Chest Pain? The Causes Could Go Beyond a Heart Problem, Doctors Say
This article was medically reviewed by Raj Dasgupta, M.D., an associate professor of clinical medicine at the Keck School of Medicine of USC and member of the Prevention Medical Review Board, on January 21, 2021.
There it is: that discomfort in your chest. It’s probably from the pizza you just inhaled. But wait—it is chest pain. In the moment, it’s not a giant leap from pass the Tums to Oh no, could it be my heart?
Well, yeah, it could, and you absolutely need to rule it out (more on that below). But the odds are also very good that it’s something else and not life-threatening.
“Many of the nerves in our chest are shared by the organs there: the skin in the front and the back of the chest, the bones, the muscles, the esophagus, and the lungs,” says Karol Watson M.D., Ph.D, attending cardiologist and professor of medicine at the David Geffen School of Medicine at UCLA and a member of the Prevention Medical Review Board. “You can’t know just by a pain in your chest what it is, which is why you want to rule out the things that’ll kill you.”
If that sounds overly alarmist, it’s not. While most chest pain does not indicate a heart condition (one study found that in around 10-15% of people who visit their regular doctors complaining of chest pain, it had something to do with their heart), most people who are having a heart attack do experience some pain, discomfort, or tightness in the chest, according to the Centers for Disease Control and Prevention (CDC). Because a heart problem may be immediately life-threatening, says Dr. Watson, it needs to be crossed off your list.
But there are other potential issues to be aware of when pain kicks in. Ahead, doctors break down the more common reasons why your chest hurts, and what you can do to find long-lasting relief.
Unless you know for sure that pain in your chest has nothing to do with your heart, it’s better to be safe than sorry. Sure, it might be heartburn, but “honestly you cannot tell the difference sometimes,” says Dr. Watson. “A rule of thumb is, any symptom from the nose to the navel that comes on with exertion and goes away with rest, you have to think about your heart.”
If the pain lasts mere seconds, it’s probably something else. But if it “comes on over minutes, lasts minutes, and goes away over minutes,” you want to take it seriously, says Dr. Watson. Heart disease, of which there are many kinds, is the number one killer of women and men, accounting for around one in five women’s deaths in 2017 and about one in four men’s deaths the same year.
One pain in the chest, angina, happens when the heart isn’t getting enough blood and is a symptom of many forms of coronary artery disease, including a heart attack, an aortic dissection, cardiomyopathy, among others, according to the CDC.
“For most people, once you have been diagnosed with heart disease and you feel pain, what you’re looking for is a change in the pattern,” says Dr. Watson. Chest pain can feel like tightness, fullness, squeezing, or nausea, and can be different for different people. “The good news is, it’s pretty stereotypical for each person—what your heart pain felt like the first time, it will feel the same,” she explains. “The intensity may be different, but the quality is the same.”
❗What to do about it: If you feel any type of chest pain or discomfort, especially if you also feel it in your jaw, neck or throat, or back or upper abdomen, and/or have fatigue, vomiting, or nausea, dial 911 or get to an emergency department.
Up to half the time someone goes into the ER with chest pain it turns out to be some kind of musculoskeletal issue in the chest. You may have tweaked a muscle or nerve, scooped up a heavy child, inflamed the cartilage in your chest wall, or maybe even bruised a rib. Sometimes you don’t ever figure out what it is, but it usually goes away on its own after a few days or sometimes weeks.
One common musculoskeletal cause of chest pain is costocondritis, an inflammation of the cartilage that connects your rib to the breastbone, can happen after strenuous exercise or trauma to the area. “It’s relatively benign,” says Raj Dasgupta, M.D.,, associate professor of clinical medicine in the division of pulmonary, critical care, and sleep medicine at the University of Southern California Keck School of Medicine.
❗What to do about it: Head to your doctor to rule out a heart issue, but if your chest hurts and you can reproduce the pain (say, when you press on the area) and comes with certain types of movement but not others, it’s probably musculoskeletal, says Dr. Dasgupta.
If the doctor agrees, they’ll likely advise easing the pain with a nonsteroidal anti-inflammatory drug, like ibuprofen, adding helpful stretches to your routine, and using cold or warm compresses, he says. If it lasts longer than a week or keeps you up at night, the doctor might prescribe something stronger, like a corticosteroid injection, or continue the chest pain investigation.
This is where heartburn comes in. Again, it’s confusing because one symptom of a “silent” heart attack, especially in women, could be nausea or indigestion.
Still, around 20% of the time, chest pain has something to do your esophagus, the muscular tube that hooks up your stomach to your throat, says Scott Gabbard, M.D., a gastroenterologist at Cleveland Clinic. You might feel a painful burning or pressure at any point along that area.
One cause of this is acid reflux, which occurs when the little valve at the base of the esophagus opens when it’s not supposed to, and what you recently ate (including stomach acid) sloshes its way into the esophagus.
“Acid itself is not the problem,” says Dr. Gabbard. It’s what breaks down your food in your stomach—but it is supposed to stay there, not travel up into your esophagus. “Acid in the esophagus can cause ulcers, a narrowing of the esophagus, and rarely, esophageal cancer,” he says. Gastroesophageal reflux disease (GERD) is a chronic form of acid reflux, in which the burning feeling occurs two or more times a week, along with other symptoms like difficulty swallowing, regurgitation of liquid or food, a lingering cough, and more. That said, some patients with acid reflux may not even feel it.
However, not everything that feels like heartburn is due to acid. It could also be functional esophageal pain, pain in the nerves of the esophagus, or an esophageal spasm, although that is less likely, says Dr. Gabbard.
