Chest pain is one of the most common reasons people seek medical attention, and understandably so. It can be alarming. The chest is home to the heart, lungs, major blood vessels, and many muscles and nerves, so discomfort in this area often raises concern about a possible heart problem. While some cases do relate to the heart, many others are caused by non cardiac conditions such as muscle strain, inflammation of the chest wall (costochondritis), acid reflux, or even heightened stress and anxiety.
As a cardiologist, I regularly see patients referred for chest pain, and one of the most important parts of my role is to help clarify what is, and what is not, coming from the heart. In this article, we explore the many potential causes of chest pain, how they are evaluated, and what symptoms should prompt closer attention. Whether the cause is cardiac or not, understanding the source of the pain can offer both reassurance and the opportunity for targeted treatment.
If you are currently experiencing ongoing or severe chest discomfort, or feel unwell, it is important to seek medical advice without delay.
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Cardiac Causes of Chest Pain
One of the most recognised heart-related causes of chest pain is angina. This occurs when the heart muscle temporarily does not receive enough oxygen-rich blood, usually due to narrowing in the coronary arteries. These arteries can become narrowed by fatty deposits known as plaques that gradually build up along the vessel walls.
When the heart’s demand for oxygen increases — for example, during exercise, stress, or cold weather — the restricted blood flow can lead to symptoms. People often describe angina as a sensation of pressure, tightness, squeezing, or burning in the chest. It can also spread to the shoulders, arms, neck, jaw, or back.
There are two main types of angina:
- Stable angina: Brought on by exertion or stress and relieved by rest or medication.
- Unstable angina: Occurs unpredictably, including at rest, and may indicate a higher risk of heart attack.
Recognising and treating angina early is vital, as it is a sign of underlying coronary artery disease.
Fatty plaque deposits narrowing a coronary artery, reducing oxygen-rich blood flow to the heart muscle. This reduction can result in the chest pain known as angina.
Heart Attack (Myocardial Infarction)
A heart attack occurs when blood flow to a part of the heart is suddenly blocked, usually by a clot forming over a ruptured plaque. Without blood supply, the affected part of the heart muscle begins to suffer damage.
Symptoms of a heart attack may include:
- Crushing or heavy chest pain
- Shortness of breath
- Nausea or cold sweats
- Pain radiating to the arm, jaw, or back
- Feeling faint or unusually fatigued
Not all heart attacks present in a textbook way. Women, older adults, and people with diabetes may experience less typical symptoms such as breathlessness, fatigue, or indigestion-like discomfort. Seeking help early can save heart muscle and lives.
Video showing how a blood clot can block a narrowed coronary artery, cutting off blood flow to part of the heart.
Aortic Dissection
This rare but life-threatening condition occurs when the inner layer of the aorta tears, allowing blood to flow between the layers of the vessel wall. The result is a splitting or dissection of the vessel, which may rupture.
Pain is typically described as sudden, severe, and tearing, often radiating from the chest to the back. Other signs include fainting, shortness of breath, or signs of shock. Emergency treatment is essential.
Pericarditis
Pericarditis refers to inflammation of the pericardium — the protective sac around the heart. It can develop after viral infections, autoimmune disease, or even heart surgery.
The chest pain of pericarditis is sharp, worsens with deep breathing or lying flat, and may improve when sitting up or leaning forward. Anti-inflammatory medications are often used for treatment.
Comparison between a healthy and inflamed pericardium. Inflammation can cause sharp, positional chest pain and irritation around the heart.
Myocarditis
Myocarditis refers to inflammation of the heart muscle, known as the myocardium. This condition can impair the heart’s ability to pump blood effectively and may lead to a range of symptoms depending on its severity. It is most commonly caused by viral infections, such as enteroviruses, adenoviruses, or influenza. More recently, myocarditis has also been associated with COVID-19 infection. In rare instances, cases have been reported following mRNA COVID-19 vaccination, typically in younger males, though these are usually mild and resolve with supportive care.
Symptoms can vary widely. Some people may have only mild symptoms or none at all, while others may experience chest pain, palpitations, fatigue, shortness of breath, or swelling in the legs. In more severe cases, myocarditis can lead to abnormal heart rhythms (arrhythmias), reduced heart function, or even heart failure.
