Chest pain refers to pain felt anywhere in the chest area from the level of your shoulders to the bottom of your ribs. It is a common symptom. There are many causes of chest pain. This leaflet only deals with the most common. It can often be difficult to diagnose the exact cause of chest pain without carrying out some tests and investigations.
It is important to take chest pain seriously because it can sometimes indicate a serious underlying problem. Any new, severe, or persisting chest pain should be discussed with your doctor. This is particularly important if you are an adult and have a history of heart or lung disease. If the chest pain is particularly severe, especially if it is radiating to your arms or jaw, you feel sick, feel sweaty or become breathless, you should call 999/112/911 for an emergency ambulance. These can be symptoms of a heart attack.
Causes of chest pain
There are many possible causes of chest pain. Below is a brief overview of some of the more common causes.
Angina is a pain that comes from the heart. It is usually caused by narrowing of the coronary arteries, which supply blood to the heart muscle.
In the early stages, blood supply may be adequate when you are resting. However, when you exercise, your heart muscle needs more blood and oxygen, and if the blood cannot get past the narrowed coronary arteries, your heart responds with pain.
The chest pain caused by angina may feel like an ache, discomfort or tightness across the front of your chest.
During a heart attack (myocardial infarction), a coronary artery or one of its smaller branches is suddenly blocked. This cuts off the blood supply to part of the heart muscle completely.
The most common symptom of a heart attack is severe chest pain at rest. Unless the blockage is quickly removed, this part of the heart muscle is at risk of dying. To find out more about the symptoms and treatments for heart attack, see the separate leaflet called Heart Attack (Myocardial Infarction).
Gastro-oesophageal reflux disease
This is a general term which describes a range of situations including acid reflux and oesophagitis (inflammation of the lining of the oesophagus, or gullet).
Heartburn - usually a burning in the lower chest and upper abdomen - is the main symptom of gastro-oesophageal reflux disease. Severe chest pain can develop in some cases and can be mistaken for a heart attack. To find out more about the symptoms and treatments, see the separate leaflet called Acid Reflux and Oesophagitis (Heartburn).
The rib cage is a bony structure that protects the lungs inside. Softer, more flexible cartilage attaches the ribs to the breastbone (sternum) and the sternum to the collar bones (clavicles) at joints. In costochondritis, there is inflammation in one or more of these joints.
Costochondritis causes chest pain, felt at the front of the chest. This is typically a sharp, stabbing chest pain and is worse with movement, exertion and deep breathing. For more details on symptoms and treatment options, see the separate leaflet called Costochondritis.
Strained chest wall muscle
There are various muscles that run around and between the ribs to help the rib cage to move during breathing. These muscles can sometimes be strained and can lead to chest pain in that area. If a muscle is strained, there has been stretching or tearing of muscle fibres, often because the muscle has been stretched beyond its limits. For example, a strained chest wall muscle may sometimes develop after heavy lifting, stretching, sudden movement or lengthy (prolonged) coughing. The chest pain is usually worse on movement and on breathing in.
Anxiety is quite a common cause of chest pain. In some people, the chest pain can be so severe that it is mistaken for angina. Chest pain due to anxiety is known as Da Costa's syndrome. Da Costa's syndrome may be more common in people who have recently had relatives or friends diagnosed with heart problems, or in people who themselves have recently had a heart attack. Investigations show that the coronary arteries are normal with no narrowing. See the separate leaflet called Anxiety for more details.
Less common causes of chest pain
Some of the less common causes of chest pain include the following.
Pleurisy is due to inflammation of the pleura, a thin membrane with two layers - one which lines the inside of the muscle and ribs of the chest wall, the other which surrounds the lungs. It can cause a 'pleuritic' chest pain. This is a sharp, stabbing chest pain, typically made worse by breathing in or by coughing.
Less common but more serious causes of pleuritic pain include pneumonia, or a blood clot in the lung (pulmonary embolism - see below) or a collapsed lung (pneumothorax - see below).
For more information about pleurisy, including causes, symptoms and treatments, see the separate leaflet called Pleurisy.
