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Chest pain: symptoms, causes and what to do

Chest pain can take many forms, from sharp stabbing to dull throbbing. It can be a crushing pressure or a burning sensation. It may climb up to your neck, shoot into your jaw, and radiate to your back or one or both arms. Chest pain can be triggered by a variety of problems. Among the most dangerous causes are diseases of the heart and lungs. Because of these risks, it is essential to seek medical help immediately when chest symptoms appear. Depending on what causes the chest pain, it can produce many different sensations. Often its onset has nothing to do with your heart, although this is difficult to determine without a medical examination.

Characteristics of heart-related chest pain

Some people with heart disease experience an indistinct unpleasant sensation that they may not necessarily identify as pain. It is more often an uncomfortable pressure, as if a band were wrapped tightly around the chest.

In general, complaints due to a heart attack or other heart problems may include the following:

you feel pressure, fullness, burning or tightness in your chest,
a squeezing, burning, gripping pain in the chest,
the pain radiates to your back, neck, jaw, shoulders, one or both arms, or sometimes just under the ribs or to your upper abdomen,
the pain lasts longer than a few minutes and may worsen with movement,
the symptoms may come and go, or their intensity may change,
your breaths become shorter, you feel you cannot fill your lungs with air,
your skin is cool and sweaty,
dizziness or a feeling of weakness may accompany it,
nausea or vomiting can occur.

There are many possible causes of chest pain, all of which require medical evaluation.

Heart-related

Myocardial infarction (heart attack). Heart muscle cell death occurs when blood does not reach a specific area of the heart because the supplying artery or arteries are partly or completely blocked by spasm or a blood clot.

Angina pectoris. This pain is caused by impaired blood supply to the heart. A common explanation is that deposits build up on the inner walls of the coronary arteries. As the layer thickens, it narrows the vessels. Beyond a certain point, it limits the heart's blood supply. Especially during physical activity or increased demand, not enough fresh (oxygen-rich) blood reaches the heart muscle and the lack of oxygen triggers the pain.

Aortic dissection (aortic tear). This is a life-threatening condition caused by a tear in the wall of the aorta, the main artery leaving the heart. The layers of the vessel wall separate and blood flows between them, causing a tearing pain. If not recognized in time, the outer layer can rupture and the patient can bleed to death internally.

Pericarditis (inflammation of the pericardium). The pericardium is the “sac” surrounding the heart. It usually causes sharp pain that worsens with inhalation or when lying down.

Digestive causes

Disorders of the digestive system can also be among the possible causes, such as:

Heartburn (acid reflux). A painful, burning sensation behind the breastbone that occurs when stomach acid flows into the esophagus.

Swallowing disorders. Poor function of the esophagus can make swallowing difficult and even painful.

Gallbladder or pancreatic problems. Gallstones, inflammation of the gallbladder or pancreas can cause abdominal pain that may radiate to the chest.

Muscle and bone causes

Some types of chest pain may be related to injuries, while others originate from the elements of the chest wall.

Costochondritis (inflammation of the rib cartilage). The cartilaginous parts of the rib cage, especially where the ribs attach to the breastbone, become painfully inflamed.

Muscle soreness. Chronic pain syndromes such as fibromyalgia can cause persistent, muscle-related chest pain.

Injured ribs. Bruised or fractured ribs from a fall or accident can also cause chest pain.

Causes related to the lungs

Many lung disorders can cause chest pain.

Pulmonary embolism. This occurs when a blood clot travels to a pulmonary artery and blocks blood flow to the lung.

Pleurisy (pleural inflammation). Inflammation of the membrane covering the lungs can cause aching chest pain that worsens with breathing and coughing.

Collapsed lung (pneumothorax). Sudden pain. For example, after a rib fracture in an accident the bone end can "poke" the lung. With every breath a little air enters the space between the lung and the chest wall (a pneumothorax). Gradually more air accumulates outside the lung, slowly compressing the affected lung. Breaths become increasingly shallow.

Pulmonary arterial hypertension (PAH). High blood pressure in the arteries that supply the lungs can also be associated with chest pain.

Other causes

Panic attack. A state of intense fear and a sense of impending doom, which may be accompanied by sharp chest pain, rapid heartbeat, rapid breathing, heavy sweating, shortness of breath, nausea and dizziness.

Shingles (herpes zoster). A condition that can occur in people who had chickenpox earlier; it causes a stabbing sensation and the appearance of blisters. It always affects one side of the body, does not cross the midline, and follows one or a few intercostal nerve distributions. It can appear decades after the initial infection, especially in states of weakened immunity.

When should you see a doctor?

If you experience newly onset chest pain of unknown cause, seek emergency care immediately.

Making the diagnosis

Chest pain is not always a sign of a heart attack. In emergency care, however, this is always the first thing doctors try to rule out. A heart attack is the most life-threatening condition and requires immediate treatment. After that, the lungs and other life-threatening conditions related to them (blood clots in the vessels or collapsed lungs) can be checked.

Immediate tests for chest pain

The following tests are usually performed.

Electrocardiogram (ECG). Through 10 electrodes placed on the skin (4 limb electrodes and 6 chest electrodes from the sternum to the armpit line), the electrical activity of the heart is recorded. The electrical impulses of damaged heart muscle tissue clearly show the injury. Therefore, an ECG can detect if you are having or have had a heart attack.

Laboratory (blood) tests. With these the doctor checks for elevated levels of certain proteins and enzymes. These are normally present in heart muscle cells, but during a heart attack the cells are damaged and their proteins and enzymes leak into the blood. Their elevated levels can be detected and indicate heart muscle injury.

Chest X-ray. This examination can assess the state of the lungs and the size and shape of the heart and major vessels. Certain lung problems, such as pneumonia or a collapsed lung, can be seen immediately on the film.

Computed tomography (CT scan). This is necessary if there is suspicion of a pulmonary embolism (a blood clot in the lung) or an aortic dissection.

Further diagnostic tests

Depending on the results of the initial tests, the following may also be needed:

Echocardiography (heart ultrasound). Using ultrasound (sound waves at frequencies inaudible to the human ear), images are made of the heart's motion and blood flow in the vessels. The examination can be performed through the chest, but sometimes a small device is passed into the esophagus to obtain images from different perspectives.

Cardiac CT. A CT study different from the one mentioned earlier can directly assess obstruction of the heart's arteries. During coronary angiography, contrast dye is used to map the heart and lung arteries and thus identify blockages and other problems.

Exercise stress test (stress ECG). This assesses how your heart, coronary arteries and blood pressure respond to physical exertion. It is indicated if your chest pain is suspected to be heart-related. The test can be performed in various ways. You may be asked to walk or run on a treadmill or pedal on a bicycle ergometer while connected to an ECG, with continuous recording of the heart's electrical activity and repeated blood pressure measurements.

Coronary catheterization (angiography). This test identifies narrowed or blocked arteries of the heart (coronary arteries). A long thin catheter is introduced via an artery in the wrist or groin and advanced to the heart, then contrast dye is injected into the coronary arteries. X-ray imaging follows the dye as it flows through the arteries. The images outline the vessels and reveal sections causing narrowing or blockage. If the test shows certain abnormalities, immediate treatment is often possible: the narrowed vessel can be dilated or an obstructing lesion can be removed right away.

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