Chest pain is one of those symptoms that immediately demands attention — and rightly so. But in clinical practice, the vast majority of chest pain presentations are not from the heart. They are from the chest wall muscles, the oesophagus, the lungs, or anxiety.
The challenge is telling the difference. I am going to give you the clinical framework I use, in plain English.
The causes of chest pain — a brief overview
| Cause | How common in A&E | Typical characteristics |
|---|---|---|
| Musculoskeletal (chest wall) | Very common (~30%) | Worsens when you press on the chest, move, or breathe deeply |
| Gastrointestinal (GORD, oesophageal spasm) | Common (~20%) | Often burning, related to food or lying flat |
| Anxiety/panic | Common (~15%) | Associated with palpitations, breathlessness, dizziness |
| Cardiac (angina, heart attack) | Less common (~15%) | Pressure, tightness, spread to arm/jaw, not position-related |
| Pulmonary (PE, pneumonia) | Less common (~10%) | Often with breathlessness, cough, fever |
| Other | Remainder |
The cardiac features to take seriously
Chest pain that is most likely to be cardiac has specific features:
Character: Pressure, tightness, heaviness, squeezing. Not sharp. Not a stab. Patients often describe it as "like someone sitting on my chest" or "like a band tightening."
Location: Central or left-sided. May radiate to the left arm (classic), both arms, the jaw, the neck, or the back between the shoulder blades.
Context: Brought on by exertion (angina) or can occur at rest (heart attack). Not reproducible by pressing on the chest.
Associated symptoms: Shortness of breath, sweating, nausea, vomiting, palpitations, a feeling of doom or severe anxiety.
Risk factors: Male sex, older age, smoking, diabetes, hypertension, high cholesterol, family history of heart disease, obesity.
If pain has these features: call 999.
Case study: Samuel's two chest pain presentations
Samuel, 58, a Ghanaian-born accountant in London with hypertension and type 2 diabetes, had two chest pain episodes within six months.
First episode: Sharp pain on the left side of his chest, worse when he pressed on his ribs, present for 2 days after moving furniture. No sweating, no arm pain, no shortness of breath. I examined him — he had a clearly tender spot over his 5th rib. Diagnosis: costochondritis (inflammation of the rib cartilage). Treated with ibuprofen. Resolved in a week.
Second episode: Central chest tightness, "like pressure," came on while climbing stairs. Lasted 5 minutes and then eased. Mild sweating. No arm pain, but he felt "off." He waited two days before calling me because the first episode had "turned out to be nothing."
I immediately referred him to the emergency department. His ECG showed ST changes. Troponin was elevated. He had had a NSTEMI (a type of heart attack). He went to the catheterisation lab that night and had a stent placed in a blocked coronary artery.
He is now on appropriate secondary prevention treatment and is well. But he nearly waited another day.
The first episode was nothing serious. The second was a heart attack. Same person. Similar location. Very different character.
What causes musculoskeletal chest pain?
The most common cause of chest pain overall. Key features:
- Sharp, well-localised pain
- Clearly worse when you press on a specific spot on your chest
- Worse with certain movements, twisting, or deep breathing
- Often follows physical activity, coughing, or an injury
- Not associated with sweating, radiation, or exertion
Costochondritis (inflammation of the cartilage joining ribs to the breastbone) is a common culprit. Treatment: NSAIDs (ibuprofen), rest, heat. Usually resolves over 1–2 weeks.
Gastrointestinal chest pain
GORD (acid reflux): Burning sensation behind the breastbone, often after meals, worse lying flat, may wake you at night. Sour taste in the mouth. Often confused with cardiac pain.
Oesophageal spasm: Can mimic cardiac pain very closely — severe pressure-like chest pain. May respond to GTN (nitrate spray), adding to the confusion. Usually related to swallowing or spontaneous. Diagnosis requires investigations.
Anxiety and panic — physical symptoms are real
As I discussed in the anxiety article, panic attacks cause genuine physiological symptoms including chest tightness, racing heart, dizziness, and shortness of breath. These can be indistinguishable from cardiac symptoms subjectively.
However — and this matters — anxiety is a diagnosis of exclusion. Before attributing chest pain to anxiety, cardiac causes should be ruled out, particularly in patients with risk factors.
Do not let a doctor attribute your chest pain to anxiety without checking an ECG and troponin if you have any cardiac risk factors.
The simple decision tree
Call 999 immediately if:
- Central/left chest pressure, tightness, or squeezing
- Pain spreading to arm, jaw, or back
- Associated sweating, shortness of breath, nausea
- Sudden severe chest pain of any type
- You think it might be your heart
See your GP same-day or go to urgent care if:
- Sharp chest pain with no concerning features but persisting
- Chest pain with a cough or fever (possible pneumonia)
- Pain related to food or heartburn that is new or worsening
Book a routine GP appointment if:
- Reproducible chest wall pain after physical activity
- Typical heartburn symptoms you have had before
- Anxiety-related symptoms with no cardiac features
When in doubt: go to A&E. The cost of an unnecessary visit is inconvenience. The cost of missing a heart attack is catastrophic.
Sources: NICE Clinical Guideline CG95 — Chest Pain of Recent Onset (2010, updated 2016); British Heart Foundation chest pain guidelines; NICE NG185 — COVID-19 Rapid Guideline: Managing the Long-Term Effects (for reference on post-viral chest pain).