Chest Pain

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The Many Causes of Chest Wall Pain
Chest Wall Pain
When Is Chest Pain An Emergency? Evaluating the Cause of Chest Pain
How to Survive a Heart Attack

The Many Causes of Chest Wall Pain

Chest pain is not a symptom you should ever ignore, for obvious reasons — it may indicate a cardiac problem. For this reason alone, if you have chest pain you should be evaluated by a doctor. Making an expeditious diagnosis of angina(chest discomfort caused by insufficient blood flow to the heart muscle), or even an actual heart attack, can permit the appropriate treatment to prevent permanent heart damage.

Many people who are evaluated for chest pain, however, are diagnosed with conditions that have nothing to do with the heart. This is because chest discomfort is a common symptom that accompanies many different medical problems. Some of these medical problems are quite significant and require aggressive treatment. Others are basically benign and are often treated with reassurance.

But either way, if you have chest pain — whether or not it turns out to be cardiac in nature — you need to be seen by a doctor.

What Is Chest Pain?

"Chest pain" is a less precise term than you might think. It is often used to describe any pain, pressure, squeezing, choking, numbness or any other discomfort in the chest, neck, or upper abdomen, and is often associated with pain in the jaw, head, or arms. Depending on the underlying cause, symptoms can last from less than a second to days or weeks, can occur frequently or rarely, and might occur either sporadically and unpredictably, or under specific conditions and quite predictably.

The reason "chest pain" encompasses such a broad range of symptoms is that chest pain can be produced by a similarly broad range of medical conditions. Because chest pain can accompany medical conditions ranging from catastrophic to trivial, when a person experiences chest pain it is important for a doctor to characterize that pain as rapidly as possible, to determine whether it represents a problem that is likely benign, or quite serious.

What Medical Conditions Can Cause Chest Pain?

Chest pain can be caused by medical conditions affecting any of the organs located in the chest or upper abdomen, including the heart, blood vessels, lungs, airways, muscles, bones, esophagus or stomach.

Here is a list of the more common causes of chest pain, roughly in the order in which they are seen in a typical hospital emergency room. Follow the links provided for more details on each condition:

  • ”Typical” angina due to coronary artery disease.
  • Acute coronary syndrome, which may include unstable angina or a frank heart attack.
  • Heartburn is a common cause of chest pain, and if untreated can lead to serious consequences.
  • Chest wall pain (musculoskeletal chest pain) is more common than many people realize, and while not particularly significant from a medical standpoint, it can be quite alarming and anxiety-provoking.
  • Anxiety or panic disorder is commonly accompanied by chest pain.
  • Pulmonary problems — asthma, bronchitis, pneumonia, pleuritis — often produces chest pain.
  • Mitral valve prolapse (MVP) is often blamed for episodes of chest pain, though probably causes chest pain much less often than doctors tend to believe.
  • Pericarditis typically produces chest pain.
  • Peptic ulcer disease may produce pain that is perceived as coming from the chest.
  • Angina due to coronary artery spasm.
  • Angina due to microvascular coronary artery disease.
  • Aortic dissection is a catastrophic condition that produces sudden, severe chest pain.

What Should You Do If You Have Chest Pain?

From this list of conditions that can produce chest pain, it should be obvious that, if you have chest pain, you need to be evaluated by a doctor.

But how can you tell if your chest pain is dangerous, or constitutes an emergency? And what should you expect the doctor to do in order to make a quick and accurate diagnosis? While there are no hard and fast rules to answer these questions, there are some general guidelines that can be very helpful. Read more about how chest pain should be evaluated.


Buntinx F, Knockaert D, Bruyninckx R, et al. Chest Pain in General Practice or in the Hospital Emergency Department: is It the Same? Fam Pract 2001; 18:586.

Ruigómez A, Rodríguez LA, Wallander MA, et al. Chest Pain in General Practice: incidence, Comorbidity and Mortality. Fam Pract 2006; 23:167.

