Why Does My Chest Hurt? Causes and When to Call 911

Chest pain has many causes. Most of them are harmless — a strained muscle, heartburn or anxiety — but some, like a heart attack, a blood clot in the lungs or a tear in the main artery, are life-threatening and need help within minutes. If you are unsure, treat chest pain as an emergency.

Heart-related causes

• Heart attack (myocardial infarction) — a coronary artery is blocked and heart muscle starts to die. Typical: pressure, tightness or squeezing in the center of the chest lasting more than a few minutes, often spreading to the left arm, jaw or back. Every minute counts.
• Angina — narrowed coronary arteries cause chest tightness during exertion or stress that eases with rest within a few minutes. New, worsening or resting angina ("unstable angina") is an emergency.
• Pericarditis — inflammation of the sac around the heart, often after a viral infection. The pain is sharp, worse when lying down or breathing in, and better when leaning forward.
• Aortic dissection — a tear in the wall of the aorta. Sudden, extremely severe, tearing or ripping pain in the chest or between the shoulder blades. Long-standing high blood pressure is the main risk factor.

Lung causes

• Pulmonary embolism — a blood clot in the lungs, often from a leg vein. Sudden shortness of breath, sharp pain when breathing in, fast heartbeat, sometimes coughing blood. Higher risk after surgery, long trips, immobility, pregnancy or with hormonal contraception.
• Pneumonia or pleurisy — fever, cough and stabbing pain when breathing.
• Pneumothorax (collapsed lung) — sudden one-sided chest pain and breathlessness, sometimes in tall, thin young people or smokers.

Digestive causes

• Reflux (heartburn) — burning behind the breastbone, often after meals or when lying down, with a sour taste. Very common, but it can feel exactly like heart pain.
• Esophageal spasm — cramping of the food pipe that can cause sudden, intense squeezing pain, sometimes eased by nitroglycerin, which makes it especially hard to tell apart from angina.
• Gallbladder, stomach ulcer or pancreas problems — pain can radiate up into the chest.

Muscles, bones and nerves

A pulled muscle, a bruised or cracked rib, or inflammation where the ribs meet the breastbone (costochondritis) cause pain that gets worse when you press on the spot, twist or breathe deeply. Shingles can cause burning chest pain a few days before the rash appears.

Anxiety and panic attacks

Panic attacks can cause chest tightness, a racing heart, shortness of breath, tingling and fear of dying. They usually peak within ten minutes. Because the symptoms overlap so much with a heart attack, a first episode — or any episode that feels different from usual — should be checked by a doctor. Never assume "it's just anxiety" if you are not sure.

Heart attack warning signs

Women, older adults and people with diabetes more often have the less typical symptoms, sometimes with little or no chest pain. Diabetes can dull nerve signals so that a heart attack feels like mild discomfort or just breathlessness. These "atypical" presentations are a common reason why help is called too late.

How doctors find the cause

In the emergency department, an ECG and a blood test for troponin (a marker of heart muscle damage) are done quickly. Depending on the findings, a chest X-ray, CT scan, ultrasound of the heart or a stress test may follow. Chest pain that is new or unexplained always deserves a medical check, even if it has passed.

Chest pain and blood pressure

High blood pressure is a major risk factor for heart attack and aortic dissection. Chest pain together with a very high reading — 180/110 or higher — can be a hypertensive emergency: call 911 (US) or your local emergency number. Read about the other warning signs of hypertension, and make sure your blood pressure is checked and treated. Common risk factors such as smoking, diabetes and high cholesterol raise the risk further.