Pulmonary embolism (PE)
A PE occurs when there is a blockage in one of the artery blood vessels in the lungs - usually due to a blood clot (thrombus) which formed in another part of the circulation. A PE usually causes sharp chest pain felt when breathing in (pleuritic chest pain). Other symptoms include coughing up blood (haemoptysis), mild fever and rapid heart rate.
See the separate leaflet called Pulmonary Embolism for more details on this medical emergency.
A pneumothorax is air that is trapped between a lung and the chest wall. The air gets there either from the lungs or, following chest wall injury, from outside the body.
A pneumothorax typically causes sudden, sharp, stabbing chest pain on one side. The pain is usually made worse by breathing in and you can become breathless. Usually, the larger the pneumothorax, the more breathless you become. See the separate leaflet called Pneumothorax.
A peptic ulcer is an ulcer on the inside lining of the upper gut caused by stomach acid.
A common symptom of a peptic ulcer is pain in the upper tummy (abdomen) just below the breastbone (sternum). Complications of peptic ulcers, which can be serious, include bleeding from the ulcer, and perforation, where the the ulcer goes right through (perforates) the wall of the gut.
Shingles is an infection of a nerve and the area of skin supplied by the nerve. It is caused by the same virus that causes chickenpox. Anyone who has had chickenpox in the past may develop shingles.
The usual symptoms are pain and a rash over the strip of skin supplied by one nerve, sometimes on the chest wall. The pain often starts before the rash appears.
How to know if chest pain is serious
Seek medical help immediately if you have chest pain that is in the middle of your chest, is crushing or squeezing and comes with any of the following symptoms:
- Pain that spreads to the neck, jaw, or one or both shoulders or arms.
- Shortness of breath.
- Feeling sick (nausea) or being sick (vomiting).
- Dizziness or light-headedness.
- Fast or irregular pulse.
You should call 999/112/911 for an emergency ambulance.
There are many different causes of chest pain. Some are more serious than others. Any new, severe, or persisting chest pain should be discussed with your doctor. This is particularly important if you are an adult and have a history of heart or lung disease.
What investigations may be advised?
Your doctor will usually ask you some questions to try to determine the cause of your chest pain. He or she may also examine you. Based on what they find, he or she may advise you to have some investigations, depending on what cause for your chest pain they suspect. Investigations for chest pain can include:
A 'heart tracing'
There are usually typical changes to the normal pattern of the 'heart tracing' (electrocardiogram, or ECG) in a heart attack. See the separate leaflet called Electrocardiogram (ECG).
A blood test that measures a chemical called troponin is the usual test that confirms a heart attack. Damage to heart muscle cells releases troponin into the bloodstream. Another blood test that may be suggested is a D-dimer test. This detects fragments of breakdown products of a blood clot. A positive D-dimer test may raise the suspicion of a deep vein thrombosis (DVT) or a PE.
A chest X-ray can look for pneumonia, collapsed lung (pneumothorax) and other chest conditions.
Other scans and imaging
- Myocardial perfusion scan - often done to confirm the diagnosis of heart chest pain (angina).
- Cardiac magnetic resonance imaging - also to confirm heart chest pain, this is a type of magnetic resonance imaging (MRI) scan.
- CT coronary angiogram - a quicker alternative to an MRI scan, in which a CT scan is used to to look in detail at your coronary arteries.
- Coronary angiography - this test uses specialist X-ray equipment and dye injected into the coronary arteries to show the location and severity of any narrowing of the arteries.
- Isotope scan and CTPA scan look at the circulation in the lung. CTPA stands for 'computerised tomography pulmonary angiogram'. They can show quite accurately whether or not a PE is present.
- Endoscopy - which uses a thin, flexible telescope passed down your gullet (oesophagus) to examine your stomach lining. This may be recommended if your team thinks your chest pain could be caused by gastro-oesophageal reflux disease or a peptic ulcer.
What may be advised to help manage the problem?
This will depend on the cause that is found for your chest pain. Follow the links above to the separate leaflets for more information about the treatment for the different causes.
If the problem is not an emergency, your doctor may refer you to a consultant for further specialist investigations, as described above.
Further reading and references
; NICE Clinical Guideline (March 2010, updated Nov 2016)
; Causes of chest pain in primary care--a systematic review and meta-analysis. Croat Med J. 2015 Oct56(5):422-30.
; NICE CKS, January 2017 (UK access only)