Chest Wall Pain

The Many Causes of Chest Wall Pain (Musculoskeletal Chest Pain)

Chest pain is always an alarming symptom since it usually raises the fear of heart disease. And because chest pain may indeed be a sign of angina or of some other underlying heart problem, it is always a good idea to have it checked out. But heart disease is only one of the many conditions that can produce chest pain.

Read about all the common conditions that can cause chest pain.

One of the more frequent causes of non-cardiac chest pain is chest wall pain or musculoskeletal chest pain - that is, chest pain related to the muscles and bones of the chest wall.

Doctors diagnose chest wall pain in at least 25% of patients who come to the emergency room for chest pain. Unfortunately, however, in many cases, that’s as far as the doctor takes the diagnosis. This is because ER doctors usually are focused on making sure it’s not cardiac pain - once they have ruled out a serious problem, their job is done.

If you are the person with this “chest wall pain,” however - as thankful as you may be that you don’t have a heart problem - you still have pain. You’re interested in an actual diagnosis since that might help you to understand what you can do about the pain.

There are several causes of chest wall pain, and fortunately, in the great majority of instances, the underlying cause of chest wall pain is benign and most often is self-limited. However, some types of chest wall pain may indicate a serious problem, and may require specific treatment.

Here are the most common causes of chest wall pain:

Chest Trauma

Trauma to the chest wall can cause muscle sprains or strains, and bruises or fractures of the ribs. The trauma may be due to some dramatic event (such as being struck by a baseball), or to some more subtle trauma (such as lifting a heavy object) that may be more difficult to recollect, or to relate to chest pain whose onset may be delayed.

So the doctor will often need to ask the patient with suspected chest wall pain about activities that potentially might have caused chest wall trauma.


Costochondritis - sometimes called costosternal syndrome or anterior chest wall syndrome - merely indicates pain and tenderness in the costochondral junction - the area along the sides of the breastbone where the ribs attach.

The pain is generally localized to one particular spot, most typically on the left side of the breastbone. (Whether left-sided costochondritis is actually more common, or whether people with left-sided chest pain are simply more likely to see a doctor, is unknown.) The pain of costochondritis usually can be reproduced by pressing on the affected area.

The causes of costochondritis are very poorly understood.

While the suffix "-itis" is generally used in medicine to indicate inflammation, there is actually no evidence of inflammation with costochondritis - that is, there is no swelling, redness or heat in the painful area.

Especially in children and young adults this syndrome appears sometimes to be related to strain or weakening of the intercostal muscles (muscles between the ribs), following repetitive activities that stress those muscles, such as carrying a heavy book bag.

In a few cases, costochondritis seems to be related to a subtle dislocation of a rib. (Chiropractors are well aware of rib dislocation as a cause for costochondritis; physicians have seldom heard of it.) The dislocation may actually originate in the back, where the rib and the spine join.

This relatively slight dislocation causes torsion of the rib, and along the breast bone (that is, at the costochondral junction), pain results. The rib may "pop" in and out of its proper orientation (usually with some reproducible movement of the trunk or shoulder girdle), in which case the pain will come and go. Chiropractors are generally adept at manipulating a dislocated rib back into its normal position, and relieving the pain.

Costochondritis is usually a self-limited condition. Sometimes it is treated with localized heat or stretching exercises, but it is unclear whether such measures help. If the pain of costochondritis persists for more than a week or so, an evaluation looking for other chest wall conditions may be a good idea; and consulting with a chiropractor may also be useful.

Lower Rib Pain Syndrome

Lower rib pain syndrome (also called slipping rib syndrome) affects the lower ribs, and people who have this condition usually complain of pain in the lower part of the chest, or in the abdomen. In this syndrome, one of the lower ribs (eighth, ninth or tenth rib) becomes loosened from its fibrous connection to the lower part of the breastbone, usually following some type of trauma. The "moving" rib impinges on nearby nerves, producing pain. This condition is usually treated conservatively (that is, avoiding activities that reproduce the pain, in an attempt to allow the ribs to heal), but surgery may be required to stabilize the slipping rib.

