Chest pain
Most chest pain has nothing to do with the heart. But this is the subject where the price of getting it wrong is highest, which is why the page opens not…
On this page
- Call an ambulance immediately if
- A heart attack does not always look like one
- Aortic dissection
- Pain that gets worse on breathing in and coughing
- Pain that depends on movement and on pressing
- Burning behind the breastbone with a sour taste
- Pain that goes with anxiety
- Angina: pain that arrives on schedule
- Online consultation
Most chest pain has nothing to do with the heart. But this is the subject where the price of getting it wrong is highest, which is why the page opens not with a list of causes but with the signs that mean calling an ambulance — read the first section before anything else. What follows is about pain deep in the chest and behind the breastbone. If what hurts is the breast itself, its tissue or the nipple, that is a different matter with its own page, «Breast pain».
Call an ambulance immediately if
- a pressing, squeezing, tightening or burning pain has come on behind the breastbone, lasts longer than a few minutes and does not settle with rest;
- the pain spreads to the left or right arm, to the neck, the jaw, between the shoulder blades or to the upper abdomen;
- along with the pain there is breathlessness, cold clammy sweat, nausea or vomiting, weakness, dizziness, sudden pallor;
- there is a sense of impending disaster, a fear you cannot account for;
- the person has collapsed and is breathing in irregular gasps or not breathing at all.
Do not expect it to look like it does in films. Clutching your chest and falling over is not part of the requirement. People far more often say «heaviness», «like a brick sitting on me», «burning, like indigestion», «a band tightening round me» — and it is exactly that ordinariness that keeps them waiting for hours for it to pass. If it is not passing, ring. Being wrong and calling out an ambulance for nothing is neither shameful nor harmful; missing a heart attack cannot be undone.
112 is the single European emergency number and works in Spain, Italy, Portugal, Poland and Ukraine; elsewhere dial your local emergency number.
While the crew is on its way: sit or half-lie down, loosen tight clothing, unlock the door in advance and do not stay on your own. Do not drive and do not walk to hospital — you can lose consciousness on the way, whereas an ambulance starts treatment and records a heart tracing in the vehicle itself. If glyceryl trinitrate has been prescribed for you, take it sitting down only: it drops the blood pressure sharply and it is easy to fall while standing. If the emergency call handler tells you to chew an aspirin, do so; take no other medicine on your own initiative. If the person is unconscious and not breathing normally, start chest compressions and follow the call handler's instructions.
A heart attack does not always look like one
The classic picture is the one above, but in a proportion of people it simply never appears. In women, in older people and in people with diabetes a heart attack frequently runs without marked pain behind the breastbone, and that is precisely why help arrives late most often in these groups. In diabetes the nerves that carry pain are damaged, and the attack can pass almost painlessly.
What to watch for instead of pain:
- sudden breathlessness on exertion that used to be easy, or breathlessness at rest;
- an abrupt unexplained weakness, as though the battery had been taken out;
- nausea, vomiting, heaviness and discomfort at the top of the stomach, mistaken for food poisoning or indigestion;
- pain or dragging in the back between the shoulder blades, in the neck, the jaw, one arm or both;
- cold sweat for no reason, dizziness, fainting;
- in an older person, sudden confusion or an unexplained fall.
The rule is simple: if the sensation is new, unexplained, worse on exertion and easier at rest, it needs sorting out today rather than next week. All the more so with diabetes, past sixty, and where close relatives had heart attacks young.
Aortic dissection
An uncommon cause that must not be missed, because the clock runs in hours. The wall of the body's main artery tears from the inside and blood begins to split its layers apart. This pain is recognised by several features:
- it starts abruptly and is at its worst from the first instant, without the gradual build-up of a heart attack;
- it is described as tearing, ripping or cutting;
- it radiates to the back between the shoulder blades and may travel downwards, to the lower back and the abdomen;
- the blood pressure and pulse differ between the right and left arm;
- fainting, weakness in an arm or leg, or slurred speech are sometimes added.
It is likelier in people with long-standing high blood pressure, with an aortic aneurysm, with inherited connective tissue disorders such as Marfan syndrome, and in late pregnancy. There is only one action here: an ambulance, straight away.
Pain that gets worse on breathing in and coughing
If a deep breath, a cough or a twist of the trunk makes the pain leap and you start breathing shallowly to avoid provoking it, the source is usually the pleura — the membrane covering the lungs — or the lung itself.
- Pleurisy and pneumonia. Fever, shivering, a cough sometimes productive of phlegm, and a general flattening are added. A medical examination is needed, and with a high temperature and breathlessness it is needed the same day.
- Pulmonary embolism. Sudden breathlessness together with pain on breathing in and a fast heartbeat, sometimes a cough streaked with blood. What went before helps raise the suspicion: a long flight or journey, recent surgery, a plaster cast, bed rest, cancer, combined hormonal contraceptives, pregnancy and the first weeks after delivery. More so if one calf is swollen and sore. This is an ambulance.
- Pneumothorax. Sudden one-sided pain and increasing breathlessness, often out of a clear sky, commoner in tall slim young people and in smokers. Also an ambulance.
