🩺 Chest pain

## Overview Chest pain (ICD-10: R07) is any discomfort or abnormal sensation felt between the neck and the upper abdomen. It is one of the most common reasons adults visit emergency departments worldwide, accounting for approximately 5–8 million ED visits per year in the United States alone [1]. The symptom ranges from a sharp, momentary stab to a dull, persistent pressure and may originate from the heart, lungs, esophagus, musculoskeletal structures, or nerves of the chest wall. Chest pain is a leading health-related search term online because it provokes immediate anxiety: people understandably worry about heart attack. However, studies in primary-care settings show that **musculoskeletal and gastrointestinal causes account for more than half of all chest-pain presentations**, while cardiac etiologies represent roughly 8–18 % of cases evaluated in outpatient clinics [2, 5]. Distinguishing benign from life-threatening causes is critical, and no internet resource can replace an in-person medical evaluation. > **Disclaimer:** This article is for educational purposes only. If you are currently experiencing chest pain—especially with shortness of breath, sweating, or radiation to the arm or jaw—**call emergency services (911 / 112 / 999) immediately**. --- ## Common Causes The causes of chest pain can be broadly grouped by the organ system involved. Below they are ranked roughly by frequency of presentation in outpatient and emergency settings [2, 5]. ### 1. Musculoskeletal (30–50 % of outpatient chest pain) - **Costochondritis / chest-wall strain:** Inflammation of the costo-sternal or costo-chondral junctions causes localized, reproducible tenderness. It is the single most common diagnosis in primary-care chest-pain evaluations. - **Muscle strain:** Overuse of pectoral or intercostal muscles (e.g., heavy lifting, new exercise regimen) produces activity-related soreness. - **Rib fracture or contusion:** Trauma or severe coughing can fracture ribs, causing sharp, movement-dependent pain. ### 2. Gastrointestinal (10–20 %) - **Gastroesophageal reflux disease (GERD):** Acid reflux irritates the esophageal mucosa, producing a burning retrosternal sensation ("heartburn") that may closely mimic angina. - **Esophageal spasm:** Uncoordinated contraction of esophageal smooth muscle causes episodic, squeezing substernal pain. - **Peptic ulcer disease:** Epigastric pain may be perceived as lower chest discomfort. ### 3. Cardiac (8–18 % in outpatient; higher in ED populations) - **Stable angina pectoris:** Atherosclerotic narrowing of coronary arteries reduces myocardial oxygen supply during exertion, producing predictable pressure-like pain relieved by rest or nitroglycerin. - **Acute coronary syndrome (ACS):** Plaque rupture and thrombus formation partially or completely occlude a coronary artery. ACS encompasses unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) [1, 4]. - **Pericarditis:** Inflammation of the pericardial sac produces sharp pain that worsens when lying flat and improves with sitting forward. - **Myocarditis:** Viral or autoimmune inflammation of the myocardium may cause chest pain with associated heart-failure symptoms. ### 4. Pulmonary (5–10 %) - **Pulmonary embolism (PE):** A blood clot lodged in the pulmonary vasculature causes pleuritic chest pain, dyspnea, and tachycardia. - **Pneumothorax:** Air in the pleural space collapses the lung, producing sudden, sharp unilateral pain. - **Pneumonia / pleuritis:** Infection or inflammation of lung tissue or pleura produces pain that worsens with breathing or coughing. ### 5. Psychological / Functional (10–30 %) - **Panic disorder / anxiety:** Sympathetic activation during panic attacks can cause chest tightness, palpitations, and hyperventilation that closely mimic cardiac symptoms. - **Somatic symptom disorder:** Chronic, medically unexplained chest pain may be related to heightened visceral sensitivity. ### 6. Other - **Herpes zoster (shingles):** Reactivation of varicella-zoster virus in a thoracic dermatome causes unilateral, burning pain that may precede the rash by days. - **Aortic dissection:** A tear in the aortic intima produces sudden, "tearing" pain radiating to the back—a surgical emergency. --- ## RED FLAGS Seek **immediate emergency care (call 911 / 112 / 999)** if chest pain is accompanied