Precordial Catch

"Precordial catch" is a completely benign and very common condition, generally seen in children or young adults, in which sudden, sharp chest pain occurs, usually on the left side of the chest, lasting for a few seconds to a few minutes. It typically occurs at rest, and during the episode, the pain increases with breathing. After a few seconds or a few minutes, the pain resolves completely. This condition has no known medical significance.


Fibromyalgia is a relatively common syndrome consisting of various, diffuse musculoskeletal pains. Pain over the chest is common in this condition. Fibromyalgia often has many other symptoms in addition to pain - such as fatigue, sleep disorders, and gastrointestinal symptoms - that cause many to characterize this condition as one of the dysautonomias.

Rheumatic Diseases Associated With Chest Wall Pain

Chest wall pain associated with inflammation of the spine or rib joints can be seen with several rheumatic conditions, in particular, rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. While it is uncommon for chest pain to be the only symptom associated with any of these conditions, unexplained chest wall pain - especially if an evaluation suggests it is related to arthritis or any other type of inflammatory disorder - should lead a physician to at least consider a rheumatic disease as a possible cause.

Stress Fractures

Stress fractures of the ribs can be seen in athletes who engage in strenuous, repetitive motions involving the upper body, such as rowers or baseball pitchers. Stress fractures can also be seen in people with osteoporosis or vitamin D deficiency.


Advanced stages of cancer invading the chest wall can produce significant pain. Breast cancer and lung cancer are the two most common kinds of cancer that produce this problem. Primary cancer of the ribs is an extremely rare condition that can produce chest wall pain.

Sickle-Cell Crisis

It is now believed that the chest wall pain sometimes seen in patients with sickle-cell crisis may be due to small infarctions in the ribs. The rib pain usually resolves relatively quickly as the sickle-cell crisis is brought under control.


Chest wall pain is very common in people seen by doctors for chest pain. In the large majority of cases, it is relatively easy for an attentive physician to diagnose the cause of chest wall pain, and to recommend appropriate treatment.


Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil 1992; 73:147.

Eslick GD. Classification, natural history, epidemiology, and risk factors of noncardiac chest pain. Dis Mon 2008; 54:593.

Almansa C, Wang B, Achem SR. Noncardiac chest pain and fibromyalgia. Med Clin North Am 2010; 94:275.

When Is Chest Pain An Emergency? Evaluating the Cause of Chest Pain

The most important decision that has to be made when evaluating chest pain is yours. Should you try to “ride out” your symptoms, or should you seek immediate medical help? On one side of the question a wrong decision can lead to unnecessary expense and inconvenience. But on the other side of the question a wrong decision can lead to permanent disability or death.

If you have read Part 1 of this series, you know that the term “chest pain” encompasses many different kinds of symptoms and many different kinds of medical disorders.

Some of these disorders are quite benign and trivial, but some are dangerous and life-threatening.

So when you have chest pain, how do you know when to treat it as an emergency?

There are no hard and fast rules here. Sometimes even minor chest symptoms can turn out to be due to coronary artery disease (CAD). In fact, up to 30% of all heart attacks are accompanied by symptoms so trivial that the victim does not notice them — or brushes them off. These are called “silent heart attacks.”

You should always tell your doctor about any chest pain you experience. But here are some general guidelines that are useful for deciding whether you need to go to the emergency room.

Clues That You Should Get Immediate Help

Chest pain is relatively likely to represent a dangerous condition — and should be treated as an emergency — if any of the following are true:

You are 40 years old or older, and have one or more risk factors for CAD (family history, smoking, obesity, sedentary lifestyle, elevated cholesterol, diabetes). Read more about risk factors for CAD.

  • You are any age and have a very strong family history of early heart disease.
  • The pain can best be described by the terms tightness, squeezing, heaviness, or crushing.
  • The pain is accompanied by weakness, nausea, shortness of breath, sweating, dizziness or fainting.
  • The pain “radiates” to the shoulders, arms, or jaw..
  • The pain is accompanied by the uncontrollable feeling that something is horribly wrong (this is often called by doctors, “a sense of impending doom”).
  • The pain gets continually worse over the first 10 or 15 minutes.
  • The pain is new –- you have never experienced anything like it before.

