Chest Pain

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If you are experiencing severe chest pain and are concerned for your safety, please immediately contact your emergency services.

In Iraq you should call for an ambulance on 115.

Disclaimer

The information in this article is written for general information purposes only, and is not a substitute for professional medical advice, treatment or care. It is incredibly important that you do not make decisions regarding any symptoms based on this information alone. If you are worried about any symptoms you may be having, or have any further questions about this condition, please speak to a qualified and trustworthy medical professional.

What is chest pain?

Chest pain is not an uncommon problem, and will affect 20-40% of people at some point during their lives.1 Most of the medical problems that can cause chest pain are not serious. That said, chest pain can be a symptom of several dangerous conditions, so it is important that you do not ignore it.

There is a wide range of medical problems that can cause chest pain. This is because there are many physical structures within the chest, and a range of medical problems that can affect each physical structure.

Man with chest pain clutching his chest and leaning against a wall.

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Anatomy of the chest

The chest area of the body is typically thought of as the area from the collar bone to the bottom of the ribcage. This is quite a large space and within it are many important structures, such as  the heart, major blood vessels, and the lungs. The chest also includes the oesophagus (food pipe or gullet) and the top of the stomach.

Anatomy of the chest

Additionally, the chest area contains the rib cage, which protects these structures. The rib cage is made up of rib bones and has muscle in between the bones called intercostal muscles. If any of these structures develop a problem, pain may occur in the chest area.

Medical conditions that affect the lungs, heart or blood vessels are particularly dangerous.

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Types of chest pain​

As chest pain can come from many different physical structures and medical conditions, it can  show up in many different ways. Therefore, to determine the cause, doctors will look at the features of chest pain.

Features of chest pain:​

  • Type of pain: The pain may feel dull, sharp, stabbing, tight or crushing. 

  • Location of pain: It may be felt in a specific area of the chest, or more generally across the chest. It may feel like it spreads out of the chest, for example to the arm, jaw or back.

  • Pattern of pain: The pain may be triggered by factors such as exercise, eating, lying down, leaning forward or breathing in.

  • Accompanying symptoms: There may be other symptoms that occur with chest pain, such as:

      • coughing
      • difficulty breathing 
      • dizziness
      • nausea/vomiting
      • feeling clammy
      • bitter taste in the mouth
      • frequent burping

It can be useful to make a note of any features of the chest pain you are experiencing, as these can be useful if you need to discuss your chest pain with a doctor.

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What causes chest pain?

The below medical conditions can cause chest pain in the body. 

We’ve grouped these causes into sections based on which physical structure within the body the medical problem is coming from. 

For common conditions, we’ve gone into detail about their symptoms, diagnosis, and treatment. We’ve also briefly listed some of the more rare conditions that can cause chest pain.

Digestive tract

Indigestion is one of the most common causes of chest pain. You may have also heard it called heartburn, reflux or GERD (gastro-esophageal reflux disorder). 

 

Indigestion causes chest pain when stomach acid, which is used to digest food, leaves the stomach area and travels up the oesophagus (food pipe or gullet). 

 

Indigestion is more likely to happen in pregnancy, as the pregnancy hormones cause the muscles in the oesophgaus to relax more, allowing more stomach acid to flow up from the stomach.

 

What are the symptoms of acid reflux?

 

Acid reflux is usually felt as a pain or burning sensation behind the breastbone (sternum). It typically occurs after eating or when lying down. You may also experience a  bitter taste of stomach acid in your mouth, belching or burping.

 

How is acid reflux diagnosed?

 

Acid reflux is usually diagnosed based on the history of your symptoms, and a trial period of taking anti-reflux medications to see if your symptoms improve.

 

How is acid reflux treated?

 

Occasional episodes of heartburn are no cause for concern and can usually be managed with simple anti-reflux medications that you can buy over the counter. 

 

Avoiding certain foods may also help reduce symptoms, such as: 

 

  • Spicy foods 
  • Onions
  • Tomatoes 

If you suffer regularly from heartburn, you should see your doctor, as the stomach acid can damage your oesophagus over time and lead to other conditions.

Oesophageal spasm is a rare cause of chest pain. The oesophagus (food pipe or gullet) is made of muscle which contracts to move food down towards the stomach. Sometimes this muscle can contract in unusual spasms, which may cause central pain in the chest.

 

It is not yet clear what causes oesophageal spasm, but it is thought to be caused by problems within the muscle of the oesophagus, or with the nerves that send signals to the oesophagus.

