What Causes Chest Pain? (hint: It’s not always a heart attack)

Chest pain isn’t always a sign of a heart attack. Read on to discover what else could be causing your chest to ache.

What comes to mind when you hear the phrase “chest pain?” Most people’s brains immediately focus on the worst-case scenario and associate chest pain with a heart attack. And, in some cases, they may be right. Chest pain is something that should never be ignored. 

Non-traumatic chest pain is the second leading cause of emergency room visits in the United States, bringing close to 7 million people through the hospital doors each year. However, most people with chest pain are not having an acute heart attack. In fact, a recent study found that less than only 5.5 percent of people arriving at the emergency room with chest pain had an immediate life-threatening heart issue. 

While it may bring relief to know that most chest pain is not a heart attack, it still may signal a life-threatening problem. Pain, no matter the location, is a warning sign that something has gone awry. It’s our body’s way of sending an SOS. And, if neglected, it may lead to catastrophic results.

man experiencing cardiac event

The heart is located in the front of the chest, sitting slightly left of the breastbone. This strong muscle pumps blood throughout the body through thousands of vessels. Just as all body parts require oxygenated blood, so does the heart. 

Cardiac-related chest pain presents differently in each individual. However, it often results in left-sided chest pain. There are several reasons the cardiovascular system can cause chest discomfort, including:

Heart attack

A heart attack, also known as a myocardial infarction (MI), happens when the flow of blood that brings oxygen to the heart is blocked. Without enough blood, the heart muscle begins to spasm and cause pain. 

Typical characteristics of heart attack pain include: 

  • May be sudden and intense or may come on more slowly
  • Uncomfortable pressure, squeezing, fullness, burning, or tightness in chest
  • Usually lasts more than a few minutes or may go away and come back again
  • May present in other parts of your body, such as your arms, back, neck, jaw, and stomach
  • Occurs at rest or when active 

Coronary artery disease

Coronary artery disease (CAD) is caused by damaged blood vessels that supply the heart with oxygen. In CAD, plaque deposits gather along the artery walls, narrowing the blood’s pathway to get to the heart. Deprived of oxygen, the heart cries out with chest pain, also called angina. 

Typical characteristics of CAD (angina) pain include:

  • May be mild or severe
  • Heaviness, tightness, aching, pressure, burning, fullness, squeezing, dull ache in chest 
  • Discomfort may also present in the shoulder, arm, neck, back, or jaw
  • Chest pain typically limited to physical activity or when under stress

Myocarditis, pericarditis, or endocarditis 

As the names suggest, myocarditis, pericarditis, and endocarditis all indicate inflammation around the heart. Pericarditis involves inflammation in the sac that surrounds the heart. Myocarditis is inflammation of the heart muscle itself. Endocarditis impacts the inner layer of the heart. Inflammation of the heart often reduces its ability to pump effectively and can lead to irregular heart rhythms. 

Typical characteristics of inflammatory heart pain include:

  • Tightness or squeezing in the middle or left side of the chest
  • Often felt behind the breastbone or collarbone
  • Present with rest and with exertion
  • Chest pain is usually made worse by movement such as coughing, breathing, or swallowing
  • Chest pain is sometimes relieved when leaning forward and typically worsens with lying flat
  • Pain may spread to the neck, back, and shoulders

Aortic aneurysm or dissection 

An aortic aneurysm is an enlargement or ballooning of a section of the aorta, the major artery that carries blood out of the heart. An aortic dissection occurs as a result of a tear in the wall of the aorta. This life-threatening condition must be diagnosed and treated promptly. 

Typical characteristics of aortic pain include:

  • Sudden severe and sharp pain in the chest and upper back
  • Often produces a tearing or ripping sensation
  • Pain may move from one location to another 

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy occurs when the heart muscle thickens, making it difficult to pump effectively. 

