Chest Pain
Chest pain can originate from cardiac, gastrointestinal, pulmonary, musculoskeletal, or psychological causes. Proper evaluation is essential to determine the underlying cause and appropriate treatment. Some chest pain requires emergency care.
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What Causes Chest Pain?
Chest pain can originate from multiple systems within and around the chest. While many people fear cardiac causes, only 15-20% of chest pain presentations are cardiac in nature. However, cardiac causes must always be ruled out first because they can be life-threatening.
Chest pain can result from cardiac, gastrointestinal, pulmonary, musculoskeletal, psychiatric, or other causes. The location, character, duration, associated symptoms, and triggers help identify the cause. Proper evaluation is essential to differentiate between serious and benign causes.
At MyDoc Urgent Care, we provide rapid evaluation with ECG and cardiac biomarkers to rule out acute coronary syndrome. This rapid assessment allows us to identify serious causes and provide appropriate treatment or referral to emergency care.
Typical Symptoms
Sharp, stabbing chest pain
Dull, aching chest discomfort
Tightness or pressure in chest
Burning sensation in chest
Squeezing sensation in chest
Pain radiating to left arm
Pain radiating to jaw or neck
Pain between shoulder blades
Shortness of breath with chest pain
Nausea or vomiting
Sweating or cold sweats
Dizziness or lightheadedness
Types of Chest Pain by Cause
Chest pain is categorized by the underlying system involved. Understanding the category helps guide evaluation and treatment.
Cardiac (Heart-Related)
Prevalence: 15-20% of chest pain presentations
Common Causes: Acute coronary syndrome, angina, myocardial infarction, arrhythmias
Characteristics: Central chest pain; may radiate to arms, jaw, neck
Associated Symptoms: Dyspnea, diaphoresis, nausea, syncope
Typical Onset: Sudden or gradual; may worsen with exertion
Critical - requires emergency evaluation
Gastrointestinal
Prevalence: 30-40% of chest pain presentations
Common Causes: GERD, esophageal spasm, peptic ulcer disease, esophagitis
Characteristics: Burning sensation; epigastric or substernal
Associated Symptoms: Dysphagia, regurgitation, bloating, abdominal pain
Typical Onset: Often after meals or when lying down
Low to moderate - rarely emergent
Pulmonary (Lung-Related)
Prevalence: 10-15% of chest pain presentations
Common Causes: Pneumonia, pulmonary embolism, pneumothorax, pleuritis, asthma
Characteristics: Pleuritic (worse with breathing); usually unilateral
Associated Symptoms: Cough, dyspnea, fever, hemoptysis, hypoxia
Typical Onset: Variable; may be acute or gradual
Moderate to critical - depends on cause
Musculoskeletal
Prevalence: 20-30% of chest pain presentations
Common Causes: Costochondritis, muscle strain, rib fracture, nerve irritation
Characteristics: Reproducible with palpation; sharp; localized
Associated Symptoms: Localized tenderness, pain with movement, bruising
Typical Onset: Often after trauma, repetitive activity, or lifting
Low - rarely emergent
Psychiatric/Anxiety
Prevalence: 10-15% of chest pain presentations
Common Causes: Panic attack, anxiety disorder, depression, somatization
Characteristics: Sharp, localized; variable location
Associated Symptoms: Palpitations, hyperventilation, tremor, fear, dizziness
Typical Onset: Often during stress or anxiety episode
Low - but always requires cardiac evaluation first
Other Causes
Prevalence: 5-10% of chest pain presentations
Common Causes: Herpes zoster, breast pain, referred pain from abdomen/spine
Characteristics: Depends on underlying cause
Associated Symptoms: Skin changes (zoster), localized tenderness, radiation
Typical Onset: Variable
Low to moderate - depends on cause
Cardiac Causes of Chest Pain
Cardiac causes include acute coronary syndromes (MI), angina, arrhythmias, myocarditis, pericarditis, and aortic dissection. These require urgent evaluation and treatment.
