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, indigestion, 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

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 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 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 acute coronary syndromes, 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)
• A tear of the esophagus
• 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

People with chest pain should have an evaluation 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, people with new chest pain (within several days), who have a warning sign, or who suspect that a heart attack is occurring (for example because symptoms resemble a previous heart attack) should see a doctor right away. They 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 within several days 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. 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.

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Some Causes and Features of Chest Pain Causes* Common Features† Tests‡ Heart disorders Heart attack (myocardial infarction) or unstable angina, which are acute coronary syndromes Immediately life threatening Sudden, crushing pain that Spreads to the jaw or arm May be constant or come and go 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 markers) If ECG and cardiac marker levels are normal, CT of heart arteries or a stress test If ECG or cardiac marker 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 and have a history of high blood pressure Warning signs§ Chest x-ray CT of the aorta Transesophageal echocardiography (ultrasonography of the heart with the ultrasound device passed down the throat) Pericarditis (inflammation of the membrane around the heart) Potentially life threatening Sharp pain that Is constant or comes and goes Is often worsened by breathing, swallowing food, or lying on the back Is relieved by leaning forward An abnormal heart sound, heard through a stethoscope ECG Echocardiography Digestive tract disorders Esophageal rupture 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 X-rays of the esophagus taken after the person swallows water-soluble contrast (esophagography) Pancreatitis Potentially life threatening Severe, constant pain that Occurs in the upper middle of the abdomen or in the lower chest Is often worse when lying flat Is relieved by leaning forward Vomiting Upper abdominal tenderness Shock Often in people who abuse alcohol or who have gallstones Blood tests to measure an enzyme produced by the pancreas (lipase) Sometimes CT of the abdomen Peptic ulcer* Recurring, vague discomfort that Occurs in the upper middle of the abdomen or lower chest Is relieved by food, antacids, or both Often in people who smoke, drink alcohol, or do both No warning signs§ A doctor's examination Sometimes endoscopy Esophageal reflux (GERD)* Recurring, burning pain that Spreads from the upper middle of the abdomen to the throat Is worsened by bending over or lying down Is relieved by antacids A doctor's examination Sometimes endoscopy Gallbladder and bile duct disorders (biliary tract disease)* Recurring discomfort that Occurs in the upper right of the abdomen or the lower middle of the chest Occurs after meals (but not after exertion) Ultrasonography of the gallbladder Swallowing disorders in which there is abnormal movement (propulsion) of food through the esophagus Pain that Has developed gradually over a long period of time May or may not occur during swallowing Usually difficulty swallowing Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow) 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, or a cast or splint on a leg, older age, smoking, or cancer) CT 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 Pneumonia 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 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 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 Is typically persistent (lasting days or longer) Is worsened by movement and/or breathing May have no apparent cause or may result from coughing or overuse Tenderness in one spot on the chest No warning signs§ Only a doctor's examination Herpes zoster infection* Sharp pain in a band around the middle of the chest 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 *Unless otherwise described, causes are usually not dangerous although they are uncomfortable. †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 is taken. §Warning signs include Abnormal vital signs (an abnormally slow or fast heart rate, rapid breathing, and abnormally low blood pressure) Signs of decreased blood flow (such as confusion, pale or gray skin color, and excessive sweating) Shortness of breath Abnormal breath sounds or pulses New heart murmurs CT = computed tomography; ECG = electrocardiography. Some Causes and Features of Chest Pain Causes* Common Features† Tests‡ Heart disorders Heart attack (myocardial infarction) or unstable angina, which are acute coronary syndromes Immediately life threatening Sudden, crushing pain that Spreads to the jaw or arm May be constant or come and go 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 markers) If ECG and cardiac marker levels are normal, CT of heart arteries or a stress test If ECG or cardiac marker 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 and have a history of high blood pressure Warning signs§ Chest x-ray CT of the aorta Transesophageal echocardiography (ultrasonography of the heart with the ultrasound device passed down the throat) Pericarditis (inflammation of the membrane around the heart) Potentially life threatening Sharp pain that Is constant or comes and goes Is often worsened by breathing, swallowing food, or lying on the back Is relieved by leaning forward An abnormal heart sound, heard through a stethoscope ECG Echocardiography Digestive tract disorders Esophageal rupture 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 X-rays of the esophagus taken after the person swallows water-soluble contrast (esophagography) Pancreatitis Potentially life threatening Severe, constant pain that Occurs in the upper middle of the abdomen or in the lower chest Is often worse when lying flat Is relieved by leaning forward Vomiting Upper abdominal tenderness Shock Often in people who abuse alcohol or who have gallstones Blood tests to measure an enzyme produced by the pancreas (lipase) Sometimes CT of the abdomen Peptic ulcer* Recurring, vague discomfort that Occurs in the upper middle of the abdomen or lower chest Is relieved by food, antacids, or both Often in people who smoke, drink alcohol, or do both No warning signs§ A doctor's examination Sometimes endoscopy Esophageal reflux (GERD)* Recurring, burning pain that Spreads from the upper middle of the abdomen to the throat Is worsened by bending over or lying down Is relieved by antacids A doctor's examination Sometimes endoscopy Gallbladder and bile duct disorders (biliary tract disease)* Recurring discomfort that Occurs in the upper right of the abdomen or the lower middle of the chest Occurs after meals (but not after exertion) Ultrasonography of the gallbladder Swallowing disorders in which there is abnormal movement (propulsion) of food through the esophagus Pain that Has developed gradually over a long period of time May or may not occur during swallowing Usually difficulty swallowing Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow) 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, or a cast or splint on a leg, older age, smoking, or cancer) CT 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 Pneumonia 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 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 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 Is typically persistent (lasting days or longer) Is worsened by movement and/or breathing May have no apparent cause or may result from coughing or overuse Tenderness in one spot on the chest No warning signs§ Only a doctor's examination Herpes zoster infection* Sharp pain in a band around the middle of the chest 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 *Unless otherwise described, causes are usually not dangerous although they are uncomfortable. †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 is taken. §Warning signs include Abnormal vital signs (an abnormally slow or fast heart rate, rapid breathing, and abnormally low blood pressure) Signs of decreased blood flow (such as confusion, pale or gray skin color, and excessive sweating) Shortness of breath Abnormal breath sounds or pulses New heart murmurs CT = computed tomography; ECG = electrocardiography.

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

If symptoms suggest an acute coronary syndrome 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 several ECGs. If these tests do not show an acute coronary syndrome, doctors often then do a stress test (see Diagnosis of Heart and Blood Vessel Disorders: Stress Testing) before people go home or within a few days. For a stress test, ECG or an imaging test (such as echocardiography) is done during exercise (often on a treadmill) or after a drug is given to make the heart beat fast.

If pulmonary embolism is suspected, computed tomography (CT) 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 ultrasonography of the legs or CT of the chest, 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

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. Symptoms are treated with acetaminophenSome Trade Names
TYLENOL
or opioids as needed until a diagnosis is made.

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 needed to determine a cause.

Last full review/revision October 2012 by Lyall A. J. Higginson, MD