Chest pain

What chest pain actually feels like

People describe chest pain in very different ways, and the words matter less than you might expect. It can be a pressure or a band tightening across the chest, a heaviness or dull ache in the centre that does not shift, a sharp or stabbing pain, or a burning that feels a lot like indigestion.

Heart symptoms are rarely the dramatic, crushing chest pain you see on television. Most of the time it is a pressure, heaviness, tightness or burning that people have explained away as indigestion or stress for weeks before coming in.

The most useful thing is not where it hurts or how it feels, but the pattern. When the discomfort occurs, how long it lasts, what brings it on, what relieves it and what other symptoms come with it will often tell a cardiologist more than any single test.

In Dr Jogiya's practice, around two out of three patients referred with chest pain turn out not to have classical angina once the full picture has been put together, which is why a proper assessment matters before anyone is labelled. That figure describes people who were well enough to be referred and seen, not people with symptoms happening right now.

• A pressure, or a band tightening across the chest
• Heaviness, or a dull ache in the centre of the chest that does not shift
• Burning, or a sensation that feels like indigestion
• A sharp or stabbing pain, sometimes worse when you breathe in deeply
• Discomfort spreading to the left arm, both arms, the jaw, the neck, the upper back or the stomach

The common causes that are not the heart

The chest contains several organs and structures, including the heart, the lungs, the oesophagus, the muscles and the ribs. Because of this, chest discomfort can originate from many different sources.

Sometimes the sensation is caused by inflammation in the muscles between the ribs. Symptoms that change with body movement, that worsen when you press on the chest wall, or that improve when you stretch the muscles are more likely to be coming from the musculoskeletal system than from the heart.

Digestive conditions such as acid reflux can produce a burning feeling behind the breastbone, particularly after meals. Stress and anxiety may produce chest tightness as well, sometimes alongside palpitations or rapid breathing. Although these causes are generally less serious, persistent or unexplained chest symptoms should still be evaluated.

Not every cause outside the heart is harmless. Severe, sudden breathlessness alongside chest pain can also be a clot on the lung, known as a pulmonary embolism, and that is a 999 call rather than something to wait out. This page does not cover every possible cause of chest pain, so a cause that is not listed here is not a cause that has been ruled out.

• Muscle and rib pain, including inflammation in the muscles between the ribs
• Acid reflux, which tends to burn behind the breastbone and is often worse after meals
• Stress and anxiety, which can tighten the chest and arrive with palpitations or rapid breathing
• Lung problems, which usually bring their own pattern of cough, wheeze or breathlessness

When chest pain is coming from the heart

When chest symptoms are related to the heart, they are often caused by reduced blood flow to the heart muscle. This happens when the coronary arteries, which supply oxygen rich blood to the heart, become narrowed or blocked.

Heart related chest discomfort is commonly associated with a condition known as angina. Angina occurs when the heart muscle does not receive enough oxygen during periods of increased demand, such as physical exertion or emotional stress. People usually describe pressure or tightness in the centre of the chest, a feeling of heaviness or squeezing, or discomfort that spreads to the arm, neck, jaw or back. Unlike some types of chest pain, angina may improve with rest.

If blood flow to the heart becomes suddenly blocked, it can lead to a heart attack. In that situation chest discomfort is often more severe and more persistent, and it commonly comes with shortness of breath, sweating, nausea, lightheadedness or pain radiating to the jaw, the back or the left arm. If you or someone with you has those symptoms now, call 999 rather than waiting to see whether they pass. This may be a heart attack and minutes matter.

Coronary artery disease is the most common heart related cause of chest discomfort, but it is not the only one. Inflammation of the lining around the heart, known as pericarditis, produces a sharper pain that is usually worse when you lie flat and noticeably better when you sit up and lean forward. Heart rhythm disorders, heart valve disease and cardiomyopathy affecting the heart muscle can all cause chest discomfort too.

Symptoms in women often do not match the textbook description. Chest pain does still occur, but it is more likely to be pressure, tightness, burning or heaviness, and jaw, neck, back or upper stomach discomfort is more commonly reported as a heart symptom in women than in men. Research has shown women are around 50 per cent more likely to be initially misdiagnosed after a heart attack, so a symptom that feels different from anything you have felt before is worth acting on rather than explaining away.

