | Usually only a doctor's examination Sometimes chest x-ray study or ultrasound scan |
Potentially life threatening Fever, chills, cough, and usually yellow or green phlegm Often shortness of breath Sometimes pain when breathing in A rapid heart rate and congested lungs, detected during the examination | Chest x-ray studies | |
Pneumothorax (a collapsed lung) | Potentially life threatening Sudden, sharp pain, usually on one side of the chest Sometimes shortness of breath Sometimes weak breath sounds on one side, heard through a stethoscope | Chest x-ray study or ultrasound scan |
Pleuritis (inflammation of the membrane around the lung)§ | Sharp pain when breathing Usually in people who have recently had pneumonia or a viral respiratory infection Sometimes cough No warning signs‡ | Usually only a doctor's examination |
Other disorders | ||
Pain in the chest wall,including the muscles, ligaments, nerves, and ribs (musculoskeletal chest wall pain)§ | Pain that
Tenderness maximally in one spot on the chest No warning signs‡ | Only a doctor's examination |
Pain that is
| Only a doctor's examination | |
Sharp pain in a band around the chest and often the back but only on one side A rash of many small blisters. sometimes filled with pus, in the painful area and sometimes appearing only after the pain | Only a doctor's examination | |
Cancers of the chest or chest wall | Sometimes pain that is worse when breathing in Sometimes chronic cough, smoking history, weight loss, swelling of lymph nodes in the neck | Chest x-ray study Chest CT scan |
* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. | ||
† For most people with chest pain, the oxygen level in blood is measured with a sensor placed on a finger (pulse oximetry), ECG is done, and a chest x-ray study is taken. | ||
‡ Warning signs include
| ||
§ Unless otherwise described, causes are usually not dangerous, although they are uncomfortable. | ||
CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging. | ||
Testing
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)
Electrocardiography (ECG)
Chest x-ray study
Ultrasound study of the heart (echocardiography) sometimes
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 biomarkers) in the blood (at least 2 separate times over a few hours) and do repeated ECGs.
If these tests do not show an acute coronary syndrome, doctors often then do a stress test or CT angiography before people go home or within a few days. However, if a cardiac biomarker measurement, 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
If pulmonary embolism is suspected, CT angiography (CT with intravenous contrast) of the lungs or a lung scan 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 ultrasound studies 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 study and ECG and then do other tests based on the person's symptoms and examination findings.
Sometimes the cause of chest pain, even after a complete evaluation, cannot be determined.
Treatment of Chest Pain
Key Points
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.