Acute Coronary Syndrome (ACS)
Subtypes: Unstable angina, NSTEMI, STEMI
Prevalence: Leading cause of cardiac chest pain; affects millions annually
Typical Presentation: Central, crushing chest pressure; radiation to arm/jaw/back
Associated Symptoms: Dyspnea, diaphoresis, nausea, anxiety, syncope
Risk Factors: Age >40, male sex, smoking, diabetes, hypertension, hyperlipidemia, family history, sedentary lifestyle
Treatment: Aspirin, antiplatelet agents, anticoagulation, revascularization (PCI/CABG)
Yes - Call 911 immediately
Stable Angina
Subtypes: Chronic stable angina pectoris
Prevalence: Affects 1-2% of population
Typical Presentation: Predictable chest pressure/discomfort with exertion; relieved by rest/nitrates
Associated Symptoms: Dyspnea, fatigue, arm pain, jaw pain
Risk Factors: Same as ACS but more chronic presentation
Treatment: Nitrates, beta-blockers, calcium channel blockers, statins, aspirin
Usually not; but persistent/worsening angina requires urgent care
Pericarditis
Subtypes: Acute, recurrent, constrictive pericarditis
Prevalence: Rare; 5-10 cases per 100,000 per year
Typical Presentation: Sharp, pleuritic chest pain; worse with lying down, deep breathing; better with sitting forward
Associated Symptoms: Friction rub on auscultation, dyspnea, fever, malaise
Risk Factors: Viral infection, autoimmune disease, trauma, uremia, malignancy, post-MI
Treatment: NSAIDs, colchicine, corticosteroids; drain if effusion/tamponade
Yes if tamponade or constrictive features present
Arrhythmia
Subtypes: Atrial fibrillation, SVT, ventricular arrhythmias
Prevalence: Affects 1-2% of population; increases with age
Typical Presentation: Chest discomfort, palpitations, syncope, dyspnea
Associated Symptoms: Palpitations, irregular heartbeat, syncope, hypotension
Risk Factors: Age, hypertension, heart disease, thyroid disease, electrolyte abnormalities
Treatment: Depends on type: rate control, rhythm control, or anticoagulation
Yes if rapid rate, hemodynamic instability, or syncope
Myocarditis
Subtypes: Viral, bacterial, autoimmune myocarditis
Prevalence: Rare; 1-10 cases per 100,000 per year
Typical Presentation: Chest pain, dyspnea, fever, malaise; may mimic MI
Associated Symptoms: Fever, viral prodrome, arrhythmias, hemodynamic compromise
Risk Factors: Recent viral infection, autoimmune disease, toxin exposure
Treatment: Supportive care, NSAIDs, ACE inhibitors, immunosuppression if severe
Yes if hemodynamic instability or arrhythmias
Aortic Dissection
Subtypes: Type A (ascending), Type B (descending)
Prevalence: Rare; 5-30 cases per 1 million per year
Typical Presentation: Sudden, severe, tearing chest/back pain; 'worst pain of life'
Associated Symptoms: Severe hypertension, syncope, neurologic deficits, hypotension
Risk Factors: Hypertension, connective tissue disease, cocaine use, trauma
Treatment: Type A: emergency surgery; Type B: medical management typically
Yes - Immediate emergency, life-threatening
Gastrointestinal Causes
GI causes account for 30-40% of chest pain. These include GERD, esophageal spasm, peptic ulcer disease, and esophagitis. Usually non-life-threatening but can cause severe symptoms.
