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Chest Pain: Causes, Warning Signs & Emergency Red Flags

Chest pain ranges from a minor muscle strain to a life-threatening heart attack. Recognising the difference can save your life: or someone else's.

Written by Suman Konda, Clinical Pharmacist · Based on peer-reviewed sources · Editorial policy · Not medical advice

Last updated: · How we check our content

Affects
~8M US ER visits/yr
Heart origin
~15–25 % of cases
Age of concern
Any age
999/112/911
Always for crushing pain
Call Emergency Services NowCrushing, squeezing, or pressure chest pain, especially with arm/jaw pain, sweating, or breathlessness, is a medical emergency. Do not drive yourself. Call 911 / 999 immediately.

Quick answer

Chest pain has many causes, but emergency departments first rule out the three most dangerous: heart attack, pulmonary embolism and aortic dissection. A 12-lead ECG is done within 10 minutes; high-sensitivity troponin at 0 and 1 to 2 hours rules heart attack in or out. Pain reproduced by pressing the chest wall points to muscle or rib causes.

Common Causes of Chest Pain

CauseTypical FeelKey Clue
Heart attackCrushing, pressure, radiates to left arm/jawSweating, nausea
AnginaSimilar to MI but fades with rest/nitratesTriggered by exertion
CostochondritisSharp, worsens with palpationTender rib joints
GERD / acid refluxBurning, behind sternumWorse after meals
Pulmonary embolismSudden, with breathlessness & fast HRRecent long trip/surgery
Pneumonia / pleuritisSharp, worsens with breathFever, cough
Anxiety / panicTight, comes with racing heartResolves with calm
Key points
  • The three dangerous causes ruled out first: heart attack, pulmonary embolism, aortic dissection.
  • ECG within 10 minutes of arrival; ST elevation signals STEMI needing immediate reperfusion.
  • High-sensitivity troponin at 0 and 1 or 2 hours allows rapid rule-in or rule-out.
  • The HEART score stratifies risk; scores 0 to 3 can be safely discharged.
  • Chest-wall tenderness on pressing suggests muscle or rib pain, rarely an emergency.
  • Burning pain after meals, worse lying down, relieved by antacids suggests GERD.

Heart Attack Warning Signs

  • Pressure or squeezing in centre of chest lasting >2 minutes
  • Pain spreading to shoulders, neck, jaw, arms
  • Sudden shortness of breath
  • Cold sweat, nausea, or lightheadedness
  • Pale or grey complexion
Women's Symptoms DifferWomen are more likely to have atypical heart attack symptoms: jaw pain, fatigue, nausea without chest pain. Take these seriously too.1

When Is Chest Pain NOT an Emergency?

Musculoskeletal Pain

If pressing on your chest wall reproduces or worsens the pain, it is likely a muscle or rib issue: still worth a GP visit but rarely an emergency.

Acid Reflux

A burning sensation that worsens when lying down after eating and improves with antacids points toward GERD rather than cardiac causes.

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How do I tell a heart attack from heartburn?
Heart attack pain is typically pressure-like, may radiate to the arm or jaw, and does not improve with antacids. Heartburn is burning, central, and often relieved by antacids or sitting upright. When in doubt, call emergency services.
Can anxiety cause real chest pain?
Yes. Panic attacks can cause genuine chest tightness, palpitations, and shortness of breath. However, always rule out cardiac causes first if the symptom is new.
Should I go to A&E for chest pain?
If chest pain is new, severe, or accompanied by breathlessness, arm/jaw pain, sweating, or fainting: go to A&E or call 999/911 immediately.
Can chest pain be caused by the spine?
Yes. Thoracic spine problems can refer pain to the chest. A physiotherapist or GP can assess this after cardiac causes are ruled out.
Shortness of BreathCauses & red flags

How chest pain is investigated in A&E

When you arrive at an emergency department with chest pain, the initial workup is designed to rule out the three most dangerous causes: acute myocardial infarction (heart attack), pulmonary embolism, and aortic dissection.3

The 12-lead ECG

A 12-lead electrocardiogram (ECG) is performed within 10 minutes of arrival. ST-segment elevation signals a STEMI (heart attack requiring immediate reperfusion); ST depression or T-wave changes suggest a non-ST-elevation MI (NSTEMI). A normal ECG does not exclude a heart attack but dramatically lowers the probability.

High-sensitivity troponin

Troponin is a protein released by injured heart muscle cells. High-sensitivity troponin assays (hs-cTnI or hs-cTnT) can detect myocardial injury within 1–3 hours of symptom onset. Serial measurements at 0 and 1 or 2 hours allow a rapid rule-in / rule-out strategy recognised in the 2015 ESC NSTEMI guidelines.2 A troponin rise-and-fall pattern is required to diagnose a heart attack; a single elevated result without the pattern may reflect chronic myocardial injury (e.g., from heart failure or chronic kidney disease).

The HEART score

The HEART score (History, ECG, Age, Risk factors, Troponin) stratifies chest pain patients into low, moderate, and high risk for major adverse cardiac events. Patients scoring 0–3 have a 6-week MACE rate of 1.7% and can be safely discharged without admission.4

D-dimer and CT-PA

If pulmonary embolism is suspected (e.g., following a long-haul flight, immobility, or surgery), a D-dimer blood test is checked first. A negative D-dimer in a low-probability patient excludes PE. A positive result triggers a CT pulmonary angiogram (CT-PA) for definitive diagnosis. See the D-dimer test guide for normal ranges and what results mean.

Non-cardiac chest pain: when the heart is cleared

Around 50–80% of chest pain presentations to A&E are ultimately non-cardiac in origin. The most common non-cardiac causes are musculoskeletal (especially costochondritis) and gastrointestinal (GERD, oesophageal spasm). Reassurance is important: patients who have had a thorough cardiac work-up and are discharged often re-present because they remain anxious about the cause. A clear explanation of the diagnosis and safety-net advice (when to return) reduces unnecessary re-attendance.

References

Sources cited on this page. PubMed links open the original abstract.

  1. Mehta LS, Beckie TM, DeVon HA, et al. Acute Myocardial Infarction in Women. Circulation. 2016;133(9):916–934. PMID 26811316 · doi:10.1161/CIR.0000000000000351
  2. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2016;37(3):267–315. PMID 26320110 · doi:10.1093/eurheartj/ehv320
  3. Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720–3826. PMID 37622654 · doi:10.1093/eurheartj/ehad191
  4. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153–2158. PMID 23465250 · doi:10.1016/j.ijcard.2013.01.255
Medical Disclaimer: This page is for general education only and does not replace professional medical advice. Always consult a qualified healthcare provider.
Written and medically reviewed by Suman Konda, Clinical Pharmacist · Sources linked to PubMed · Not medical advice: see our disclaimer