Chest Pain: When to Worry, When to Wait

If you're reading this with chest pain happening right now and any of the following are also true, stop reading and call 911. The pain is severe, you're sweating, you feel sick to your stomach, you're short of breath, the pain is going into your jaw or down your arm, you feel lightheaded, or you've had heart problems before. None of those are things to talk yourself out of. Help arriving fast saves heart muscle.

For everyone else reading without active emergency symptoms, this article is the long version of the conversation I have many times a week in clinic. I'm Dr. Damian Rasch, a cardiologist in Encinitas. The goal here is to give you the framework I use to think about chest pain, what makes a doctor worry, what doesn't, and how to know which bucket your symptom falls into.

What Cardiac Chest Pain Usually Feels Like

Classic cardiac chest pain has a recognizable shape. It sits in the middle of the chest, often described as pressure or squeezing or a heavy weight. It comes on with exertion, including walking uphill, carrying groceries, or climbing stairs. It gets better with rest, often within a few minutes. It can radiate into the jaw, the neck, the left arm, or both arms. Sometimes there's no actual pain at all, just a tight or full feeling.

If your symptom matches that pattern, you should be evaluated. The next step is figuring out how urgent.

When Cardiac Chest Pain Doesn't Look Classic

Women often present differently than men. Women with heart disease may report jaw pain, back pain between the shoulder blades, nausea, severe fatigue without an obvious chest component, or shortness of breath as the dominant symptom. The VIRGO study, which followed women under 55 hospitalized with heart attacks, showed that more than 60 percent had at least one symptom that wasn't chest pain. Many delayed coming in because what they were feeling didn't match the picture they had in their head.

Diabetic patients also tend to have less typical symptoms. Diabetic neuropathy can blunt the pain signal from the heart. A diabetic patient with new shortness of breath, fatigue, or vague upper-body discomfort deserves a workup that takes the heart seriously.

Older patients often present with confusion, weakness, falls, or fainting rather than chest pain. The threshold to think cardiac in someone over 75 is low.

When the Chest Pain Is Probably Not Your Heart

Several patterns suggest the pain is coming from somewhere other than your coronary arteries. None of these are a guarantee, and any new chest discomfort deserves a thoughtful evaluation, but the patterns can help you decide whether to call your doctor versus head to the ER.

Reflux (GERD): burning chest sensation, often after eating, worse when lying flat, sometimes with sour taste in the back of the throat. Relieved by antacids. Can mimic cardiac pain closely, which is why a trial of acid-suppressing therapy is sometimes diagnostic.

Musculoskeletal pain: sharp or stabbing rather than pressure, reproduced by pressing on the chest wall, worse with twisting or deep breathing. Often follows physical exertion involving the upper body or a recent injury.

Pericarditis: sharp, positional pain that's worse lying down and better sitting forward. Often follows a viral illness. Can be cardiac in origin but is not a coronary problem.

Anxiety or panic attacks: chest tightness with shortness of breath, dizziness, tingling fingers, sense of doom. Often associated with a triggering thought or situation. Resolves over 10 to 20 minutes.

Costochondritis: inflammation of the cartilage where the ribs meet the sternum. Reproducible by pressing on the rib joints. Worse with deep breathing.

If your symptom pattern fits one of these, that's reassuring but doesn't replace a clinical evaluation, especially if you have any cardiovascular risk factors (high blood pressure, high cholesterol, diabetes, smoking history, family history of early heart disease).

The Dangerous Mimickers

A few non-coronary causes of chest pain are themselves life-threatening and need to be on the radar.

Aortic dissection presents as sudden, severe, tearing chest pain that often radiates to the back between the shoulder blades. Patients describe it as the worst pain of their life. Blood pressure may differ between arms. This is a surgical emergency. Call 911.

Pulmonary embolism presents with sudden shortness of breath, sometimes with sharp chest pain that worsens with breathing, and can include leg swelling on one side. Risk factors include recent surgery, long flights, cancer, hormone therapy, and pregnancy.

Pneumothorax (collapsed lung) causes sudden sharp one-sided chest pain with shortness of breath. More common in tall, thin young men.

Esophageal rupture or severe pancreatitis can also present as chest or upper abdominal pain that needs urgent evaluation.