Gastroesophageal Reflux Disease (GERD)
Prevalence: Affects 20% of population regularly
Typical Presentation: Burning sensation behind breastbone; worse after meals or lying down
Associated Symptoms: Regurgitation, dysphagia, bloating, belching, hoarseness
Risk Factors: Obesity, pregnancy, smoking, alcohol, large meals, caffeine, fatty foods
Treatment: Lifestyle modifications, antacids, H2 blockers, PPIs
Esophageal Spasm
Prevalence: Rare; affects <1% of population
Typical Presentation: Severe chest pain; feels like cardiac pain; may have dysphagia
Associated Symptoms: Dysphagia, food sticking sensation
Risk Factors: Stress, anxiety, hot/cold foods, GERD history
Treatment: Nitrates, calcium channel blockers, anticholinergics, botulinum toxin
Peptic Ulcer Disease
Prevalence: Affects 4-5% of population
Typical Presentation: Epigastric or substernal burning pain; variable relationship to meals
Associated Symptoms: Nausea, vomiting, hemoptysis (if bleeding), weight loss
Risk Factors: H. pylori infection, NSAIDs, smoking, stress, alcohol
Treatment: PPIs, H. pylori eradication, avoid NSAIDs
Esophagitis
Prevalence: Varies; depends on underlying cause
Typical Presentation: Severe burning chest pain with dysphagia, odynophagia
Associated Symptoms: Fever (if infectious), dysphagia, regurgitation
Risk Factors: GERD, immunosuppression, radiation therapy, caustic ingestion
Treatment: PPIs, antiinfectives if needed, address underlying cause
Pulmonary Causes
Pulmonary causes account for 10-15% of chest pain. These include PE, pneumonia, pneumothorax, and pleuritis. Some causes require emergency intervention.
Pulmonary Embolism (PE)
Prevalence: Affects 60-100 per 100,000 per year
Typical Presentation: Acute dyspnea, pleuritic chest pain, tachycardia, tachypnea
Associated Symptoms: Syncope, hemodynamic instability, hypoxia, signs of DVT
Risk Factors: Immobility, surgery, malignancy, hypercoagulability, oral contraceptives, pregnancy
Yes - Call 911 immediately
Pneumonia
Prevalence: Affects 1-2% of population annually
Typical Presentation: Productive cough, fever, dyspnea, pleuritic chest pain
Associated Symptoms: Fever, chills, myalgias, fatigue, hemoptysis
Risk Factors: Age, smoking, COPD, immunosuppression, aspiration
Yes if severe (sepsis, hypoxia, hemodynamic instability)
Spontaneous Pneumothorax
Prevalence: Affects 18-28 per 100,000 per year
Typical Presentation: Acute unilateral chest pain, dyspnea, tachycardia
Associated Symptoms: Decreased breath sounds on affected side, hypoxia, hemodynamic instability if tension
Risk Factors: Tall lean males, COPD, connective tissue disease, smoking
Yes if tension pneumothorax or hemodynamic instability
Pleuritis/Pleurisy
Prevalence: Variable; depends on underlying cause
Typical Presentation: Sharp, pleuritic chest pain worse with deep breathing; dry cough
Associated Symptoms: Fever, cough, may have friction rub
Risk Factors: Viral infection, SLE, rheumatoid arthritis, pulmonary infarction
No unless complications
Musculoskeletal Causes
Musculoskeletal causes account for 20-30% of chest pain. These include costochondritis, muscle strain, rib fractures, and thoracic outlet syndrome. Usually non-life-threatening and reproducible with palpation.