Oesophageal rupture is another uncommon cause of chest pain. The oesophagus is made of pretty thick muscle, so it does not easily rupture (break or split). It can however rupture after violent vomiting or certain surgical procedures, and very rarely it can happen on its own.

Mental health

Panic attacks are a major cause of chest pain. 1 in 4 people that go to their doctor for chest pain are found to have panic disorder.2 

 

Panic disorder is a condition which involves panic attacks, where the person may experience: 

 

  • Chest pain 
  • A pounding heart
  • Difficulty breathing
  • Nausea (queasiness) 

Panic attacks can be extremely upsetting. You can read more about panic attacks here.

Lungs

Although Covid-19 can cause chest pain, this is not one of its main features. 

 

The key symptoms of a possible covid infection are:

  • Loss/change of smell/taste
  • A new and continuous cough, and 
  • A temperature 

If you have these symptoms along with your chest pain, then you may be at risk for Covid-19 infection and should follow your country’s guidance on what to do. 


You can read more about Covid-19 here.

If an infection develops in the lungs, this is known as a chest infection or pneumonia. Chest infections can be caused by viruses or bacteria. 

 

What are the symptoms of a chest infection?

 

Although not their main symptom, chest infections can also cause pain in the chest. 

 

Other symptoms include:

 

  • Coughing
  • Feeling shortness of breath, or 
  • Wheezing 

Chest infections can also cause general aches and tiredness.

 

How is a chest infection diagnosed?

 

Chest infections are usually diagnosed based on your symptoms and medical history, but blood tests and a chest x-ray can also be used to confirm the diagnosis: 

 

  • The blood test may show increased levels of inflammatory markers, which suggest that there is an infection 
  • The chest x-ray can look for visual signs in the lungs that there is an infection

How is a chest infection treated?

 

Most chest infections will get better on their own. You should try to get plenty of rest and keep yourself hydrated. If you are finding it a bit difficult to breathe when lying down, it may be helpful to prop your head up with pillows.

 

Sometimes antibiotics may be given to treat the bacteria causing the infection. There is no medication to treat the viruses that cause chest infections. 

 

You should see a doctor if: 

 

  • you are finding it very hard to breathe
  • you are coughing up blood, or 
  • you are feeling drowsy and confused

If the lungs are injured, they may collapse or cave in, leading to chest pain and difficulty breathing. This is known as Pneumothorax or collapsed lung and may require urgent medical attention. If you have experienced an injury to the chest and are struggling to breathe, you should seek medical attention to rule out the possibility of a pneumothorax.

A blood clot can form when blood clumps together inside the blood vessels. If a blood clot develops in the lungs, or travels there from another part of the body, it can block the veins in the lungs and stop blood from flowing to them. This is known as a pulmonary embolism (PE). This is incredibly dangerous and can lead to collapse and death if it is not treated urgently.

 

What are the symptoms of a PE?

 

Someone with a pulmonary embolism will usually feel a sharp pain in their chest, which feels worse when they are breathing in, and they will generally find it hard to breathe. Some people may cough up blood. 

 

If the blood clot developed in the lower legs before travelling to the lungs, there may also be pain, tenderness or swelling around one of the calves.

 

How is a PE diagnosed?

 

The healthcare team will ask you some questions about your medical history and symptoms,  and examine you. Based on how likely they think a PE is, they might want to take  a blood test or a scan: 

 

  • The blood test checks for the level of a small protein fragment called D-dimer. High levels of D-dimer suggest that bits of the clot are in the bloodstream and that a PE might be present. If the D-dimer levels are high, a scan will be ordered.

  • The scans used are ventilation-perfusion scan (VQ scan) or CT pulmonary angiogram (CTPA). Both of these scans look at the lungs to see if there is a clot. If the doctors suspect there is a high chance of a PE, they will order the scan without waiting for the blood test.

The healthcare team may also perform an ultrasound scan on your leg, called a doppler scan, to see if there is a clot there that may have caused the PE.

 

How is a PE treated?

 

A pulmonary embolism is usually treated with medications that stop the clot from getting bigger. These are called anticoagulants. The most commonly used anticoagulants are dalteparin, which is injected into the fat below the skin, or a type of tablets called novel oral anticoagulants (NOACS). 

 

The bigger PEs may be treated with clot-busting drugs that dissolve (break up) the clot, in a treatment called thrombolysis. 