by any of the following: - **Crushing, squeezing, or heavy pressure** in the center of the chest lasting more than a few minutes - **Radiation** of pain to the left arm, jaw, neck, shoulder, or back - **Shortness of breath** at rest or with minimal exertion - **Diaphoresis** (cold sweats) unrelated to ambient temperature or exercise - **Syncope or near-syncope** (fainting or lightheadedness) - **New-onset palpitations** or a sensation of a racing, irregular heartbeat - **Sudden, severe "tearing" or "ripping" pain** radiating to the back (suggests aortic dissection) - **Unilateral leg swelling** combined with pleuritic chest pain (suggests pulmonary embolism) - **Hemoptysis** (coughing up blood) - **Cyanosis** (bluish discoloration of lips or fingertips) - **Known history of coronary artery disease, heart failure, or recent cardiac procedure** with new chest symptoms - **Pain not relieved by three doses of nitroglycerin** (in patients prescribed sublingual NTG) > **Important:** Women, people with diabetes, and elderly individuals may present with **atypical symptoms** such as isolated fatigue, nausea, back pain, or epigastric discomfort rather than classic chest pressure [3]. A low threshold for seeking care is essential in these populations. --- ## Self-Care at Home The following non-pharmacological measures may help **only after a serious cause has been excluded** by a healthcare professional. ### For musculoskeletal chest pain - **Rest and activity modification:** Avoid movements that reproduce the pain (e.g., heavy lifting, push-ups) for 1–2 weeks. - **Local heat or ice:** Apply a warm compress or ice pack to the tender area for 15–20 minutes several times daily. Ice is generally preferred in the first 48 hours; heat may be more soothing thereafter. - **Gentle stretching:** Doorway pectoral stretches and thoracic extension exercises may relieve costochondral tension after the acute phase. - **Posture correction:** Prolonged forward-hunched posture (desk work) can exacerbate chest-wall pain. Ergonomic adjustments may help. ### For GERD-related chest pain - **Elevate the head of the bed** by 15–20 cm (6–8 inches) using blocks or a wedge pillow. - **Avoid trigger foods:** Common triggers include spicy food, citrus, tomato-based sauces, chocolate, caffeine, and alcohol. - **Do not eat within 2–3 hours of lying down.** - **Maintain a healthy weight:** Obesity increases intra-abdominal pressure and worsens reflux. - **Wear loose-fitting clothing** around the abdomen. ### For anxiety-related chest tightness - **Diaphragmatic (belly) breathing:** Inhale slowly through the nose for 4 seconds, hold for 4 seconds, exhale through the mouth for 6 seconds. Repeat for 5 minutes. - **Progressive muscle relaxation** and mindfulness-based stress reduction have been shown to reduce panic-related chest symptoms. - **Regular aerobic exercise** (150 minutes per week of moderate activity) is associated with reduced anxiety severity. --- ## OTC Medications That May Help Over-the-counter options are appropriate **only for non-cardiac, clinician-evaluated chest pain**. Never self-treat chest pain you suspect may be cardiac in origin. | Class | Example | Typical Adult Dose | Mechanism | Key Contraindications / Notes | |---|---|---|---|---| | **NSAIDs** | Ibuprofen (Advil, Motrin) | 200–400 mg every 4–6 h (max 1200 mg/day OTC) | Inhibits COX-1/2, reducing prostaglandin-mediated inflammation and pain | Avoid in known CAD, heart failure, renal impairment, active GI bleeding, third-trimester pregnancy. Use the lowest effective dose for the shortest duration. | | **NSAIDs** | Naproxen (Aleve) | 220 mg every 8–12 h (max 660 mg/day OTC) | Same as above; longer half-life allows less frequent dosing | Same as ibuprofen; may carry slightly lower cardiovascular risk among NSAIDs (AHA statement) | | **Acetaminophen** | Paracetamol / Tylenol | 500–1000 mg every 4–6 h (max 3000 mg/day for regular use) | Central analgesic; mechanism not fully elucidated; does not reduce peripheral inflammation | Hepatotoxicity risk at supratherapeutic doses; avoid with heavy alcohol use or liver disease | | **Antacids** | Calcium carbonate (Tums), aluminum/magnesium hydroxide (Maalox) | Per package directions (e.g., 1–2 tablets as needed) | Neutralize gastric acid on contact | Short duration of action; calcium-based products