Call 108 immediately, or go to the nearest emergency department. Do not wait to see whether it settles, do not take an antacid and wait an hour, do not wait for a reply to a message, and do not drive yourself.
Why chest pain is hard to judge from the outside
The chest contains the heart, the lungs, the oesophagus, the great vessels, the ribs and the muscles between them, and the nerves supplying all of it converge on the same few segments of the spinal cord. The brain receives the signal and can only guess at its origin. This is why a heart problem can be felt in the jaw, why acid reflux can feel exactly like a cardiac squeeze, and why a strained intercostal muscle can be frightening out of all proportion to what is wrong.
It follows that severity is a poor guide. Some of the most severe chest pain a person will ever experience is oesophageal spasm, which is not dangerous. Some heart attacks are described afterwards as no more than a heaviness, or as indigestion. Pattern is more informative than intensity.
The pattern that raises cardiac suspicion
Classical cardiac chest pain — angina — has a recognisable shape, and it is the shape rather than any single feature that matters.
- It is a heaviness, pressure, squeezing or tightness rather than a sharp stab. People often describe it with a fist on the sternum rather than a fingertip.
- It sits centrally, behind the breastbone, and is diffuse. Pain a person can cover with one fingertip is rarely cardiac.
- It is brought on by exertion or by emotion, and it eases within a few minutes of stopping. Walking up an incline, climbing stairs, carrying shopping, walking against a cold wind — the same amount of effort tends to bring on the same discomfort.
- It may spread to the jaw, the neck, the left arm or shoulder, occasionally both arms, or through to the back.
- It often comes with breathlessness, sweating or nausea rather than existing on its own.
- It is not made worse by pressing on the chest wall, and not altered by taking a deep breath or changing position.
Reliably reproducible discomfort on exertion that stops with rest is the single most important pattern in this article. It is also the one people most often dismiss, because it goes away, and because it is easy to reinterpret as being out of shape.
The patterns that are usually something else
None of the following excludes a cardiac cause, and none of them should be used to talk yourself out of an assessment. But they are the common alternatives, and they account for the large majority of chest pain seen in clinic.
Acid reflux
Burning behind the breastbone, worse lying down or bending forward, worse after a heavy or late meal, often with an acid or bitter taste, and often present for months. Its overlap with cardiac pain is genuinely close, and it is the commonest reason people delay seeking help during a heart attack.
Musculoskeletal pain
Sharp and well localised, reproduced by pressing on the spot, worse with a particular movement, twist or deep breath, and frequently following unaccustomed lifting, a new gym routine, or a bout of coughing. It can last for days to weeks and is often worse in the morning.
Anxiety and panic
Tightness with rapid shallow breathing, tingling in the hands or around the mouth, a sense of dread, and a strong awareness of the heartbeat. It frequently occurs at rest rather than on exertion. It is a real and unpleasant physical experience, and it is not a diagnosis to be made by the person having it — particularly not on a first episode.
Lung causes
Pain that is clearly worse on breathing in, with cough or fever, points towards the lung or the lining around it. Sudden severe breathlessness with chest pain is an emergency in its own right, whatever its origin.
When the usual pattern does not apply
Two groups deserve particular caution, because in them the textbook description is often simply absent.
In people with long-standing diabetes, the nerves carrying cardiac pain may be affected, and a significant event can present as breathlessness, unusual fatigue, sweating or vomiting with little or no chest discomfort at all. In women, the presentation is more frequently breathlessness, nausea, extreme tiredness, or discomfort in the upper back or jaw rather than a central chest squeeze. Older people, and people who have had a previous stroke, may similarly present without the classical pain.
What raises the stakes on any given symptom
The same symptom carries a different weight depending on who is describing it. The background that matters includes diabetes, high blood pressure, high cholesterol, smoking or tobacco use in any form, a family history of heart disease at a young age, chronic kidney disease, and known coronary disease or a previous stent or bypass. Age matters, but far less than people assume — coronary disease presents a decade earlier in South Asians than in Western populations, and a man in his late thirties with diabetes and a smoking history is not too young for it.
How chest pain is actually assessed
The assessment is mostly conversation. A careful history — what brings it on, how long it lasts, what relieves it, where it spreads, what else happens with it — does more work than any single test, and it is why the story you tell matters more than any number. That is followed by examination and usually an ECG.
Where the story raises a real question, an echocardiogram shows the heart muscle and valves, and a treadmill test looks at the heart under load. Where those raise a further question, a coronary angiogram shows the arteries directly. Assessment moves from the least to the most invasive, and most people never reach the far end of that sequence.
A reasonable rule of thumb
- Happening now, severe, prolonged, or with sweating, vomiting, breathlessness or collapse — call 108. This is not a decision to be deliberated over.
- Settled, but brought on by exertion and relieved by rest, and reproducible — that is worth a cardiac assessment without a long delay, even though it is not an emergency.
- Settled, clearly related to a meal, a movement or a strain, present for months without change, and not associated with effort — worth mentioning at consultation, and rarely urgent.
- New in a person with diabetes, known heart disease, or several risk factors — lower the threshold in every one of the categories above.
The purpose of this article is not to help you rule out a heart problem at home. It is to help you recognise the difference between something to raise at your next appointment and something that needs attention within the hour.
This article is general education about a condition or a test. It is not medical advice about you, it does not create a doctor and patient relationship, and it is not a substitute for consultation with a qualified doctor who has examined you.