Diagnosis often involves a combination of tests, including an electrocardiogram (ECG), blood tests for cardiac enzymes and markers of inflammation, echocardiography to assess heart function, and sometimes cardiac MRI to detect inflammation or scarring in the heart muscle. In selected cases, a biopsy may be needed to confirm the diagnosis.
Treatment depends on the underlying cause and the severity of the condition. Mild cases may improve with rest and supportive care alone. Others may require medications to reduce inflammation, control arrhythmias, or support heart function. In some cases, immunosuppressive therapy or hospital admission may be necessary. Most people recover well, but ongoing follow up with a cardiologist is often advised to monitor heart health over time.
Non Cardiac Causes of Chest Pain
Many cases of chest pain have nothing to do with the heart. Some common non-cardiac causes include:
- Musculoskeletal: Costochondritis (inflammation of the rib joints), strained chest muscles, or rib fractures. Pain is often sharp and worsens with movement or pressing on the area.
- Gastrointestinal: Acid reflux or oesophageal spasm can mimic cardiac chest pain. Symptoms may include a burning sensation or sour taste in the mouth.
- Respiratory: Infections (such as pneumonia or pleurisy), pulmonary embolism, or a collapsed lung can cause sharp, pleuritic chest pain worsened by breathing.
- Neurological: Shingles may cause a band-like burning chest pain before a rash appears.
- Psychological: Anxiety or panic attacks can cause chest tightness, racing heart, and breathlessness.
As a cardiologist, I am often referred patients for assessment of chest pain, and in many cases, the cause is not cardiac. Rather, the discomfort stems from other contributing factors. It is important to remember that the chest contains a number of vital structures, not just the heart, but also the lungs, ribs, intercostal muscles, nerves, and the upper digestive tract. Gastric conditions such as acid reflux or oesophageal spasm can closely mimic heart related pain. Chest pain can also be referred from musculoskeletal issues, including problems affecting the shoulder, upper back, or cervical spine. Understanding this wide range of potential causes helps explain why chest pain is so common and why careful evaluation is essential to determine its true origin.
How Chest Pain Is Assessed
When someone presents with chest pain, the first and most important step is to take a careful history. Your healthcare team will ask about the nature of the pain, when it started, where it is felt, whether it radiates to other areas, what brings it on, and what relieves it. Associated symptoms such as breathlessness, dizziness, nausea, or palpitations also help guide the assessment. Your medical history, medications, and risk factors such as high blood pressure, diabetes, or smoking are all taken into account. A physical examination is then performed to check the heart, lungs, and chest wall for any signs that might point to a specific cause.
From there, a range of tests may be used to investigate further. These tests are chosen based on your individual presentation and may include an ECG, blood tests for markers of heart strain or injury, and imaging such as chest X-rays or scans. In some cases, additional assessments like stress testing or endoscopy may be needed to rule out less common causes. The goal is to gather enough information to make a clear and accurate diagnosis so that the appropriate care can be provided.
To recap, some of the common investigations your healthcare professional may arrange for you include:
- Electrocardiogram (ECG): To detect abnormal rhythms or signs of heart damage
- Blood tests: Including troponin, a marker of heart injury
- Chest imaging: X-rays, CT scans, or MRIs to examine the lungs, heart, and vessels
- Stress testing: To assess blood flow to the heart during exertion
- Endoscopy: May be recommended if gastrointestinal causes are suspected
Conclusion
Chest pain is a common but often complex symptom. It can arise from a range of causes, some of which are minor and self limiting, while others may involve the heart, lungs, or digestive system. Understanding the possible sources of chest pain is the first step in making sense of what your body may be trying to tell you.
Not all chest pain feels the same, and it does not always present in predictable ways. What may seem mild or vague can still be important. This is why any new, unexplained, or persistent chest discomfort should be taken seriously. If symptoms are severe, last more than a few minutes, or come with breathlessness, nausea, dizziness, or discomfort in other areas, it is important to seek medical advice.
Even when the cause is not related to the heart, finding out what is behind your symptoms can offer peace of mind and ensure you receive the right care. Prompt assessment can help guide the next steps and support your overall health and wellbeing.
Peter is an interventional cardiologist and the Founding Editor of Heart Matters, a trusted resource for heart health education. With more than 20 years of clinical experience, he is dedicated to making cardiovascular care more understandable and accessible. His work bridges patient care, research, and public education, empowering individuals to take control of their heart health. Professor Barlis is internationally recognised for his contributions to cardiology, with numerous publications and speaking engagements around the world.