If any of these conditions pertain to your chest pain, you should treat it as an emergency.

Clues That The Chest Pain Is Less Likely To Be Dangerous

Chest pain is relatively unlikely to represent a dangerous cardiac disorder if any of the following are true:

  • The pain reliably and reproducibly changes with changes in body position.
  • The pain is momentary or fleeting.
  • You have had identical pains in the past, and a cardiac disorder was ruled out after a complete medical evaluation.

If your pain seems reasonably likely to fit into the "dangerous" category, get yourself to an emergency room. Otherwise, at the very least, you should still let your doctor know about your symptoms.

Evaluating Chest Pain in the Emergency Room

If you decide you need immediate attention for your chest pain, in general the safest thing to do is to call 911 and be taken to a nearby emergency room. The responding EMTs or paramedics will be able to do a rapid baseline evaluation, and help to stabilize your medical condition (should you need it) even before you arrive at a medical facility.

Once you are in front of a doctor, the first evaluation will typically be to determine whether the chest pain is brand new (acute), or if it represents a more chronic problem.

If The Chest Pain Is Acute In Onset:

If you are being evaluated for acute onset chest pain, the doctor can usually get to the root of your problem quite rapidly by 1) taking a brief, directed medical history, 2) performing a physical examination, 3) getting an ECG and cardiac enzymes.

This evaluation most often will determine whether you are dealing with a cardiac emergency. If after this initial evaluation the diagnosis is still in doubt, further testing will be needed, depending on which medical conditions seem likely to your doctor at that point.

To reiterate, the first order of business is to rule out a potentially life-threatening cardiac problem — acute coronary syndrome (ACS), with or without an actual myocardial infarction (heart attack), usually being the main concern. (Aortic dissection — a tearing of the wall of the aorta — is also life-threatening, but far less common.) Rapidly diagnosing a heart attack is especially important since immediate treatment can significantly limit the amount of permanent cardiac damage that occurs, and can save your life. Almost as important is the diagnosis of unstable angina, since rapid and aggressive treatment of this condition is also necessary to avoid permanent cardiac damage.

If ACS is strongly suspected, you will probably be admitted to an intensive care unit and medical treatment will be instituted. Your doctors may also want additional studies to be performed right away, in order to pin down the diagnosis - possibly including an echocardiogram, a thallium scan, a CT scan, or cardiac catheterization.

Read about how to survive a heart attack.

On the other hand, if a life-threatening problem has been ruled out, most emergency room doctors will then make a presumptive diagnosis as to what actually is the cause of your chest pain (that is, they will say something like, “This is probably what’s causing your pain,”) and refer you to your own physician for follow-up evaluation and treatment.

If the Chest Pain is a More Chronic, Recurrent, or Non-acute Symptom

If your chest pain is something you've had before, your doctor's main concern probably will be whether you have angina. Angina is usually caused by typical CAD, but can also be produced by less common cardiac conditions such as coronary artery spasm or cardiac syndrome x. Depending the emergency room doctor’s level of suspicion, a cardiologist may be consulted immediately, or you may be referred back to your own doctor (or to a cardiologist) for a fuller evaluation.

When something other than angina is thought to be causing your chest pain, a firm diagnosis also needs to be made so that appropriate therapy can be started. Depending on which medical problems your doctor suspects to be the cause, you may need x-rays, endoscopy of your GI tract, pulmonary (lung) function tests, or other testing to pin down the diagnosis. Most typically, an emergency room doctor will refer you to your own doctor (or to an appropriate specialist) to make the final diagnosis.


As you can see, the first order of business in evaluating chest pain is to make sure you are not going to die, or suffer permanent cardiovascular damage. Accomplishing this goal depends on two things. First, you yourself need to make an appropriate decision about seeking immediate medical care. (When in doubt, do so.) And second, the doctor needs to perform an expeditious evaluation to make sure there is no ongoing or impending cardiac catastrophe, or any other truly life-threatening medical emergency.

