What causes chest pain?

Most chest pain is not a heart attack. But several of the causes that aren't a heart attack are just as dangerous, and none of them can be told apart reliably at home. This page helps you understand what might be going on and, more importantly, which ones need 999.

At a glance

The dangerous ones

Heart attack

A blood clot blocks one of the arteries supplying the heart muscle, and the muscle beyond the block starts to die. The classic feeling is pressure or tightness in the middle of the chest, "like an elephant sitting on me" or "a tight band". It usually builds over minutes rather than being instant, and doesn't change when you breathe or move. See the home page for the full list of signs and what to do.

Aortic dissection

The wall of the aorta, the main artery from the heart, tears. It's rare but kills quickly. The pain is usually sudden, maximal from the very start, and described as tearing or ripping, often felt in the back between the shoulder blades. People may have a much weaker pulse in one arm, or stroke-like symptoms. High blood pressure, Marfan syndrome and cocaine use raise the risk. This is a 999 call, and it's worth telling the crew the pain was "tearing" and sudden, because it's treated differently from a heart attack.

Pulmonary embolism

A blood clot, usually from a leg vein, travels to the lungs. Sharp chest pain that's worse when you breathe in, sudden breathlessness, a fast heartbeat, sometimes coughing up blood. Look at your calves: if one is swollen, red or painful, that's a strong clue. Long-haul travel, recent surgery, being immobile, pregnancy, cancer and the combined pill or HRT all increase the risk. Call 999.

Pneumothorax

Air leaks into the space around a lung and the lung collapses. Sudden one-sided sharp pain and breathlessness, sometimes after nothing at all. Tall slim young men, smokers and people with asthma or COPD are more prone. It can quickly become life-threatening if the pressure builds. Call 999.

The ones that mimic a heart attack

Acid reflux and heartburn

Stomach acid irritates the oesophagus. Burning behind the breastbone, worse after eating, lying flat or bending, often with a sour taste or burping. Antacids help within minutes. The catch: heart attacks can feel exactly like indigestion too, and "it's just heartburn" is a phrase that ambulance crews and coroners hear far too often. If it's a new feeling, it doesn't ease with antacids, or it comes with sweating, breathlessness or sickness, call 999. If it's a familiar feeling you get after a curry and settles with Gaviscon, you're probably right, but see your GP if it's happening more than twice a week.

Panic attacks

A surge of adrenaline causes a racing heart, tight chest, shaking, tingling fingers and lips, feeling unable to breathe, and a terrifying sense that you're dying. It peaks within about 10 minutes and passes within 20 to 30. It's real and it's frightening, but it isn't dangerous. However, the first time it happens nobody can tell the difference from home, and a heart attack can also cause overwhelming anxiety. First time: call 999. If you've had panic attacks diagnosed before and this feels the same, use your usual breathing techniques, and call 999 if it lasts longer than usual or feels different.

Muscle and rib pain

Strained chest wall muscles, bruised ribs, and costochondritis (inflammation where the ribs meet the breastbone) are the commonest causes of chest pain in younger people. The giveaways are that you can make it worse by pressing on a specific spot, twisting, lifting your arms or taking a deep breath, and it's often sharp rather than pressing. It doesn't cause sweating, sickness or breathlessness. Rest and ibuprofen or paracetamol usually settle it in a week or two.

Stable angina

Narrowed heart arteries can't deliver enough blood when the heart works harder. So the pain comes on with exertion, stress, cold weather or after a big meal, and goes within a few minutes of resting. It's predictable and the same each time. It needs GP assessment and usually medication, but it's not an emergency in itself. It becomes one when the pattern changes. See the angina page.

Pericarditis

Inflammation of the sac around the heart, often after a cold or flu. Sharp central pain that's worse lying flat and breathing in, and much better sitting up and leaning forward. Usually settles with anti-inflammatories, but it needs an ECG and blood tests to confirm, so call 111 today.

Chest pain in children and teenagers

Heart attacks in children are extremely rare. Chest pain in the young is nearly always muscular, from the chest wall, from asthma, or from anxiety. Still, call 999 if a child has chest pain with breathlessness, collapse, a blue tinge to the lips, or the pain came on during sport. A child who faints during exercise needs urgent cardiology review even if they recover.