 

In life-threatening cases, surgery may be considered to remove the clot in a procedure known as thrombectomy.

Various long term lung conditions can worsen or flare-up to cause chest pain. Flare ups can be triggered by factors, such as: 

 

  • Infections
  • Smoking, or 
  • Missing routine medication for the condition

For example, people with Asthma or Chronic Obstructive Pulmonary Disease (COPD) can experience flare ups in which they may feel tightness or pain in their chest.

Heart & blood vessels

Angina is chest pain which occurs when the heart tissue does not get enough oxygen. This usually happens when the blood vessels that supply the heart with oxygen-rich blood (coronary arteries) become diseased. This is known as coronary artery disease. 

 

Coronary artery disease occurs when there is a build-up of fatty plaques (deposits) on the artery walls. The deposits make the inside of the vessels much thinner. Because the vessels are thinner, less oxygen-rich blood can flow through to the heart.

 

What are the symptoms of Angina?

 

Angina usually occurs when the heart is having to work harder than normal, for example during physical activity. The blood vessels cannot supply the heart tissue with the extra oxygen it needs, and tissue that does not receive enough oxygen causes pain. The pain typically feels dull or achy and is felt in the centre of the chest. The pain may also spread to the arm or jaw.

 

There are two main types of angina:

 

  • Stable Angina: Pain that occurs when we’re physically active and stops when we rest is known as stable angina. Stable angina accounts for around 10% of chest pain seen in the community.3

     

  • Unstable Angina: Unstable angina is where episodes of chest pain come on without any triggers. This type is especially worrying, and you should get medical help to prevent the condition from getting worse.

How is Angina diagnosed?

 

To diagnose angina, doctors may: 

 

  • Ask you questions about your symptoms and medical history
  • Complete a physical exam, and 
  • Run special tests 

Electrocardiogram (ECG)

 

One test which can usually be done in the community is an electrocardiogram (ECG). This looks at the electrical activity of the heart, which are the signals that cause the heart to beat. 

 

An ECG may sometimes be used as part of an exercise test. The person is asked to walk on a treadmill whilst a machine records their heart’s electrical signals. As the exercises get harder, the ECG may start to show unusual electrical signals. Doctors can look at these signals to tell if there are parts of the heart that aren’t getting enough oxygen.

 

Coronary Angiography

 

Another test is coronary angiography, where dye is injected into the person’s veins. The dye travels to the heart and an x-ray machine is used to see this dye in the arteries (blood vessels) of the heart. From here, doctors can spot any areas where plaque is causing the arteries to become more narrow.

 

How is Angina treated?

 

Treatment is often with medications that allow the arteries to relax and become wider, allowing more blood to reach the heart. 

 

Usually the first medication given is a spray that you use under your tongue, called glyceryl trinitrate (GTN) spray. You may also be given tablets to take regularly to help reduce symptoms, such as calcium channel blockers and beta-blockers. 

 

Lifestyle changes are also important, such as:

 

  • Losing weight 
  • Eating healthy 
  • Exercising more 
  • Stopping smoking
  • Drinking less alcohol

If angina is unstable, a procedure to remove the plaque from the arteries may be needed, which is called a percutaneous coronary intervention (PCI).

A heart attack, known in the medical world as a myocardial infarction, is where a blood clot blocks the arteries (blood vessels) that supply the heart with oxygen-rich blood. 

 

It is a medical emergency. Urgent treatment is required to bring blood supply back to the heart before the heart tissue dies from a lack of oxygen. 

 

The main cause of heart attacks is coronary artery disease. With coronary artery disease, the fatty plaques (deposits) that build up within the blood vessel walls can tear, causing a blood clot to form and block off the vessel. This stops blood from flowing to the heart.

 

What are the symptoms of a heart attack?

 

Someone experiencing a heart attack will usually feel chest pain in the middle of their chest that feels tight or crushing. The pain can often spread to their left shoulder or arm and jaw. People experiencing heart attacks can often feel clammy, sweaty and nauseous.

 

How is a heart attack diagnosed?

 

An electrocardiogram (ECG) test is used to check the electrical activity in the heart. Certain patterns of unusual activity in the heart can suggest a heart attack. 

 

A blood test called Troponin can also be useful in diagnosing a heart attack because troponin levels rise when heart tissue is damaged.

 

How is a heart attack treated?

