Chest pain can arise from the heart, lungs, oesophagus, muscles, ribs, nerves, skin or other structures and ranges from harmless to immediately life-threatening. Common non-cardiac causes include muscle strain, costochondral inflammation, indigestion or gastro-oesophageal reflux, anxiety and respiratory infections. More serious causes include heart attack, angina, pulmonary embolism, aortic disease, pneumothorax and severe pneumonia. NHS guidance emphasises that most chest pain is not caused by a heart problem, but chest pain cannot safely be classified as benign based solely on how it feels. Sudden, persistent or severe symptoms, especially when accompanied by breathlessness, sweating, nausea, light-headedness or pain spreading to the arm, jaw, back or stomach, require emergency assessment.
Cardiac chest pain commonly results from inadequate blood flow to heart muscle. In angina, narrowed coronary arteries restrict blood flow during exertion or other demand, producing pressure, tightness or discomfort that often improves with rest. A heart attack occurs when blood supply to part of the heart becomes critically interrupted, usually because a coronary artery is blocked by a blood clot forming over a ruptured atherosclerotic plaque.
Symptoms may include pressure or squeezing, burning or indigestion-like discomfort, and pain can radiate to either arm, the neck, jaw, stomach or back. Associated sweating, nausea, breathlessness or light-headedness increase concern. Not every heart attack produces classic severe central chest pain, which is why atypical presentations must also be taken seriously.
Pulmonary causes can also produce chest pain. A pulmonary embolism occurs when a blood clot blocks a blood vessel in the lungs and can be life-threatening. Typical features include sudden breathlessness, chest pain that may worsen during inspiration and coughing up blood; a deep-vein thrombosis may cause pain, redness or swelling in one leg. Pneumonia or pleurisy can cause pain associated with breathing or coughing, while a pneumothorax can produce sudden chest pain and breathlessness when air enters the space around a lung. Because several pulmonary conditions can have overlapping symptoms, sudden chest pain accompanied by breathing difficulty should not be assumed to be muscular or anxiety-related without appropriate assessment.
Musculoskeletal chest pain is another common category. Strained chest-wall muscles, injuries to the ribs and inflammation where ribs join the breastbone can produce pain that changes with movement, posture, breathing or pressure over the affected area. Such pain may be sharp or aching and can follow exercise, coughing or physical injury. Although reproducible tenderness can support a chest-wall explanation, it does not by itself exclude serious disease. Chest pain may also arise from the oesophagus through acid reflux or oesophageal spasm, producing burning discomfort that can resemble cardiac pain. Distinguishing these causes requires considering the full symptom pattern and, where appropriate, examination and testing rather than relying on one feature.
Gastro-oesophageal reflux can cause a burning sensation behind the breastbone, particularly after meals or when lying down, and may be accompanied by a sour taste or regurgitation. Anxiety and panic attacks can cause chest tightness, rapid heartbeat, breathlessness, dizziness and tingling and can feel physically intense. However, psychological or gastrointestinal explanations should not automatically be assigned to new chest pain before dangerous cardiac and pulmonary causes have been considered, especially when symptoms are sudden, persistent or associated with cardiovascular risk factors. The fact that anxiety can produce genuine physical chest symptoms does not mean that all chest pain occurring during anxiety is caused by anxiety.
Less common but important causes include inflammation of the sac surrounding the heart, inflammation of the heart muscle, aortic dissection and serious infection. Pericarditis can produce sharp pain that may change with breathing or position, whereas aortic dissection can cause abrupt severe chest or upper-back pain and requires immediate emergency treatment. Chest pain may also occur with shingles, sometimes before the skin rash appears. The wide anatomical range of possible sources explains why chest pain cannot be diagnosed from a single symptom descriptor. Clinicians may use examination, electrocardiography, blood tests, chest imaging and other investigations depending on the suspected cause.
Chest-pain assessment focuses on onset, duration, location, quality, radiation, triggers, relieving factors and associated symptoms. Exertional pressure raises concern for coronary disease, while pain strongly linked to breathing can suggest a pleural or pulmonary process, and pain linked to meals may suggest an oesophageal cause, although these are patterns rather than definitive tests. Risk factors such as smoking, diabetes, high blood pressure, high cholesterol, previous cardiovascular disease and a family history can change the probability of cardiac disease. A person's age and medical history also matter. Importantly, symptom severity alone cannot reliably distinguish dangerous from benign chest pain.
Sudden chest pain that does not go away, particularly if it feels like pressure, squeezing, burning or indigestion, or spreads to an arm, neck, jaw, stomach or back, warrants calling 999, especially when accompanied by sweating, nausea, light-headedness or shortness of breath. Severe breathing difficulty, fainting or rapid heartbeat with chest or upper-back pain can also indicate pulmonary embolism or another emergency. Chest pain that comes and goes or resolves quickly but remains concerning should still receive medical advice. The key principle is that potentially life-threatening causes must be excluded before assuming that chest pain is musculoskeletal, gastrointestinal or psychological.