Costochondritis
Prevalence: Affects 4% of population; common cause of chest wall pain
Typical Presentation: Sharp, reproducible chest wall pain; worse with movement or palpation
Associated Symptoms: Localized swelling, tenderness, pain with deep breathing
Risk Factors: Repetitive activities, trauma, poor posture, fibromyalgia
Treatment: NSAIDs, ice, rest, physical therapy, local injections if severe
Muscle Strain
Prevalence: Common; especially with heavy lifting or trauma
Typical Presentation: Sharp, localized pain; worse with movement
Associated Symptoms: Localized tenderness, bruising, weakness
Risk Factors: Heavy lifting, repetitive activities, poor form, sedentary individuals
Treatment: Rest, ice, NSAIDs, physical therapy, gradual return to activity
Rib Fracture
Prevalence: Common with trauma; ribs 4-8 most common
Typical Presentation: Sharp, severe pain; worse with breathing or movement
Associated Symptoms: Bruising, localized tenderness, splinting, shallow breathing
Risk Factors: Trauma, falls, severe coughing, osteoporosis
Treatment: Analgesia, breathing exercises, possible rib belt, treatment of pneumothorax if present
Thoracic Outlet Syndrome
Prevalence: Rare; affects <1% of population
Typical Presentation: Chest/shoulder/arm pain; worse with certain arm positions
Associated Symptoms: Arm pain, paresthesias, weakness, swelling
Risk Factors: Repetitive overhead activities, trauma, anatomical variants
Treatment: Physical therapy, ergonomics, possible surgical decompression
Risk Factors for Cardiac Chest Pain
Understanding risk factors helps identify those at higher risk for cardiac causes of chest pain. Multiple risk factors increase risk exponentially.
Age
Risk increases with age; males at higher risk <40; females catch up after menopause
Male Sex
Men have higher risk of cardiac causes before age 60; hormonal protection in women until menopause
Smoking
Significantly increases risk of MI, aortic dissection, and COPD-related causes
Hypertension
Major risk factor for MI and aortic dissection; increases cardiac workload
High Cholesterol
Accelerates atherosclerosis; increases MI risk
Diabetes
Diabetes patients at 2-4x higher risk of MI; may have atypical presentation
Obesity
Increases cardiovascular disease risk and GERD symptoms
Sedentary Lifestyle
Increases cardiovascular disease risk; improves with exercise
Family History
Strong predictor of premature MI; genetic factors important
Substance Abuse
Cocaine, amphetamines increase MI risk and cause arrhythmias
Oral Contraceptives
Slightly increase venous thromboembolism risk
Connective Tissue Disease
Increased risk of aortic dissection and myocarditis
Diagnostic Tests for Chest Pain
Multiple diagnostic tests help identify the cause of chest pain. The choice of tests depends on the clinical presentation and suspected cause.
12-Lead ECG
Purpose: First-line test for cardiac chest pain; detects acute MI, ischemia, arrhythmias
Time to Results: Immediate
Urgency: Immediate (should be done within 10 minutes of arrival)
Limitations: Can be normal in early MI or in non-cardiac chest pain
Cardiac Troponins
Purpose: Detect myocardial necrosis; elevated in MI
Time to Results: 30 minutes to 3 hours (high-sensitivity troponin faster)
Urgency: High priority; serial measurements improve sensitivity
Limitations: May be elevated in other conditions (PE, sepsis, heart failure, renal disease)
Chest X-Ray
Purpose: Detect pneumonia, pneumothorax, heart failure, aortic pathology
Time to Results: 10-15 minutes
Urgency: Moderate; within 30 minutes for chest pain
Limitations: May be normal in early MI, PE, or early pneumonia
CT Angiography (CTA) Chest
Purpose: Detect PE, aortic dissection, pneumonia
Time to Results: 15-30 minutes
Urgency: High for suspected PE or dissection
Limitations: Radiation exposure, contrast allergies possible, may not detect small PE
Echocardiography
Purpose: Assess cardiac structure/function; detect effusion, wall motion abnormalities
Time to Results: 30 minutes to 2 hours
Urgency: Moderate to high depending on presentation
Limitations: Limited by body habitus, cannot fully rule out ACS
Stress Test
Purpose: Assess for inducible ischemia; cannot do acutely
Time to Results: 1-2 hours
Urgency: Low; done after acute event ruled out
Limitations: Cannot interpret if abnormal baseline ECG; less accurate in women; cannot do if active chest pain
Coronary Angiography
Purpose: Gold standard for coronary disease; allows intervention
Time to Results: Depends on availability; ideally within 60 minutes for STEMI
Urgency: High if STEMI or high-risk NSTEMI
Limitations: Invasive procedure; carries small risk of stroke, MI, arrhythmia
D-Dimer
Purpose: Screening test for VTE; highly sensitive but not specific
Time to Results: 30 minutes
Urgency: High if PE suspected
Limitations: Very non-specific; positive in many conditions; not useful if high clinical suspicion
Upper Endoscopy (EGD)
Purpose: Visualize esophagus, stomach, duodenum; diagnose GI causes
Time to Results: Variable; procedure time 10-15 minutes
Urgency: Low; not done in acute setting unless bleeding
Limitations: Invasive; risk of perforation, bleeding
Treatment Options
Treatment of chest pain depends entirely on the underlying cause. Proper diagnosis is essential for appropriate treatment. Treatment ranges from reassurance for benign causes to emergency interventions for life-threatening causes.