 

Heart attacks are treated by bringing blood flow back to the heart. This is done by:

 

  • Using drugs that dissolve the blood clot known as thrombolytics
  • Surgery that removes the blood clot (percutaneous coronary intervention, or PCI), or 
  • Surgery that creates a bypass around the blood clot (coronary bypass surgery)

The treatment option used will depend on when your symptoms started. As with angina, lifestyle modifications are also important.

Pericarditis is the inflammation of the connective tissue sac that surrounds the heart. Although uncommon, it does cause chest pain. It feels like a dull pain in the chest that gets worse when the person is lying down or breathing in.  

 

Pericarditis is usually caused by viruses, but may also occur as a complication after a heart attack.

This is a rare but serious condition in which the major artery (blood vessel) that flows from the heart to other important organs tears. It causes severe pain in the chest, which spreads to the back and can also cause dizziness and collapse.

Arrhythmias are a common condition, which may occasionally cause chest pain. Arrhythmias are unusual patterns of electrical activity in the heart that can cause problems with the way the heart beats. It may cause: 

 

  • Palpitations (butterflies in the chest)
  • Dizziness/light-headedness
  • And chest pain

Problems with the bones/muscles in the rib cage

In 20% of cases of chest pain, the problem will be with the bone or muscles of the ribcage, such as rib fractures or intercostal sprain. Another 13% are caused by costochondritis.3

Rib fractures typically happen after trauma to the chest, such as a fall. People with rib fractures will feel pain around the ribs, and may struggle to breathe because of the pain. 

 

Treatment will usually be with painkillers. If you are coughing up blood, or your breathing is getting worse, you should seek medical attention, as there is a risk that the spikey fractured bone may damage the lungs underneath and cause a Pneumothorax (collapsed lung).

The muscles between your ribs are called intercostal muscles. These help you to breathe. Like any other muscle, if they are overstretched they can become sprained. 

 

Intercostal muscles can become sprained through activities, such as twisting or lifting, or even coughing or sneezing and the area between your ribs will feel sore.

Costochondritis is where the cartilage (smooth flexible tissue) that connects your ribs to your breast bone (sternum) becomes inflamed. There is usually no clear cause for this. 

 

Typically the pain is felt around your breast bone, and may feel worse on breathing in. Treatment focuses on pain relief and the condition will usually improve on its own over a few weeks.

Other causes of chest pain

Medical researchers are becoming interested in a possible connection between chest pain and menstrual cycles (periods). There has been shown, in some individuals, to be a link between them.

 

Angina

 

A study with 10 participants with angina (a condition that occurs when the heart tissue does not get enough oxygen) showed that their chest pain got worse just before menstruation. This may be because of changes in the hormone levels oestrogen, which go down before menstruation starts.4 There have been other case studies of women with angina that’s related to their menstrual cycle.5

 

Endometriosis

 

Another area that medical researchers are looking at is the link between endometriosis and periods. Endometriosis is a condition where the endometrial tissue that usually lines the uterus grows elsewhere in the body. 

 

During the menstrual cycle, it is normal for this tissue to shed in the uterus. This tissue then leaves the body through the vagina as a “period”. However, when the endometrial tissue grows somewhere else, it will also shed during the menstrual cycle, causing pain in that area of the body. In rare cases of endometriosis, the tissue can grow in the chest, and cause chest pain when it sheds. 6,7

 

Both of these cases seem to be rare. More research is needed to understand if there’s a link between chest pain and periods.

Other structures that sit in the upper part of the abdomen (the area between the chest and the pelvis or hips) can sometimes cause pain that is felt in the chest. These structures include the: 

 

  • Gallbladder
  • Liver, and
  • Pancreas 

For example, someone with gallstones may experience pain from their gallstones that is then felt in their chest.

Non-specific chest pain is also common and occurs when a reason for the pain can’t be found.

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How do I know if my chest pain is serious? ​

Below are some red flags that may mean your chest pain is serious:

  • You are finding it quite difficult to breathe
  • You feel dizzy, have a low blood pressure reading, or have collapsed
  • You feel sweaty, clammy and nauseous (queasy, like you might vomit)
  • Your chest pain is in the centre of your chest and feels like it’s crushing your chest 
  • Your pain is also felt in your left arm and jaw
  • You feel confused and drowsy
  • You are coughing up blood
  • One of your calves is more swollen and tender than the other

What should I do if I think my chest pain is serious?​

If you have any of the above symptoms, you should seek urgent medical advice by calling your country’s emergency services. 

In Iraq you should call for an ambulance on 115.

Young man clutching his chest in pain

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How is the cause of chest pain diagnosed?