When to Call 911 Versus Schedule a Visit

Call 911 immediately if you have chest pain that:

- Lasts more than 15 minutes at rest

- Is associated with sweating, nausea, vomiting, lightheadedness, or shortness of breath

- Radiates to your jaw, neck, or arm

- Is severe and tearing, especially radiating to the back

- Wakes you from sleep

- Comes with a sense of impending doom

- Comes with palpitations or fainting

Go to an emergency department or urgent care promptly (within hours) if your pain:

- Is new and you have cardiovascular risk factors (over 50, diabetes, hypertension, smoking, family history)

- Comes on consistently with exertion and goes away with rest (this pattern, called stable angina, needs urgent outpatient workup)

- Is changing in pattern (more frequent, more severe, easier to provoke than before)

Schedule a primary care or cardiology visit within days for:

- Brief, atypical chest discomfort that resolves on its own

- Recurrent chest discomfort with clear non-cardiac features (positional, reproducible by pressing, after meals, etc.)

- Anxiety-related chest tightness without other cardiac risk factors

When in doubt, err toward urgency. The cost of going to the ER and being told it's not your heart is much smaller than the cost of staying home with an evolving heart attack.

What Happens in the Emergency Department

If you go to the ER for chest pain, you'll get a fairly standard workup. Within minutes you'll have a 12-lead EKG, a blood draw including a cardiac enzyme called troponin, and a focused history and exam. The EKG can identify a major heart attack within seconds, and that triggers immediate transfer to the cardiac catheterization lab.

Most chest pain in the ER doesn't show an obvious heart attack on the first EKG. The next step is risk stratification. Most ERs now use the HEART score, which combines history, EKG findings, age, risk factors, and troponin level into a number from 0 to 10. Scores 0 to 3 are low risk for a major cardiac event in the next six weeks (under 1 percent), and those patients often go home with outpatient follow-up. Scores 4 to 6 are intermediate risk and usually trigger additional testing such as a stress test or coronary CT angiogram. Scores 7 to 10 are high risk and usually mean admission and either invasive evaluation or aggressive medical management.

High-sensitivity troponin assays, now standard in most US hospitals, allow much faster rule-out than the older troponin tests. A negative high-sensitivity troponin at zero and one hour can rule out a heart attack with very high confidence in low-risk patients.

For intermediate-risk patients, the 2021 AHA/ACC chest pain guideline gives a strong endorsement to coronary CT angiography (CCTA). This is a contrast-enhanced CT scan that shows the coronary arteries directly. A clean CCTA in a patient with chest pain is highly reassuring and can avoid the need for a stress test or catheterization.

Outpatient Workup After Reassurance

If you've been to the ER and were sent home, or if your chest pain didn't seem urgent enough for the ER, a cardiology workup might still be appropriate. The standard approach includes:

A repeat EKG and physical exam in the office. A discussion of your cardiovascular risk factors and family history. Lipid panel, fasting glucose or A1C, and basic chemistries if not recent. A coronary calcium score in selected patients to estimate plaque burden. A stress test (treadmill, stress echo, or nuclear) or coronary CTA depending on your risk level and symptoms.

For patients whose chest pain is suspected to be non-cardiac, the workup pivots to gastroenterology (for reflux), musculoskeletal causes (physical exam, sometimes imaging), or psychiatric evaluation if anxiety or panic is the driver.

MINOCA: When the Arteries Look Clean

A growing area of cardiology is recognizing that some patients have heart attacks without a major blockage on angiogram. This is called MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries). It accounts for up to 10 percent of heart attacks and is more common in women.

Mechanisms include plaque erosion (a small plaque ruptures even though it didn't look severe), coronary spasm, spontaneous coronary artery dissection (SCAD, more common in young to middle-aged women), and microvascular dysfunction. The workup often includes cardiac MRI to look for scar pattern, intravascular imaging during catheterization, and provocative testing for coronary spasm.

The point for patients: a clean angiogram does not always mean your symptoms aren't real. If your chest pain is genuine and the standard workup is unrevealing, ask about microvascular testing or referral to a center that specializes in MINOCA evaluation.

Common Patient Questions

My pain only lasted a few seconds. Could that still be my heart?

Cardiac chest pain typically lasts at least several minutes. Brief sharp pains lasting a second or two are usually musculoskeletal or related to nerve sensitivity in the chest wall. They're rarely cardiac.

I felt the pain when I was at rest, not exercising. Does that rule out my heart?

No. Pain at rest can be cardiac, and is sometimes more concerning than exertional pain because it suggests an unstable plaque rather than a stable narrowing. Don't use rest versus exertion as a rule-out.

My EKG and troponin were normal in the ER. Am I safe to go home?