Aspirin
Category: Cardiac Chest Pain
Indication: Acute coronary syndrome or suspected MI
Dosing: 325-500 mg orally or 250-500 mg IV
Effectiveness: 20-25% reduction in mortality in ACS
Contraindicated if active bleeding or severe thrombocytopenia
Nitroglycerin
Category: Cardiac Chest Pain
Indication: Acute coronary syndrome, angina
Dosing: 0.3-0.6 mg sublingual; repeat every 5 minutes x 3
Effectiveness: Rapid relief in 1-5 minutes for angina; variable in MI
Do not use with phosphodiesterase inhibitors (ED drugs)
Morphine
Category: Cardiac Chest Pain
Indication: Severe chest pain unresponsive to nitroglycerin
Dosing: 2-4 mg IV, repeat every 5-15 minutes
Effectiveness: Rapid pain relief; reduces myocardial oxygen demand
Use cautiously in hypotension or respiratory compromise
Heparin/Anticoagulation
Category: Cardiac Chest Pain
Indication: Acute coronary syndrome, PE, DVT
Dosing: Variable; usually 5,000-10,000 unit bolus, then infusion
Effectiveness: Reduces mortality and recurrent events
Requires monitoring of aPTT; transition to other anticoagulants
Percutaneous Coronary Intervention (PCI)
Category: Cardiac Chest Pain
Indication: STEMI, high-risk NSTEMI, unstable angina
Dosing: Single procedure
Effectiveness: Restores coronary blood flow; reduces mortality
Preferred over thrombolytics for STEMI when available
Proton Pump Inhibitor (PPI)
Category: Gastrointestinal
Indication: GERD, peptic ulcer disease, esophagitis
Dosing: Omeprazole 20-40 mg daily; other PPIs available
Effectiveness: Highly effective for acid-related diseases
Continue for 4-8 weeks minimum for PUD
Antacid
Category: Gastrointestinal
Indication: Acute heartburn, mild GERD
Dosing: Variable; as needed
Effectiveness: Quick relief of symptoms
Short-acting; not for chronic treatment
H2 Receptor Blocker
Category: Gastrointestinal
Indication: GERD, peptic ulcer disease
Dosing: Famotidine 20 mg BID; others available
Effectiveness: Effective but less so than PPIs
Less effective than PPIs for severe disease
Thrombolytic Therapy
Category: Pulmonary
Indication: PE with hemodynamic instability
Dosing: tPA 100 mg IV over 2 hours
Effectiveness: Rapid resolution of hemodynamic instability
High risk of bleeding; reserve for massive PE
Antibiotic (Pneumonia)
Category: Pulmonary
Indication: Bacterial pneumonia
Dosing: Depends on organism; empiric coverage initially
Effectiveness: High if appropriate antibiotic
Culture-directed after initial empiric therapy
NSAIDs
Category: Musculoskeletal
Indication: Musculoskeletal chest pain, costochondritis, muscle strain
Dosing: Ibuprofen 400-600 mg TID-QID; others available
Effectiveness: Very effective for inflammatory causes
Avoid in cardiac patients or GI disease
Anxiolytic
Category: Psychiatric
Indication: Anxiety-induced chest pain, panic attacks
Dosing: Varies; benzodiazepines for acute; SSRIs for chronic
Effectiveness: Effective for anxiety-related chest pain
Always rule out cardiac causes first before treating as anxiety
Preventing Chest Pain
While not all chest pain can be prevented, many causes can be prevented through lifestyle modifications and risk factor management.