• Angina, where narrowed coronary arteries cannot meet the heart's demand for blood
• A heart attack, where blood flow to a portion of the heart muscle is suddenly blocked
• Pericarditis, inflammation of the lining around the heart
• Heart rhythm disorders
• Heart valve disease
• Cardiomyopathy affecting the heart muscle

How the patterns differ, and where that guidance stops

The pointers below are a guide to how urgently to act. They are not a way of diagnosing yourself, none of them rules the heart in or out on its own, and if you cannot tell which one describes you, treat it as though it could be the heart and get it assessed.

One exception matters more than all of the pointers put together. Unstable angina and a heart attack do not follow the exertion rule. Discomfort that comes on at rest, that wakes you from sleep, that arrives with less effort than before, or that lasts longer than it used to, is a reason to be seen urgently rather than a reason to relax.

• Points towards the heart. Discomfort brought on by exertion, emotional stress or cold weather, building gradually, easing within a few minutes of rest, and reproducible by the same level of effort.
• Points towards the chest wall. Pain that changes with body movement, that worsens when you press on the chest wall, or that improves when you stretch the muscles.
• Points towards reflux. A burning sensation behind the breastbone, particularly after meals.
• Points towards pericarditis. Sharp pain that is worse lying flat and eases when you sit up and lean forward, often a week or two after a viral illness.
• Points towards stress or anxiety. Chest tightness with rapid breathing or palpitations, in a clear emotional context.

When to see a cardiologist rather than wait

Outside an emergency, the clearest reason to arrange an assessment is a change. If your usual pattern of chest pain has changed, coming on with less effort than before, at rest, or more frequently, that is unstable angina until proven otherwise and it needs same day medical assessment rather than a routine appointment. If any of the red flags at the top of this page apply as well, that is a 999 call rather than a same day appointment.

Symptoms that are easy to explain away still deserve a proper cardiac assessment. Chest pressure put down to indigestion, breathlessness climbing the stairs, unusual fatigue or a sudden drop in your exercise tolerance are all worth investigating.

The earlier symptoms are properly investigated, the more straightforward the answers tend to be, and the more options there usually are.

• Chest discomfort that comes on with exertion and settles again with rest
• A familiar angina pattern that has changed, which needs same day assessment
• Chest discomfort alongside breathlessness, palpitations, dizziness or blackouts
• A noticeable drop in what you can manage physically
• Chest symptoms you have been putting down to stress, indigestion or being out of shape
• Chest symptoms where heart disease runs in the family, or where blood pressure, cholesterol or diabetes is already a concern

What Dr Jogiya would do about it

An assessment usually begins with a detailed discussion of your symptoms. When the discomfort occurs, how long it lasts and what activities trigger it often tells Dr Jogiya more than any single test, and the examination and your background risk factors fill in most of the rest.

A 12 lead ECG is almost always the first investigation and takes only a few minutes. It can be completely normal between episodes, so it is usually combined with blood tests, which can show signs of heart muscle injury, and an echocardiogram, an ultrasound scan that shows the structure and function of the heart at rest.

Where symptoms are clearly tied to exertion, an exercise tolerance test or a stress echocardiogram shows what happens when the heart is asked to work harder. A CT coronary angiogram gives direct anatomical information about the arteries themselves without an invasive procedure, and for many patients with stable chest pain it works better than a standard exercise stress test. If those results raise enough concern, an invasive coronary angiogram gives the most accurate map of the arteries.

Not every assessment ends in a diagnosis, and that is not a wasted appointment. A large proportion of patients are reassured after assessment, which in itself can significantly reduce anxiety, and early evaluation allows treatment to start promptly when something is found.

This page is general information about chest pain. It is not a substitute for advice about your own heart, which needs a consultation and your own test results. If you are unsure, get assessed, and if you are worried that this is happening now, call 999.

• A 12 lead ECG, which looks at the heart from twelve different electrical angles at once
• Blood tests, to look for signs of heart muscle injury and raised inflammatory or cardiac markers
• An echocardiogram, an ultrasound scan of the structure and function of the heart
• An exercise tolerance test or a stress echocardiogram, to see the heart under exertion
• A CT coronary angiogram, which images the coronary arteries without an invasive procedure
• An invasive coronary angiogram, where the clinical picture warrants the most accurate map of the arteries