Functional nerve pain can feel like heartburn, but has nothing to do with reflux (which is why meds for acid reflux likely won’t help). It flares when the nerves of the esophagus are triggered for any number of reasons, including anxiety or even something you ate. “We hear all the time that things like coffee are acidic, but when they’ve studied it, it didn’t seem to cause more acid in the esophagus,” he says. A more likely explanation, he says, is that in patients with a sensitive esophagus, the nerves get triggered by stimulating foods and beverages, such as hot peppers. “So spicy foods that contain capsaicin will activate the nerves—it causes pain, but it has nothing to do with acid.”
❗What to do about it: After a heart issue is ruled out, if your doctor suspects it’s a gastro issue, you’ll want to try lifestyle tweaks. This includes avoiding the foods that bring it on and wearing looser clothing around your middle to prevent acid from escaping your stomach. Your doc may give you a prescription-strength acid-reducing medication, such as an H2 blocker (like Pepcid) or a proton pump inhibitor (like Nexium or Prevacid), to see if that helps reduce symptoms. If it doesn’t, they might consider measuring the pH (acid level) in your lower esophagus or doing a procedure called an endoscopy, in which a long, thin tube is inserted down your throat, to see what’s going on.
If acid isn’t the culprit—say, due to diet factors, weight, pregnancy, or a hiatal hernia—it’s could be functional nerve pain, which has no standard treatment. The doctor may suggest a low dose of the antidepressant amitriptyline, which helps modulate the nerves of the esophagus and GI tract.
When a patient complaining of chest pain that is not secondary to a heart issue shows up in his office, Dr. Dasgupta is all about the “P” words, the first being “pleuritic.” The pleura is the membrane that surrounds the lungs and lines the thorax (which lies between the neck and abdomen), and it can become inflamed or irritated. “Pleuritic pain is a medical term that describes the kind of pain that’s exacerbated by breathing, coughing, or sneezing,” he says. It can feel like a burning sensation, but is usually sharp and intense, especially when you try to take a deep breath.
While a bunch of conditions can cause pleuritic pain, two biggies to look out for are a pulmonary embolism (PE) and pneumonia, which are top of doctors’ minds as severe complications of COVID-19.
A PE is a blood clot—perhaps a deep vein thrombosis, or DVT, which often originates in your legs above the knee—that travels up to your lung. “When we talk about COVID-19, we know it can cause clotting anywhere in the body,” says Dr. Dasgupta. A PE will also cause trouble with your oxygen levels, and depending on the size of the blood clot, possibly a drop in your blood pressure or a fainting episode.
Pneumonia is a common and serious side effect of COVID-19, and even in non-pandemic times, is a big reason people are admitted to the hospital worldwide. Pneumonia is an infection in the air sacs of your lungs that impedes the delivery of oxygen to the rest of your body, and can be caused by a variety of microorganisms such as bacteria, fungus, parasites, or a virus.
❗What to do about it: Depending on what’s causing your pleuritic pain, your doctor may put you on blood thinners (if they suspect a clot), antibiotics if it’s a bacterial pneumonia, and consider additional tests to rule out any other problems with your pleura. Either way, it’s not something to ignore.
Around a quarter of the people who show up at the ER with chest pain have a panic disorder, but they’re almost never diagnosed, says Reid Wilson, Ph.D., a licensed psychologist who directs the Anxiety Disorders Treatment Center in Chapel Hill and Durham, NC, and the director of Anxieties.com, a self-help educational site for people with anxiety conditions. That’s in part because physical causes need to be ruled out first. “I suspect some percentage of this is that you don’t want to start talking to a pain patient as if it’s all in their head,” says Wilson.
That’s understandable, because even if there’s no condition doctors can point to that is causing the chest to hurt, the pain is very real, and doctors don’t want to appear dismissive. Psychogenic chest pain is associated with panic disorder (which can include panic attacks), a specific phobia, or illness-related anxiety disorder (formerly called hypochondria), says Wilson.
And even though the pain may not have a structural cause, it doesn’t mean nothing physical is going on. If you’ve ever felt severe anxiety, you know that your breathing becomes shallow, your heart rate goes up, and you may start to sweat. When the anxiety escalates, “you can get in a vicious cycle physiologically—if you have it enough, there’s continued tension and there can be some changes in blood flow, then that can secrete substances that are pain inducing, and then that increases fear,” says Wilson.
Some people—especially those who have previously had angina due to heart disease—might have an anxiety sensitivity in the chest area. So, when they feel anxious they may focus on their chest, which increases the fear that they are having an actual heart issue, which ramps it up some more.
❗What to do about it: Once physical causes of the chest pain are ruled out, a lot of getting better is trusting that anxiety is, in fact, the cause, and being treated for that. “Until then, we’re trapped,” says Wilson. Many patients, convinced there is something physically wrong, spend a lot of time bouncing from doctor to doctor, and their belief that there’s something that hasn’t been uncovered grows worse. “They think, Why would I go down the path as treating this as psychological issue, and miss the moment when it’s actually a heart attack?”
Once you accept that some form of anxiety is causing your chest pain, slow, gradual exposure to the thing that seems to trigger the pain (walking on a treadmill, for instance) can teach you that you can tolerate it, reducing the anxiety. Working with a psychologist can also teach you a handful of steps to help you consciously redirect your attention when you feel the chest pain. This will dial down the physical anxiety reaction, and hence the pain. It takes practice, but it works.
Bottom line: It’s often tricky for doctors to diagnose the cause of chest pain.
Your chest can hurt for a variety of reasons beyond a problem with you heart, says Dr. Dasgupta, but it’s important to seek immediate medical attention to rule out anything life-threatening.
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