Chest Pain That Is Not a Heart Attack: Common Causes Explained
Chest pain sends a great many people to emergency departments, and in most of them the heart turns out to be fine. That is reassuring, but the reassurance is only useful once the dangerous causes have been ruled out. Never self-diagnose new chest pain.
First, the pattern that demands emergency care
Call for emergency help, or go to a hospital immediately, if chest discomfort is:
- Heavy, squeezing or like a band, rather than sharp
- Spreading to the jaw, neck, left or both arms, or between the shoulder blades
- Accompanied by sweating, nausea, vomiting or a sense of doom
- Accompanied by breathlessness or fainting
- Lasting more than a few minutes, or coming on with effort and easing with rest
- Occurring in someone with diabetes, where pain may be mild or absent and breathlessness or fatigue dominates
Women, older adults and people with diabetes often present atypically, so a “wrong-sounding” pain is not a safe reason to wait.
Musculoskeletal pain
This is the most frequent non-cardiac cause. Costochondritis, inflammation where the ribs meet the breastbone, produces a sharp, well-localised pain that you can press on and reproduce. It worsens with a deep breath, twisting or coughing, and often follows unusual lifting, a new gym routine or a chest infection with heavy coughing.
Muscle strain behaves similarly. Both usually settle over days to weeks with rest, heat and simple analgesia.
Acid reflux
Reflux causes burning behind the breastbone, sometimes with an acid taste or nocturnal cough. It typically appears after meals, on lying flat, or after coffee, alcohol, chilli or a large late dinner.
The catch is that severe reflux can mimic cardiac pain closely, and relief from an antacid does not prove the cause, because oesophageal spasm can respond too. Reflux is a reasonable explanation only when cardiac causes are unlikely or excluded.
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Anxiety and panic
Panic attacks produce genuine chest tightness, a racing heart, tingling in the hands and around the mouth, dizziness and a fear of dying. The symptoms come from hyperventilation and adrenaline, and they usually peak within ten minutes.
Because the sensations are real and frightening, people often attend hospital repeatedly. Recognising the pattern, and treating the anxiety rather than only the episodes, is what breaks the cycle.
Oesophageal spasm
The muscular wall of the food pipe can contract abnormally, causing a gripping central chest pain that may be triggered by very cold or very hot drinks and may be accompanied by difficulty swallowing. It responds to different treatment from reflux, so it is worth naming.
Lung causes
Several lung problems present as chest pain and are not benign:
- Pleurisy: sharp pain that is clearly worse on breathing in, usually after a viral or bacterial infection
- Pneumonia: pain with fever, cough and sputum
- Pulmonary embolism: sudden breathlessness with sharp pain, sometimes after long immobility, surgery, pregnancy or a leg clot, and a medical emergency
- Pneumothorax: abrupt one-sided pain with breathlessness, more common in tall young men
Shingles
Shingles in a chest nerve can cause burning pain for two or three days before the rash appears, which makes early diagnosis difficult. A band of pain on one side that does not cross the midline, with skin that feels oversensitive to clothing, is the clue.
Gallbladder and stomach
Gallstones cause pain in the upper right abdomen that can radiate into the lower chest and right shoulder blade, typically after fatty food. Peptic ulcer pain sits in the upper abdomen but is often described as chest pain.
How doctors sort it out
Assessment usually involves the history, an examination, an ECG and often a troponin blood test, which detects heart muscle injury. Depending on risk, a chest X-ray, echocardiogram, treadmill test or CT coronary angiogram may follow. A normal ECG alone does not exclude a heart attack, which is why the blood test is repeated over a few hours.
If you are unsure whether chest pain is serious, treat it as serious. The cost of an unnecessary hospital visit is far lower than the cost of a missed heart attack.