Chest pain can have different features depending on the condition that is causing it. Additionally, different factors may make certain conditions more likely to develop, like lifestyle habits or medical conditions. Therefore, a thorough medical history can provide the medical team with clues about the reason for your chest pain.

 

The medical team will want to know:

 

  • Where exactly in the chest do you feel the pain?
  • Do you feel it anywhere else in the body?
  • How would you describe the type of pain (e.g. dull, sharp, stabbing, tight, etc.)?
  • What makes the pain worse? 
  • What other symptoms do you have?
  • Have you been in an accident or hurt your chest recently?
  • Do you have a family history of any heart problems?
  • Have you ever been diagnosed with any heart problems?
  • What is your lifestyle like? (e.g. smoking/alcohol/exercise)
  •  

Certain chest pain features can be seen during a physical examination and can help doctors reach a diagnosis.

 

A typical examination for chest pain would include:

 

  • Checking blood pressure and heart rate
  • Feeling pulses
  • Listening to the sounds the heart is making
  • Feeling the rib cage for tenderness
  • Feeling the lungs to see if they are filling up equally as you breathe
  • Listening to the sounds of the chest
  • Checking the rate of breathing
  • Checking the calves for any swelling
  • Checking the abdominal area to rule out any abdominal cause of pain

In some cases, further tests may be needed to reach a diagnosis, or rule out serious conditions. This may include:

 

Blood tests, such as:

 

  • Full blood count
  • Thyroid function
  • Electrolytes (sodium, potassium etc.)
  • D-dimer
  • Troponin

Scans, such as:

 

  • Ventilation-perfusion scan
  • CT pulmonary angiogram
  • Chest x-ray
  • Doppler ultrasound scan of the leg
  • Coronary angiogram

Other investigations, such as:

 

  • ECG
  • Exercise testing
  • Trial with medications

How is chest pain treated?​​

Treating chest pain will depend on the medical condition that’s causing it.

In some cases, the healthcare team may rule out serious conditions, but may not reach a diagnosis about the cause of your chest pain. In this case, they may suggest that you simply keep an eye on your symptoms.

Some cases of chest pain will be managed in the community by family physicians, whilst some will require referral to the hospital for special tests.

Urgent cases of chest pain will require emergency admission to the hospital.

In Iraq you should call for an ambulance on 115.

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Can you prevent chest pain?​​

Chest pain can be the result of so many conditions, so it’s not possible to prevent it entirely. That said, you can take steps to reduce your risk of certain conditions.

Coronary artery disease (CAD) causes chest pain, and is one of the leading causes of death worldwide. CAD develops due to atheroscleortic (fatty) plaques forming in the blood vessels of the heart. Taking steps that reduce the build up of these plaques can reduce your risk of angina and heart attacks.

What steps can you take to reduce your risk of coronary artery disease?

  • Exercise regularly
  • Eat a healthy diet
  • Stop smoking
  • Reduce your alcohol intake
  • Manage your stress

It can be easier said than done to make these changes. It may be helpful to speak to your doctor about ways you can do this.

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  1. Ruigómez A, Rodríguez L, Wallander M, Johansson S, Jones R. Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract. 2006;23(2):167-174. doi:10.1093/fampra/cmi124 (Access here)
  2. Huffman J, Pollack M, Stern T. Panic Disorder and Chest Pain. The Primary Care Companion to The Journal of Clinical Psychiatry. 2002;04(02):54-62. doi:10.4088/pcc.v04n0203 (Access here)
  3. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38(4):345-352. (Access here)
  4. Kawano H, Motoyama T, Ohgushi M, Kugiyama K, Ogawa H, Yasue H. Menstrual Cyclic Variation of Myocardial Ischemia in Premenopausal Women with Variant Angina. Ann Intern Med. 2001;135(11):977. doi:10.7326/0003-4819-135-11-200112040-00009 (Access here)
  5. Choo W. Menstruation angina: a case report. J Med Case Rep. 2009;3(1). doi:10.1186/1752-1947-3-6618 (Access here)
  6. Chamsy DJ, Qasim S, Kho KA. Thoracic endometriosis: a case report. J Reprod Med. 2012;57(3-4):178-180. (Access here)
  7. Tong SS, Yin XY, Hu SS, Cui Y, Li HT. Case report of pulmonary endometriosis and review of the literature. J Int Med Res. 2019;47(4):1766-1770. doi:10.1177/0300060518800868 (Access here)

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