may cause constipation; magnesium-based may cause diarrhea | | **H2-receptor antagonist** | Famotidine (Pepcid AC) | 10–20 mg once or twice daily | Blocks histamine H2 receptors on parietal cells, reducing acid secretion | Generally well tolerated; reduce dose in renal impairment | | **Proton pump inhibitor** | Omeprazole (Prilosec OTC) | 20 mg once daily for up to 14 days | Irreversibly inhibits H+/K+ ATPase (proton pump) in parietal cells | Not for immediate relief; takes 1–4 days for full effect. OTC courses should not exceed 14 days without medical advice | | **Topical analgesics** | Menthol/methyl salicylate creams (Bengay, Icy Hot) | Apply to affected chest-wall area 3–4 times daily | Counter-irritant effect via TRPM8/TRPA1 activation; mild local vasodilation | Avoid on broken skin; do not use with heating pads (burn risk); methyl salicylate products carry aspirin-allergy cross-reactivity risk | > **Aspirin note:** Low-dose aspirin (162–325 mg, chewed) is recommended as **first-aid treatment** during a suspected heart attack per AHA guidelines [3], but it is not an OTC "self-care" remedy for recurrent chest pain. Do not take aspirin routinely for chest pain without medical guidance. --- ## Prescription Options Prescription medications are tailored to the underlying diagnosis. The following table summarizes common classes used when chest pain has a confirmed etiology requiring pharmacotherapy. | Class | Examples | Indication | Prescriber | Key Notes | |---|---|---|---|---| | **Nitrates** | Nitroglycerin (sublingual tablet, spray, patch), isosorbide mononitrate | Angina pectoris (acute relief and prophylaxis) | Cardiologist, internist, GP | Sublingual NTG acts within 1–3 min. Contraindicated with PDE-5 inhibitors (sildenafil, tadalafil) — risk of severe hypotension. | | **Beta-blockers** | Metoprolol, atenolol, bisoprolol | Stable angina, ACS, rate control | Cardiologist, internist | Reduce heart rate and myocardial oxygen demand. Avoid abrupt discontinuation. | | **Calcium channel blockers** | Amlodipine, diltiazem, verapamil | Vasospastic angina, stable angina (when beta-blockers contraindicated) | Cardiologist, internist | Dihydropyridines (amlodipine) preferred if LV dysfunction present; non-dihydropyridines reduce heart rate. | | **Antiplatelet / anticoagulant therapy** | Aspirin + clopidogrel/ticagrelor; heparin, enoxaparin | ACS, post-PCI, PE | Cardiologist, hematologist, pulmonologist | Dual antiplatelet therapy (DAPT) duration varies (typically 6–12 months post-ACS) [4]. | | **Statins** | Atorvastatin, rosuvastatin | Coronary artery disease, ACS | Cardiologist, internist, GP | High-intensity statin therapy recommended in all ACS patients regardless of baseline LDL [3]. | | **ACE inhibitors / ARBs** | Ramipril, lisinopril, valsartan | Post-MI with LV dysfunction, hypertension, heart failure | Cardiologist, internist | Cardioprotective; reduce remodeling post-infarction. | | **Proton pump inhibitors (Rx-strength)** | Esomeprazole 40 mg, pantoprazole 40 mg | Severe GERD, erosive esophagitis | Gastroenterologist, GP | May be needed for 8–12 weeks; long-term use associated with magnesium depletion, fracture risk. | | **Colchicine** | Colchicine 0.5 mg | Acute and recurrent pericarditis | Cardiologist, internist | The COPE and CORP trials demonstrated colchicine reduces pericarditis recurrence by ~50 % [7]. | | **Anxiolytics / SSRIs** | Sertraline, escitalopram; short-term benzodiazepines | Panic disorder, anxiety-related chest pain | Psychiatrist, GP | SSRIs are first-line for panic disorder. Benzodiazepines only for short-term bridge therapy due to dependence risk. | --- ## Lab Tests Typically Ordered The choice of investigations depends on clinical suspicion. Below are tests commonly ordered when evaluating chest pain. | Test | Rationale | Link | |---|---|---| | **High-sensitivity cardiac troponin (hs-cTnI or hs-cTnT)** | Gold-standard biomarker for myocardial injury. Serial measurements (0 h and 1–3 h) can rule in or rule out MI with high sensitivity [6]. | [Troponin test](/tests/troponin) | | **Electrocardiogram (ECG / EKG)** | Identifies ST-segment changes, arrhythmias, and conduction abnormalities. Should be obtained within 10 minutes of ED arrival for acute chest pain [3]. | [ECG](/tests/ecg) | | **Chest X-ray** | Evaluates for pneumothorax, pneumonia, pleural