- Pericarditis. Sharp pain behind the breastbone, worse lying flat on the back and on breathing in, and noticeably easier on leaning forwards. That posture is the giveaway.
Pain that depends on movement and on pressing
This is the commonest group and the most harmless. The one sign that settles almost everything: the pain can be reproduced. You find the spot with a finger, press, and get exactly the same pain. It shifts with posture, with turning the body, with moving the arm, and at night it depends on which side you lie on.
- costochondritis, inflammation of the rib cartilages where they meet the breastbone: the tenderness runs as a strip along the edge of the breastbone;
- a strain of the intercostal or chest muscles after exertion, decorating, shifting furniture or a bout of hard coughing;
- a bruised or cracked rib after a knock;
- pain referred from the upper spine.
A few days of rest, a short course of pain relief, an anti-inflammatory gel and local warmth all help. This resolves over weeks rather than days, and a slow recovery here is normal.
The same group includes shingles at its very start: burning, tingling or skin sensitivity in a strip down one side of the chest, several days before any blisters appear. If the rash is already out, it is worth being seen in the first few days, because antiviral treatment works precisely at the beginning.
And once more on telling things apart: if what hurts is the breast itself, its tissue, the skin or the nipple, the page you want is the neighbouring one, «Breast pain», where the causes are altogether different.
Burning behind the breastbone with a sour taste
Reflux is a very common cause of chest pain, and it is recognised by its circumstances rather than by its severity. The burning rises from below towards the throat, a sour or bitter taste appears in the mouth, and there may be belching. It comes on after eating, particularly a large, fatty or late meal, worsens on lying down or bending over, and often wakes people at night.
What helps: nothing to eat in the three hours before bed, raising the head of the bed, smaller portions, losing weight where there is excess, and identifying your own triggers, usually alcohol, coffee, chocolate, spicy food, acidic juices and smoking. Where necessary the doctor will choose a medicine to reduce acid.
But this is also where the most dangerous thought on this page lives: «it is only heartburn». A heart attack very often feels exactly like indigestion, and talking yourself round is the easiest thing in the world. If the burning has appeared for the first time, if it comes on with exertion and goes with rest, if breathlessness, sweating or nausea keep it company, this is not about the stomach and it needs handling as a heart problem. Separately, see a doctor about difficulty or pain on swallowing, weight loss, vomiting blood and black stools.
Pain that goes with anxiety
Anxiety and panic attacks produce genuine physical pain, not an imagined one. It is usually stabbing or sharp, often in a single spot on the left, lasts anywhere from seconds to several hours and has little to do with exertion — it tracks the situation instead.
Its companions are recognisable: fast shallow breathing, a feeling of being unable to fill the chest, palpitations, trembling, tingling and numbness in the fingertips and around the mouth, dizziness, a sense of unreality and a fear of dying. The numbness has a mechanical explanation: rapid breathing washes out carbon dioxide and alters how excitable the nerves are. Hence the manoeuvre that helps in the moment — not «take a deep breath» but the opposite: slow the breathing down and make the out-breath longer than the in-breath, through the nose, counting silently.
An important caveat. A panic attack is a diagnosis reached once everything else has been excluded, not the first explanation that comes to mind. If the episode is a first, if you are over forty, if there is diabetes, high blood pressure, smoking or early heart attacks in the family, the heart is checked first. Only then, once that is settled, is the anxiety addressed — and it responds well to treatment, incidentally.
Angina: pain that arrives on schedule
There is a particular pattern worth recognising, because it gives warning in advance. Pain or heaviness behind the breastbone appears with the same exertion each time: climbing stairs, walking uphill, stepping out into the cold, a heavy meal, an upset. It lasts a few minutes and eases as soon as you stop or take the glyceryl trinitrate you have been prescribed. That is angina, the sign that the heart muscle is short of blood when it works.
This pain does not call for an ambulance, but it does call for a doctor without putting it off: it leads to investigation of the heart's arteries and to treatment, and this is precisely the stage at which a heart attack can still be prevented.
And here is what demands an immediate response: the episodes have become more frequent, stronger or longer, they come on with less exertion than before, they appear at rest or at night, or they respond less well to the usual tablet or spray. That is unstable angina, and it is handled like a heart attack — call an ambulance.
The risk is higher in smokers and with high blood pressure, diabetes, raised cholesterol, excess weight, an inactive life and early heart attacks among close relatives. None of that is a sentence: it is the list of what can be worked on.
Online consultation
Let us be clear from the start: acute chest pain does not need an online appointment, it needs an ambulance. Everything else, though, is dealt with well at a distance. The doctor will ask in detail about the character of the pain, what brings it on and what relieves it, gather your risk factors, help separate musculoskeletal pain from cardiac pain and reflux from angina, say which investigations are worth doing and in what order, and explain which signs, in your particular case, should make you call an ambulance. It is especially useful for anyone who has already been through an episode of pain, been investigated and been left with the worry: understanding what happened settles that better than repeating the tests.
This material is for information only and does not replace medical advice.
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