Emergency warning signs — call 911 now
Pain spreading to jaw, left arm, back, or stomach · Sudden shortness of breath · Cold sweat or clamminess · Nausea or vomiting · Lightheadedness or fainting · Rapid or irregular heartbeat · Sense of impending doom · Lips or fingernails turning blue · Sudden severe tearing pain between shoulder blades (possible aortic dissection)
Never attempt to self-diagnose chest pain from a website — including this one. The overlap between dangerous and benign causes is significant. If you are uncertain, always seek emergency evaluation. The cost of a false alarm is inconvenience; the cost of ignoring a heart attack is your life.
Cardiac causes of chest pain
| Cause | Character of pain | Associated features | Urgency |
|---|---|---|---|
| Heart attack (MI) | Pressure, squeezing, heaviness — "elephant on chest"; central or left-sided; may radiate to arm, jaw, back | Sweating, nausea, breathlessness, fear; may be painless in diabetics or elderly | 911 immediately |
| Unstable angina | Similar to MI but at rest or with minimal exertion; new or worsening pattern | Not relieved by one GTN tablet; prior known angina may be present | 911 immediately |
| Stable angina | Predictable chest tightness with exertion; relieved within 5 min by rest or GTN | Known CAD or risk factors; reproducible exertion threshold | Urgent cardiology |
| Aortic dissection | Sudden, severe, tearing or ripping pain — between shoulder blades; maximal at onset | Hypertension history; unequal blood pressures in arms; pulse deficit | 911 immediately |
| Pericarditis | Sharp, worse with inspiration and lying flat; relieved by sitting forward | Recent viral illness; fever; pericardial friction rub on exam | Urgent evaluation |
Pulmonary causes of chest pain
| Cause | Character of pain | Associated features | Urgency |
|---|---|---|---|
| Pulmonary embolism (PE) | Sudden pleuritic chest pain (sharp, worse with breathing); may be central | Breathlessness, coughing blood, leg swelling, recent immobility or surgery | 911 immediately |
| Pneumothorax | Sudden sharp unilateral chest pain; worse with breathing | Breathlessness; absent breath sounds on one side; tall thin young men; Marfan syndrome | 911 immediately |
| Pleuritis | Sharp, localised; markedly worse with breathing, coughing, or movement | Recent respiratory infection; fever; pleural friction rub | Same-day evaluation |
| Pneumonia | Pleuritic pain over affected lobe; may be dull ache | Fever, cough, sputum, breathlessness; abnormal breath sounds | Same-day evaluation |
Musculoskeletal causes
Musculoskeletal causes are among the most common in primary care. Key features: pain reproducible on pressing the chest wall, worsened by specific movements, and not radiating in a cardiac pattern.
| Cause | Character | Key clue | Treatment |
|---|---|---|---|
| Costochondritis | Sharp pain at costo-sternal junction; unilateral or bilateral | Reproducible on pressing the affected cartilage; no swelling | NSAIDs; heat; reassurance; usually resolves in weeks |
| Tietze syndrome | Like costochondritis but with visible swelling | Localised swelling at 2nd or 3rd costo-sternal junction | NSAIDs; corticosteroid injection if severe |
| Intercostal muscle strain | Sharp; worsened by twisting or deep breath | History of coughing, strenuous exercise, or unusual movement | Rest; NSAIDs; resolves in 1–3 weeks |
| Rib fracture | Localised severe pain; worse with breathing and coughing | Trauma history; point tenderness over a rib | Analgesia; deep breathing exercises; rarely surgery |
Digestive causes of chest pain
The oesophagus lies directly behind the heart and shares nerve pathways. Digestive conditions can produce chest pain that is remarkably difficult to distinguish from cardiac pain — even for experienced physicians. Oesophageal spasm can cause crushing central chest pain that responds to nitroglycerin.