effusion, widened mediastinum (aortic dissection), and cardiomegaly. | [Chest X-ray](/tests/chest-xray) | | **Complete blood count (CBC)** | Anemia can exacerbate angina; leukocytosis may suggest infection or inflammation. | [CBC](/tests/cbc) | | **Basic metabolic panel (BMP)** | Electrolyte imbalances (potassium, magnesium) can provoke arrhythmias. Creatinine assesses renal function before contrast imaging. | [BMP](/tests/bmp) | | **D-dimer** | Elevated in pulmonary embolism, aortic dissection, and other thrombotic states. Most useful when pre-test probability is low-to-intermediate (Wells score). | [D-dimer](/tests/d-dimer) | | **BNP / NT-proBNP** | Elevated in heart failure; aids differentiation of cardiac vs. pulmonary dyspnea. | [BNP](/tests/bnp) | | **Lipid panel** | Assesses cardiovascular risk factors (LDL, HDL, triglycerides) in patients with suspected or confirmed CAD. | [Lipid panel](/tests/lipid-panel) | | **CT pulmonary angiography (CTPA)** | Definitive imaging for pulmonary embolism when clinical suspicion is moderate-to-high. | [CTPA](/tests/ct-pulmonary-angiography) | | **Coronary CT angiography (CCTA)** | Non-invasive assessment of coronary artery anatomy; increasingly recommended as first-line imaging for stable chest pain per 2021 AHA/ACC guidelines [3]. | [CCTA](/tests/coronary-ct-angiography) | | **Stress testing** (exercise or pharmacologic) | Evaluates inducible ischemia in patients with intermediate pretest probability of CAD. | [Stress test](/tests/stress-test) | | **Esophageal pH monitoring / manometry** | Indicated when GERD or esophageal dysmotility is suspected after cardiac causes are excluded. | [Esophageal pH study](/tests/esophageal-ph-monitoring) | --- ## Special Populations ### Children and Adolescents Chest pain in pediatric patients is overwhelmingly benign; cardiac causes account for fewer than 5 % of presentations. Common etiologies include costochondritis, exercise-induced asthma, and anxiety. However, the following warrant urgent pediatric cardiology evaluation: - Exertional chest pain with syncope - Known congenital heart disease - Family history of sudden cardiac death before age 40 or inherited channelopathies (Long QT, Brugada, hypertrophic cardiomyopathy) - Pain associated with fever and new murmur (possible myocarditis or Kawasaki disease) **Medication note:** NSAID dosing in children should follow weight-based guidelines (e.g., ibuprofen 5–10 mg/kg every 6–8 h) and must be confirmed with a pediatrician. Aspirin is generally avoided in children under 16 due to the risk of Reye syndrome, except in specific conditions (e.g., Kawasaki disease) under specialist supervision. ### Pregnancy Chest pain during pregnancy may result from physiological changes (increased plasma volume, upward displacement of the diaphragm, hormonally mediated ligamentous laxity) or pathological conditions. Important considerations: - **GERD** is extremely common in pregnancy (30–80 % prevalence). First-line treatment includes lifestyle modifications and antacids. Famotidine and omeprazole are generally considered acceptable in pregnancy when needed (former FDA Category B), but clinicians should weigh benefits and risks. - **Peripartum cardiomyopathy** is rare but serious; new dyspnea and chest pain in the third trimester or postpartum period warrant urgent echocardiography. - **Pulmonary embolism** risk is 4–5 times higher during pregnancy and the postpartum period. D-dimer is physiologically elevated in pregnancy, limiting its utility; CTPA or V/Q scanning may be required. - **NSAIDs** should be avoided, particularly after 20 weeks of gestation (risk of premature ductus arteriosus closure and oligohydramnios per 2020 FDA safety communication). - **ACE inhibitors and ARBs** are contraindicated throughout pregnancy (teratogenicity, fetal renal toxicity). ### Elderly (≥ 65 years) Older adults are more likely to present with **atypical chest pain or "anginal equivalents"** such as isolated dyspnea, fatigue, or confusion. Key considerations: - **Silent ischemia** is more prevalent in the elderly and in those with diabetes. - **Polypharmacy** increases the risk of drug interactions. NSAIDs should be used cautiously due to elevated cardiovascular, renal, and GI bleeding risks. - **Aortic stenosis** becomes increasingly common with age and can present