Once this is done, assuming that a life-threatening condition has been ruled out, you likely will be referred for an evaluation outside of the emergency room setting


Connor, RE, Bossaert, L, Arntz, H-R, et, al. On Behalf of the Acute Coronary Syndrome Chapter Collaborators. Part 9: Acute Coronary Syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010; 122:S427.

Ebell MH. Evaluation of Chest Pain in Primary Care Patients. Am Fam Physician 2011; 83:603.

Wertli MM, Ruchti KB, Steurer J, Held U. Diagnostic Indicators of Non-cardiovascular Chest Pain: a Systematic Review and Meta-analysis. BMC Med 2013; 11:239.


How to Survive a Heart Attack

The First Few Minutes and Hours Are Critical to Surviving a Heart Attack

There are two good reasons you should know how to survive a heart attack. First, odds are very high that either you or someone you love will suffer from a heart attack during your lifetime. And second, whether you survive that heart attack may depend on what you and your doctors do about it during the first few hours -- and over the long term.

What Is a Heart Attack?

A heart attack, also called a myocardial infarction (MI), is the most severe form of acute coronary syndrome (ACS).

Like all forms of ACS, an MI is usually triggered by the rupture of an atherosclerotic plaque within a coronary artery (the arteries that supply oxygen to the heart muscle). This plaque rupture causes a blood clot to form, leading to blockage of the artery. The heart muscle being supplied by the blocked artery then begins to die. An MI is diagnosed when there is death of a portion of heart muscle.

What Are the Consequences of a Heart Attack?

To a large degree, the outcome of an MI depends on how much heart muscle dies, which, in turn, is related to which coronary artery is blocked, and where in the artery the blockage occurs. A blockage near the origin of an artery will affect more heart muscle than a blockage farther down the artery.

If the heart muscle damage is severe, it is possible to develop acute heart failure during the MI itself, which is a very dangerous condition.

If the amount of heart muscle damage is less severe but still significant, heart failure can still develop later on. So, taking steps to prevent heart failure after an MI, or aggressively treating heart failure should it develop acutely, is an extremely important aspect to treating an MI.

An MI can also produce dangerous heart arrhythmias.

During the acute MI itself, electrical instability occurs that may cause ventricular tachycardia (VT) and ventricular fibrillation (VF). Later, the scar tissue that results from the healing process can cause a permanent electrical instability. So, unfortunately, cardiac arrest and sudden death are risks both during an acute MI and after full recovery from an MI.

Why Are the First Few Hours of a Heart Attack Critical?

For anyone having an MI, getting rapid medical attention is absolutely critical for two reasons:

Most of the cardiac arrests seen with acute MIs occur within the first few hours. If a cardiac arrest occurs after a heart attack victim has reached the hospital, there is an excellent chance it can be successfully treated; otherwise the odds of surviving a cardiac arrest are very low.

Both the short-term and the long-term consequences of an MI are largely determined by how much of the heart muscle dies. With rapid and aggressive medical treatment, the blocked artery can usually be opened quickly, thus preserving most of the heart muscle that is at risk of dying. If treatment is given within three or four hours, much of the permanent muscle damage can be avoided. But if treatment is delayed beyond five or six hours, the amount of heart muscle that can be saved drops off significantly. After about 12 hours, the damage is usually irreversible.

Getting rapid and appropriate medical care requires that two things happen. First, it requires that you know the signs of a heart attack, and seek medical help the moment you think you might be having one. Second, it requires that the medical personnel who are caring for you do the right things, and do them quickly. The following articles will help you do what you need to do, and to get the care you need to get.

Help Yourself Survive A Heart Attack:

How to Recognize a Heart Attack...and What to Do About It

What Is the Critical Early Treatment for a Heart Attack?

What Should Happen After the First Critical 24 Hours?


Cannon, CP, Hand, MH, Bahr, R, et al. Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program. Am Heart J 2002; 143:777.

O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:e362.


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