When faced with unexpected chest pain, it is normal for people to fear the worst, since chest pain is a symptom, which, to many people, means "heart attack." Nevertheless, chest pain can have many causes unrelated to the heart. A health care provider should evaluate any chest discomfort that is new or different. Furthermore, it is very important to note the other factors associated with chest pain (exact location, type of pain, radiation of pain, and other associated symptoms).

While it is true that heart disease is the #1 cause of death and disability, chest pain caused by a heart condition is very rare in previously healthy men under 30 years of age or women under 40, and is uncommon for either sex before the age of 50. A shooting pain lasting a few seconds is common in a healthy person and is nothing to worry about; however, the sensation of a "catch" at the end of a deep breath is clinically important for, while it usually does not represent heart disease, it may be a symptom of pulmonary embolism (clot to the lung) which requires immediate evaluation by a physician. Yet, there are certain risk factors that can increase the probability of developing early heart disease. Some of these risk factors include:

• family history of early heart disease
• cigarette smoking
• elevated cholesterol
• high blood pressure
• diabetes
• cocaine use

Chest pain that is caused by a heart problem may be mild or intense. Feelings of pressure or squeezing on the chest are often more prominent than actual pain which is usually located in the center of the chest, under the breastbone. It may also radiate to the back, jaw or shoulder (usually the left) and may be accompanied by nausea, sweating, dizziness, palpitations, or shortness of breath.

Stable angina (chest pain caused by temporary inadequacy of blood flow to the heart muscle) usually lasts 1 to 15 minutes and is provoked by exercise or stress and relieved by rest or nitroglycerin. Unstable angina is angina that either occurs at rest or is an increase in the frequency, severity, or duration of previously stable angina.

Angina and unstable angina can lead to an acute myocardial infarction (heart attack). The chest discomfort of a heart attack often is prolonged (longer than 15 or 20 minutes) and is unrelieved by rest or nitroglycerin; however, some patients, especially diabetics, can have a heart attack without feeling any chest discomfort at all. Their only symptoms might be shortness of breath, dizziness, or sweating.

Chest-wall pain (pain originating in the tissues of the chest-wall rather than the heart) can often be demonstrated by pressing a finger on the chest at the spot of discomfort, which reproduces or aggravates the pain. Heart and chest-wall pain can be present at the same time. Pleurisy (inflammation of the linings of the lungs) worsens with a deep breath or a cough while chest pain related to a heart problem usually does not. Hyperventilation, or panic attack, is a frequent cause of chest pain, especially in young people. Ulcer pain burns with an empty stomach and gets better with food. Conversely, gallbladder pain often becomes more intense after a meal.

• stable angina
• unstable angina
• acuteMI (heart attack)
• pleurisy
• hyperventilation
• gastric ulcer
• cholecystitis
• cholelithiasis
• anxiety
• pneumonia
• costochondritis
• cough (especially if long-term)
• herpes zoster
• indigestion (heartburn, gastroesophageal reflux disease)
• mitral valve prolapse
• trauma with injury to the chest
• asthma
• pneumothorax
• pulmonary embolism (blood clot to the lungs)
• aortic dissection (a tear in the lining of the aorta)

Chest-wall pain is often associated with muscular strain, such as that resulting from unusual activity, or from coughing. It can be treated with over-the-counter pain medications. Treatments such as mentholated rubs, heat, and rest can help. If symptoms persist for more than 3 to 5 days, see your health care provider and be certain to follow the therapy prescribed by the health care provider for treating the underlying cause.

Emergency measures will be taken if necessary. The medical history will be obtained and a physical examination performed. At that time, vital signs (temperature, pulse, rate of breathing, blood pressure) will be monitored. The physical examination will include emphasis on the chest wall, lungs, and heart. Hospitalization will be required in difficult or advanced cases or when the cause of the pain is unclear.

Medical history questions documenting chest pain in detail may include:

• Location
  • Is the pain between the shoulder blades (interscapular)?
  • Is it under the sternum (breastbone, substernal)?
  • Does the pain change location?
  • Is it on one side only (unilateral)?
    • Which side?
• Quality
  • How would you describe the pain?
    • Severe
    • Tearing or ripping
    • Sharp or stabbing
    • Burning
    • Squeezing, constricting, tight, pressure-like, or crushing
    • Aching
    • Dull
    • Heavy sensation

• Time pattern
  • Did the pain begin recently?
  • Does it occur repeatedly (recurrent)?
  • Does the pain occur at the same time each day?
  • Does it come on suddenly?
  • Is it worse or more frequent at night?
  • Is the pain getting worse; increasing in severity?
  • Is the pain more frequent or lasting longer than previous episodes?
    • How long does the pain last? (The pain is continuous for how long on each episode?)
• Radiation
  • Does the pain go from your chest into your shoulder?
  • From your chest into your arm?
  • From your chest into your neck?
  • From your chest into your back?
  • From your chest around the lower chest wall?
  • From your chest into your jaw?
• Aggravating factors
  • Is the pain worse when you are breathing deeply?
  • When you are coughing?
  • When you are eating?
  • When you are bending or stooping?
  • When you are under mental stress?
  • When you are moving around or changing position?
  • When you are exercising?
  • When you have exercised less than in the recent past?

• Relieving factors
  • Is the pain better after you rest?
    • Is it completely relieved or just less pain?
  • Is the pain better after you take nitroglycerin (NTG) medication?
  • After you drink milk or take antacids?
  • After belching (eructation)?
• Other
  • What other symptoms are also present?

Diagnostic tests that may be performed include:

• Blood tests (such as LDH, LDH isoenzymes, CPK, CPK isoenzymes, Troponin, CBC and blood differential)
• cardiac catheterization
• ECG
• Exercise ECG
• Lung scan
• X-rays of the chest

After seeing your health care provider, you may want to add a diagnosis related to chest pain to your personal medical record.

Note: More complex tests may be required depending on the difficulty of diagnosis or the suspected cause of the chest pain.