Typical characteristics of cardiomyopathy pain include:

  • Chest pain that typically presents after exertion or with heavy meals

Non-cardiac causes of chest pain 

Not all chest pain is related to the heart. In fact, there are several reasons why someone might experience chest pain, including: 

Lung-related causes 

woman having difficulty breathing

The lungs sit in the chest. As a result, pulmonary discomfort is often confused with cardiac pain. Acute infections such as pneumonia or Covid-19 can cause chest pain. Other lung issues that can produce chest pain include: 

  • Pulmonary embolism – A pulmonary embolism (PE), or blood clot, occurs due to a blockage in the artery of the lungs. Chest pain is typically one-sided or may present under the breastbone. It is often described as a sharp pain that worsens during inhalation.
  • Pleurisy – Pleurisy is inflammation of the thin layers covering the lungs and chest cavity. If left untreated, it can evolve into a pleural effusion, a build-up of fluid in the cavity surrounding the lungs. Pleuritic pain typically presents as a sharp, stabbing pain that worsens with breathing, sneezing, coughing, or moving. Pressure on the area sometimes relieves the pain. Pain with pleurisy sometimes radiates to the shoulders and back.
  • Pneumothorax – A pneumothorax is a medical term used to describe a collapsed lung. Pain from this condition typically is sharp and worsens with breathing or deep inhalation. Similar to pleurisy, pain with a pneumothorax often radiates to the shoulder and back.
  • Pulmonary hypertension – Pulmonary hypertension (PH), or high blood pressure in the lungs’ arteries, is an underdiagnosed cause of chest pain. Chest pain with PH often presents in the front of the chest. 

Digestive causes 

man with digestive upset

Many digestive organs sit close to the chest cavity. For example, the gallbladder sits to the right of the chest, the pancreas to the left, and the stomach slightly to the right of the center. Therefore, pain originating from these areas can feel like chest pain. 

  • GERD/Indigestion – Gastroesophageal reflux disease (GERD), also referred to as acid reflux,  heartburn, or indigestion, is a common disorder that can mimic the symptoms of a heart attack. In fact, GERD is the most common cause of non-cardiac chest pain.

With GERD, highly-acidic stomach acid flows back into the esophagus, causing a burning sensation in the chest. GERD can also cause a squeezing feeling behind the breastbone that comes and goes, much like a heart attack. GERD pain sometimes radiates to the back and shoulder as well. 

  • Gallbladder disease – The most common symptom for those with gallbladder disease is right-sided abdominal or chest pain. Gallbladder pain often radiates to the right shoulder or between the shoulder blades in the back. Gallbladder attacks often happen after meals or at night and can come and go. 
  • Esophageal conditions – The tube that connects our mouths to our stomachs is the esophagus. The esophagus runs down the center of the chest, and many disorders of the esophagus can contribute to chest pain. 

Musculoskeletal causes 

man with rib out of place

Several bones and muscles surround our chest cavity and can contribute to pain. Many wonder how to tell the difference between muscular pain and heart-related discomfort. In most cases, muscular pain worsens with movement and improves with rest. Musculoskeletal chest pain can be caused by the following: 

  • Costochondritis – Costochondritis is a condition in which the cartilage that holds the ribs to the breastbone becomes inflamed. Costochondritis often affects the upper ribs on the left-hand side of the chest, where the ribs attach to the breastbone. Pain associated with costochondritis mimics heart-associated discomfort in that it’s sharp and may radiate to the back. However, pain with costochondritis increases with a deep breath or cough. 
  • Muscle strains or spasms – Muscle strains are a common cause of chest pain and may result from weight lifting, coughing, poor posture, or blows to the chest. Muscle strains in the chest may cause sharp or dull pain that typically worsens with movement. 

Psychological causes 

older man having anxiety and chest pain
  • Anxiety or panic attacks – One of the most frightening symptoms of anxiety is chest pain. Chest pain occurs with anxiety for various reasons, including a sudden release of stress hormones that cause the blood pressure and heart rate to rise. Chest pain characteristics vary for those with anxiety but may be dull, sharp, stabbing, burning, or aching. 
  • Takotsubo (stress) cardiomyopathy – Stress cardiomyopathy, or Broken Heart Syndrome, is caused by sudden acute stress. A traumatic event such as the death of a loved one can cause a weakening of the heart muscle and symptoms that mimic a heart attack. 

When should I worry about chest pain? 

New onset chest pain should always be evaluated to rule out an immediate cardiac problem. However, the following chart may help guide decision-making when evaluating the seriousness of your chest discomfort. 

Next Steps

While no one wishes to experience pain, it’s truly a gift. Pain is a valuable signal in our bodies, alerting us that something is off-balance or needs attention. While chest pain may not always indicate a deadly heart attack, it is most certainly a cry for help. 

If you or a loved one experiences acute chest pain, seek emergency care without delay. Once the doctor has cleared you, you will want to investigate the cause of your pain. Consider working with one of our expert health providers to help uncover the root cause of your chest discomfort once and for all. 

Eat well, Live well, Think well

Medical Review: Dr. Lauren Lattanza 2022

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