with exertional chest pain, syncope, or heart failure. - **Reduced renal function** may necessitate dose adjustments for medications such as colchicine, enoxaparin, and famotidine. ### Athletes Chest pain during exercise in young athletes raises concern for: - **Hypertrophic cardiomyopathy (HCM):** The leading cause of sudden cardiac death in young athletes. Exertional chest pain, syncope, or a family history of HCM should prompt echocardiography and possible cardiac MRI. - **Coronary artery anomalies:** Aberrant coronary origins can cause exertional ischemia. - **Myocarditis:** Often post-viral; athletes should be restricted from competition for 3–6 months after diagnosis per AHA/ACC consensus. - **Commotio cordis:** A blunt impact to the precordium during a vulnerable phase of the cardiac cycle can trigger ventricular fibrillation — a medical emergency. - **Exercise-induced bronchoconstriction** is a common benign cause of chest tightness in athletes. Pre-participation cardiovascular screening (history, physical examination, and in some countries ECG) may identify at-risk individuals. --- ## When to Escalate Use the following framework to determine the urgency of medical evaluation: ### Call Emergency Services (911 / 112 / 999) Immediately - Chest pain with any red-flag features listed above - Suspected heart attack (pressure/squeezing lasting > 5 minutes, with diaphoresis, radiation, or dyspnea) - Sudden severe chest or back pain (possible aortic dissection) - Chest pain with signs of shock (hypotension, altered consciousness, pallor) ### Go to the Emergency Department / Urgent Care (Within Hours) - New chest pain at rest without red-flag features but with cardiovascular risk factors (smoking, diabetes, hypertension, hyperlipidemia, family history of premature CAD) - Pleuritic chest pain with recent immobilization, surgery, or travel (PE risk) - Chest pain with fever > 38.5 °C (101.3 °F) and productive cough (possible pneumonia) - Post-traumatic chest pain with difficulty breathing (rib fracture, pneumothorax) ### See Your GP / Primary Care Provider (Within 1–2 Days) - Recurrent, reproducible chest-wall tenderness without red flags - Chest burning that correlates with meals and is partially relieved by antacids - Chest tightness associated with known anxiety disorder, without new features - Persistent chest pain lasting more than a few days despite OTC measures ### Routine Appointment (Within 1–2 Weeks) - Mild, intermittent chest discomfort that is clearly musculoskeletal and improving - Follow-up after ED visit where serious causes were excluded - Discussion of cardiovascular risk-factor optimization (lipids, blood pressure, smoking cessation) > **General principle:** When in doubt, err on the side of seeking care sooner rather than later. Chest pain is a symptom where the cost of a "false alarm" is far lower than the cost of a missed diagnosis. --- ## References [1] Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. *J Am Coll Cardiol*. 2014;64(24):e139–e228. PMID:25260718. [2] Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. *JAMA*. 2005;294(20):2623–2629. PMID:16234498. [3] Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. *Circulation*. 2021;144(22):e368–e454. PMID:34709879. [4] Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. *Eur Heart J*. 2021;42(14):1289–1367. PMID:32860058. [5] Fruergaard P, Launbjerg J, Hesse B, et al. The diagnoses of patients admitted with acute chest pain but without myocardial infarction. *Eur Heart J*. 1996;17(7):1028–1034. PMID:8809520. [6] Body R, Carley S, McDowell G, et al. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay. *J Am Coll Cardiol*. 2011;58(13):1332–1339. PMID:21920261. [7] Imazio M, Brucato A, Cemin R, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial. *Ann Intern Med*. 2011;155(7):409–414. PMID:21873705. [8] National Institute for Health and Care Excellence (NICE). Chest pain of recent onset: assessment and diagnosis. Clinical guideline [CG95]. Updated 2016. Available at: https://www.nice.org.uk/guidance/cg95. [9] U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later. October 2020. Available at: https://www.fda.gov/drugs/drug-safety-and-availability. --- *Last reviewed: April 2026. This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment of chest pain or any medical condition.*