| Cause | Character | Clues | Treatment |
|---|---|---|---|
| Acid reflux (GORD) | Burning retrosternal pain; worse after meals and lying down | Acid taste, regurgitation; relieved by antacids; worse with fatty or spicy food | Lifestyle changes; PPIs; H2 blockers |
| Oesophageal spasm | Severe crushing chest pain — can mimic MI; often unpredictable | May follow swallowing; can respond to GTN; associated dysphagia | Calcium channel blockers; PPIs; low-dose TCAs |
| Peptic ulcer | Epigastric burning or gnawing; may radiate to chest | Worse before meals or at night; relieved by food or antacids; NSAID use | H. pylori testing and eradication; PPIs |
Anxiety, panic attacks, and chest pain
Anxiety is one of the most underappreciated causes of chest pain. During a panic attack, sympathetic activation causes real, physical chest tightness, racing heart, breathlessness, tingling, and dizziness. Features more consistent with anxiety-related chest pain include: sharp or atypical quality, emotional triggers, associated tingling or dizziness, spontaneous resolution within an hour, history of anxiety or panic disorder, and normal ECG and troponin on investigation.
Cardiac disease and anxiety frequently coexist. Cardiac causes must always be formally excluded before attributing chest pain to anxiety — especially in a new or changed presentation.
Chest pain in women: why it's different
Women having heart attacks are significantly less likely to experience classic crushing chest pressure. They more frequently present with jaw or neck pain, back pain, nausea, extreme unusual fatigue (sometimes days before the event), and breathlessness without prominent chest pain. This has historically led to delayed diagnosis and worse outcomes. Heart disease is the leading cause of death in women — not a "man's disease." Take any combination of these symptoms seriously, especially with exertion or risk factors.
How chest pain is diagnosed
In the emergency setting, the priority is rapid exclusion of life-threatening causes:
- 12-lead ECG within 10 minutes: Identifies STEMI, arrhythmias, and other cardiac abnormalities. A normal ECG does not rule out MI.
- High-sensitivity troponin: Serial measurements (0 and 1 or 3 hours) can safely rule in or rule out MI with high accuracy.
- Chest X-ray: Identifies pneumothorax, pneumonia, aortic widening, pleural effusion.
- CT pulmonary angiography (CTPA): Gold standard for diagnosing pulmonary embolism.
- CT aorta: For suspected aortic dissection.
- D-dimer: Excludes PE in low-probability patients — a negative result is highly reassuring.
- Echocardiogram: Assesses wall motion abnormalities, pericardial effusion, valve problems.
Frequently asked questions
Cardiac pain typically feels like pressure, squeezing, or heaviness — often radiating to the jaw, left arm, or back — and may be triggered by exertion. Musculoskeletal pain is usually sharp, localised, and reproducible when pressing the chest wall or moving in a specific way. However, these distinctions are not reliable enough for self-diagnosis. Any new, unexplained chest pain should be medically evaluated — and if in doubt, treated as an emergency.
Yes — anxiety and panic attacks commonly cause chest tightness, palpitations, and breathlessness through sympathetic nervous system activation. However, cardiac causes must always be formally excluded before attributing chest pain to anxiety. The two can also coexist — a person with anxiety can also have coronary artery disease.
A heart attack classically feels like pressure, squeezing, or heaviness in the centre of the chest lasting more than a few minutes — often described as "an elephant on my chest." It may radiate to the jaw, left arm, or back, and is often accompanied by shortness of breath, cold sweat, nausea, and a sense of doom. Women more frequently experience atypical symptoms — jaw or back pain, nausea, or extreme fatigue without prominent chest pain. Any suspicion of a heart attack: call 911 immediately.
- Canto JG, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation. JAMA. 2012;307(8):813–822.
- Kontos MC, et al. 2022 ACC Expert Consensus: Evaluation and Disposition of Acute Chest Pain. JACC. 2022;80(20):1925–1960.
- Body R, et al. Rapid Exclusion of Acute Myocardial Infarction With Undetectable Troponin. Circulation. 2011;123:2422–2432.
- Cayley WE. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012–2021.