Written by Dimitrios Vrachatis, Specialist Cardiologist, PhD, National and Kapodistrian University of Athens.
Chest Pain: General Information
Chest pain at rest or during exertion concerns both patients and otherwise healthy people. It is one of the most common reasons for a cardiology consultation. It may be described as angina, tightness, pressure, discomfort or thoracic pain, and may accompany or be difficult to distinguish from breathlessness.
It can be the first sign of a life-threatening condition and usually requires urgent investigation. The time from symptom onset to medical assessment should be as short as possible: every minute may matter. Not all pain means heart disease, but when it does, prompt and effective care is essential.
Assessment should therefore begin with a cardiologist, the specialist able to exclude potentially fatal cardiac causes.
When should chest pain concern us?
Even mild or atypical pain can conceal serious disease. Do not delay assessment if:
- Tightness spreads to the neck, back or left arm as pain or numbness.
- Pain is very severe, sudden or tearing in character.
- It wakes you at night or in the early morning.
- It persists rather than settling promptly.
- It accompanies cold sweats, fainting or a very fast or slow heartbeat.
- You are at high risk or have a family history of premature coronary disease.
- It resembles pain from a previous cardiac episode.
- You recently had angioplasty, bypass surgery, pacemaker implantation or arrhythmia ablation.
Even extensive recent negative tests cannot completely exclude future events. The symptom takes priority: the doctor reassesses it in light of both earlier findings and the current situation.
When is chest pain harmless?
This cannot be answered easily. Chest pain should never be underestimated. Only your treating cardiologist, who knows your history and recent tests, can guide you. When in doubt, additional assessment is preferable to leaving a serious condition untreated.
Why does early assessment matter?
Causes range from harmless muscle pain to very serious conditions. The latter must be excluded promptly: without diagnosis and treatment, they can cause disability or death. Acute myocardial infarction, aortic dissection and pulmonary embolism are life-threatening emergencies in which timely intervention can save life.
What happens during an urgent assessment?
The cardiologist takes a brief history and examines you, including listening to the heart, lungs, carotids and abdominal aorta, checking peripheral pulses and calves, measuring blood pressure in both arms, and performing an ECG and echocardiogram.
If an emergency is suspected, immediate hospital transfer is recommended. If initial findings are negative, assessment continues with:
- Blood tests, often urgently, such as blood count, high-sensitivity troponin and D-dimer
- Further investigations that may be completed later
Hospital observation may be recommended even without a definite diagnosis.
What further tests might be needed?
These may include a chest X-ray and, according to history and the possible diagnoses, an exercise test, stress echocardiogram, myocardial perfusion scan or coronary angiography. Assessment by an internal medicine, respiratory or gastroenterology specialist may also be requested.
What will the cardiologist ask?
A detailed history guides diagnosis. For either chronic or sudden symptoms, the cardiologist asks about:
- The symptom itself
- Medication: men taking medicines for erectile dysfunction must specifically tell the doctor
- Hypertension, diabetes, high cholesterol, smoking, parental cardiovascular disease and illicit drug use
Questions about the pain include:
- When it began
- How long it lasted
- Its intensity
- Its exact location
- Whether it feels stabbing, tight, crushing or burning
- Whether it spreads, for example from the chest to the back
- Associated cold sweats, belching, faintness, nausea or vomiting
- What improves or worsens it, such as walking or a deep breath
- What you were doing when it began: walking, sleeping, exercising or experiencing stress
You may not have noticed or remembered every detail. Provide what you can immediately, and tell the doctor if more information comes back to you later.
What should I bring?
A previous, ideally recent, ECG is particularly useful.
Bring your full medical records, especially if you have a cardiac history. Keeping key records, particularly an ECG, on your phone or in email can allow prompt access.
What are the cardiovascular causes?
- Coronary disease: acute myocardial infarction, unstable or stable angina
- Vasospastic angina
- Pericarditis
- Myocarditis, including after COVID-19
- Aortic syndromes, such as dissection
- Pulmonary embolism
- Aortic stenosis or other valve disease
- Rapid arrhythmias, such as atrial fibrillation with a rapid ventricular response
- Illicit drugs such as cocaine, causing coronary spasm
What are the non-cardiovascular causes?
- Lung disease, such as pneumonia, pleural fluid, pneumothorax or cancer
- Musculoskeletal strain after movement, exercise or severe coughing
- Oesophageal or stomach conditions, including reflux, oesophagitis, ulcer or hiatus hernia
- Gallbladder or bile duct disease
- Pancreatitis
- Breast pain
- Shingles
- Neuralgia
- Spinal conditions
- Rib fracture
- Psychological stress
- Panic attacks
How is it treated?
Pain is a symptom, not a disease. Treatment targets the underlying condition rather than simply masking the pain with a strong painkiller. It therefore depends on the final diagnosis.