A normal EKG and a high-sensitivity troponin at zero and one hour, combined with a low HEART score, give very high confidence that you didn't have a heart attack and your six-week risk of one is well under 1 percent. That's a strong reassurance, but it doesn't mean you don't have any coronary disease. Follow up with your primary care doctor or cardiologist for risk-factor assessment.

I get chest pain with anxiety attacks. Should I still get worked up?

Yes, at least once. Anxiety can cause real chest discomfort, but anxious patients also have heart disease. A baseline cardiac evaluation, especially if you have any risk factors, helps you (and your psychiatrist or therapist) treat the anxiety with confidence rather than wondering each time whether it's something more.

My doctor said it's probably costochondritis. How do I tell?

If pressing on the joint between your rib and your sternum reproduces the pain, costochondritis is likely. Cardiac pain is not reproduced by external pressure. Anti-inflammatory medication and rest usually resolve it over days to weeks.

I have GERD and chest pain. Is it my reflux or my heart?

Both can present similarly, and many patients have both. A trial of acid suppression often helps. If chest pain persists despite adequate acid suppression, or if you have cardiovascular risk factors, get a cardiac evaluation. The presence of one explanation doesn't preclude the other.

My Apple Watch flagged something. What does that mean?

Apple Watch and similar wearables can detect rhythm abnormalities like atrial fibrillation but are not designed to diagnose chest pain. If you have actual chest discomfort, the wearable data is secondary. Get a real EKG and an evaluation. If your watch flagged a rhythm issue but you have no symptoms, share the tracing with your doctor for context.

A Final Note From Me

Chest pain is one of the most common reasons for an ER visit in the United States. Most of those visits do not turn out to be heart attacks. The system is set up to evaluate chest pain quickly and reassure patients who don't need admission. Coming in for evaluation is not overreacting, even if everything turns out to be fine.

If you have a history of coronary disease and your usual chest pain pattern is changing, that's a reason to escalate. If you have a clean cardiac history but a new symptom that's making you worried enough to read articles like this one, get evaluated. The cost of being wrong in the cautious direction is small. The cost of being wrong in the dismissive direction can be enormous.

References

1. Gulati, Martha, Phillip D. Levy, Debabrata Mukherjee, et al. "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain." Circulation 144, no. 22 (2021): e368-e454.

2. Backus, Barbra E., A. Jacob Six, Johannes C. Kelder, et al. "A Prospective Validation of the HEART Score for Chest Pain Patients at the Emergency Department." International Journal of Cardiology 168, no. 3 (2013): 2153-2158.

3. Twerenbold, Raphael, Jasper Boeddinghaus, Thomas Nestelberger, et al. "Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction." Journal of the American College of Cardiology 70, no. 8 (2017): 996-1012.

4. Gray, Alasdair J., Carl Roobottom, Jason E. Smith, et al. "Early Computed Tomography Coronary Angiography in Patients With Suspected Acute Coronary Syndrome: Randomised Controlled Trial." Lancet 398, no. 10311 (2021): 1804-1815.

5. Lichtman, Judith H., Erica C. Leifheit-Limson, Eunice Watanabe, et al. "Symptom Recognition and Healthcare Experiences of Young Women With Acute Myocardial Infarction." JAMA Internal Medicine 175, no. 11 (2015): 1863-1871.

6. Tamis-Holland, Jacqueline E., Hani Jneid, Harmony R. Reynolds, et al. "Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association." Circulation 139, no. 18 (2019): e891-e908.

7. Löfmark, Henrik, Joakim Muhrbeck, Kai M. Eggers, et al. "HEART-score Can Be Simplified Without Loss of Discriminatory Power in Patients With Chest Pain." American Journal of Emergency Medicine 65 (2023): 178-184.

8. Hayes, Sharonne N., Esther S. H. Kim, Jacqueline Saw, et al. "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association." Circulation 137, no. 19 (2018): e523-e557.

9. Mehta, Laxmi S., Theresa M. Beckie, Holli A. DeVon, et al. "Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association." Circulation 133, no. 9 (2016): 916-947.

10. Mahler, Simon A., Robert F. Riley, Brian C. Hiestand, et al. "The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge." Circulation: Cardiovascular Quality and Outcomes 8, no. 2 (2015): 195-203.

Published on damianrasch.com. The above information was composed by Dr. Damian Rasch, drawing on individual insight and bolstered by digital research and writing assistance. The information is for educational purposes only and does not constitute medical advice.