Do not smoke; quit if you smoke currently
Maintain healthy weight (BMI 18.5-24.9)
Exercise regularly (150 minutes moderate aerobic activity per week)
Maintain healthy diet (Mediterranean diet preferred); reduce saturated fat
Manage blood pressure (<130/80 mmHg)
Control blood glucose if diabetic
Manage cholesterol (LDL <100 mg/dL, ideally <70 for cardiac disease)
Limit alcohol consumption (men <2 drinks/day, women <1 drink/day)
Manage stress through exercise, meditation, counseling
Get adequate sleep (7-9 hours per night)
Take aspirin if appropriate (discuss with doctor)
Consider statins if high cardiovascular risk
Know your family history of cardiac disease
Get routine cardiac screening appropriate for your age and risk
Take medications as prescribed for hypertension, diabetes, cholesterol
What To Do If You Have Chest Pain
If you experience chest pain, take it seriously and seek medical evaluation. Do not assume it is benign without proper assessment.
If chest pain occurs: Stop activity and rest immediately
Take antacid if suspect GERD; note if pain improves
Apply ice or heat to chest wall if suspect musculoskeletal pain
Avoid triggering foods if suspect GERD (spicy, fatty, caffeine)
Use proper posture to reduce musculoskeletal strain
Practice deep breathing exercises; avoid shallow breathing
Take NSAIDs with food to reduce GI upset
Keep track of chest pain episodes: when, duration, triggers, associated symptoms
Do not ignore persistent chest pain; seek medical evaluation
Have emergency plan prepared (know how to call 911)
Keep nitroglycerin (if prescribed) easily accessible
Avoid sudden exertion or heavy lifting
Manage stress with relaxation techniques
Follow up with doctor for persistent chest pain
Do not self-diagnose; proper evaluation is essential
When to Call 911
Certain symptoms require immediate emergency evaluation. Do not hesitate to call 911 if you experience these warning signs.
Severe Chest Pain
Sudden onset severe pain; most important emergency sign
Chest Pain with Shortness of Breath
Suggests cardiac or pulmonary cause; requires immediate evaluation
Chest Pain with Diaphoresis
Cold sweats suggest acute MI; emergency sign
Chest Pain with Syncope
Fainting suggests shock from MI, PE, or aortic dissection
Chest Pain Radiating to Arm or Jaw
Classic for MI; requires emergency evaluation
Chest Pain with Blood Pressure Change
Hypertension suggests aortic dissection; hypotension suggests shock/tamponade
Tearing Chest/Back Pain
Classic for aortic dissection; medical emergency
Persistent Chest Pain >20 Minutes
Likely cardiac cause; requires urgent evaluation
Chest Pain with Palpitations
Suggests arrhythmia; requires urgent ECG and evaluation
Chest Pain with High Fever
Suggests infection (pneumonia, myocarditis, pericarditis)
Chest Pain Requires Evaluation: Never ignore chest pain. While many causes are benign, serious cardiac causes can be fatal. Proper evaluation is essential for accurate diagnosis.
Rapid Assessment is Critical: Early identification of cardiac causes and intervention dramatically improves outcomes. The first 12 hours after symptom onset are critical.
Call 911 for Emergencies: Do not hesitate to call 911 for severe symptoms. It is better to be safe than sorry with potential cardiac conditions.
At MyDoc Urgent Care, we provide rapid evaluation with ECG and cardiac biomarkers to identify the cause of your chest pain. For cardiac emergencies, call 911 immediately. For urgent evaluation, visit one of our convenient locations in Forest Hills, East Meadow, Brooklyn, Bronx, Jackson Heights, or Little Neck. We're here to serve you with expert care and fully equipped centers.