If you have sudden, severe, crushing or squeezing chest pain, pain that spreads to your arm, jaw, neck or back, or chest pain that comes with shortness of breath, sweating, nausea, lightheadedness or fainting, call 911 now. Do not drive yourself to the hospital and do not wait to see whether it passes. Emergency crews can begin treatment on the way, and with a heart attack every minute of delay costs heart muscle. The National Heart, Lung, and Blood Institute advises calling 911 even when you are not sure it is a heart attack.
Most chest pain that brings people to our internal medicine office is not an emergency, but it still deserves a careful answer. Pain that comes with exertion and eases with rest, a pressure that has been showing up for weeks, a sharp twinge when you breathe in, or burning after meals can each point to a different organ. The heart is the first thing we rule in or out, because heart causes are the ones that cannot be missed. After that we look just as seriously at the esophagus, the lungs, the chest wall and the nervous system.
Our goal at a chest pain visit is simple: find out whether your heart is at risk, find out what is actually causing the pain, and leave you with a plan and a clear sense of which symptoms should send you to the emergency room in the future.
Who gets chest pain and what it can mean
Chest pain affects people of every age, but the stakes rise with cardiovascular risk. High blood pressure, high cholesterol, diabetes, smoking, a family history of early heart disease, excess weight and an inactive life all raise the chance that chest discomfort is coming from narrowed coronary arteries. Women, older adults and people with diabetes are more likely to have heart symptoms that do not feel like classic crushing pain: unusual fatigue, shortness of breath, nausea, or discomfort in the back, jaw or upper abdomen.
Heart-related causes include angina, which is chest pressure brought on when narrowed arteries cannot deliver enough blood during effort or stress; heart attack; inflammation of the sac around the heart (pericarditis) or of the heart muscle itself (myocarditis); disease of the heart muscle (cardiomyopathy); valve problems; and, rarely, a tear in the wall of the aorta, called aortic dissection, which causes sudden tearing pain and is an emergency.
Many chest pains come from somewhere else. Acid reflux and esophageal spasm can mimic angina closely. Strained muscles, inflamed rib cartilage and problems in the neck or upper back cause pain that changes with movement or pressing on the chest. Lung conditions such as pneumonia, pleurisy, a collapsed lung or a blood clot in the lung cause pain that worsens with breathing, often with cough or breathlessness. Gallbladder disease, shingles and panic attacks or anxiety are also common causes. Anxiety is a diagnosis we reach only after the physical causes have been properly checked, never as a shortcut.
How we evaluate chest pain at NYMD Center
The evaluation starts with a detailed history, because the story of the pain often narrows the answer more than any test: when it started, what it feels like, what brings it on, what relieves it, how long it lasts, and what comes with it. We review your medications, your risk factors and your family history, then examine your heart, lungs, chest wall and abdomen and check your blood pressure in both arms when the history calls for it.
An ECG (EKG) is done on site at the same visit. It takes a few minutes, is painless, and can show signs of strain, rhythm problems or a prior heart attack. Blood work typically includes a blood count, kidney and liver function, blood sugar and a cholesterol panel, with other tests such as thyroid function added when the picture suggests them. If anything at the visit suggests a heart attack in progress, we send you to the emergency department rather than continue testing in the office.
When the heart remains a question, we arrange further testing by referral, chosen by what we are looking for, and review the results with you. An echocardiogram uses ultrasound to show the heart's pumping strength, wall motion, valves and the lining around the heart. An exercise or stress test shows how the heart behaves under effort, which is the question behind most exertional chest pain. An ambulatory ECG monitor worn at home captures symptoms that come and go, especially when palpitations accompany the pain. A chest x-ray, CT imaging or coronary angiography are arranged when the findings point that way.
Treatment options, least invasive first
Treatment follows the cause, and for most patients it begins with measures that carry little risk and cost nothing in recovery time.
Treating non-cardiac causes
Reflux often responds to changes in meal timing and size and to acid-reducing medication. Chest wall pain usually settles with rest, anti-inflammatory medication used carefully, heat and stretching. Lung causes are treated according to what we find, and some, such as a suspected blood clot in the lung, need same-day hospital care. When anxiety or panic is the driver, we say so plainly and help you find treatment for it.
Lifestyle and risk factor control
For patients whose pain is heart-related, or whose risk is high, the foundation is risk factor control: stopping smoking, regular activity, weight management and a heart-healthy diet. We manage high blood pressure, high cholesterol and diabetes in the office with regular follow-up. These steps take effort but carry no procedural risk, and they lower the chance of a future heart attack or stroke.
Medication
Stable angina is usually treated first with medication. Depending on your situation this may include a statin, aspirin, a beta blocker or other anti-anginal drugs, and nitroglycerin to use when pain comes on. Medications require monitoring for side effects such as fatigue, low blood pressure, bleeding or muscle aches, but they avoid the risks of a procedure.
Referral for cardiology procedures
If testing shows significant blockage, pain that does not respond to medication, or a high-risk pattern, we refer you to cardiology for further evaluation such as cardiac catheterization. Stenting or bypass surgery can relieve symptoms and in some situations lower risk, but they involve catheters or surgery, a hospital stay and a recovery period, so they are reserved for the patients who need them. We stay involved in your care before and after.
What to expect at your visit
Plan on a visit that includes a conversation, an examination, an ECG and usually a blood draw. Bring a list of your medications and any previous ECGs, stress tests or hospital records. Many patients leave the first visit with a working diagnosis and a clear next step, whether that is an echocardiogram or stress test arranged by referral, a trial of treatment for reflux or chest wall pain, or reassurance backed by normal findings. We review results with you and adjust the plan as the picture becomes clear.
When to seek care urgently
Call 911 for chest pain that is sudden, severe or crushing; that spreads to the arm, jaw, neck or back; that comes with shortness of breath, sweating, nausea, fainting or a racing irregular heartbeat; or that feels like a sudden tearing pain through to the back. Go to the emergency room for chest pain with sudden shortness of breath or coughing up blood, especially after surgery, a long trip or with a swollen leg. If you have known angina and your pain is coming more often, with less effort, or at rest, that is also an emergency and should not wait for an office appointment.
Questions patients ask
How do I know if my chest pain is a heart attack?
You often cannot tell for certain on your own. Pressure, squeezing or fullness in the chest, pain spreading to the arm, jaw, neck or back, shortness of breath, sweating, nausea or lightheadedness all raise concern. Women, older adults and people with diabetes may have milder or atypical symptoms. If you think it might be a heart attack, call 911 rather than waiting or driving yourself.
Can I be seen in the office for chest pain?
Yes, for chest pain that is not an emergency, such as pain that has come and gone over days or weeks, pain tied to meals, breathing or movement, or a single episode that has fully resolved. We do an ECG on site and start the workup that day. Severe, ongoing or worsening pain belongs in the emergency room, not the office.
What tests will I need?
Most patients have a history, exam, on-site ECG and blood work at the first visit. Depending on those findings, we may arrange an echocardiogram to look at heart structure and function, a stress test to see how the heart handles effort, or an ambulatory ECG monitor for symptoms that come and go. Chest imaging or referral to cardiology is arranged when needed.
Can acid reflux really feel like heart pain?
Yes. Reflux and esophageal spasm can cause burning or squeezing pain behind the breastbone that closely resembles angina. Because the two can feel alike and can occur in the same person, we make sure the heart has been properly assessed before attributing chest pain to reflux, and then treat the reflux with meal changes and medication.
Can anxiety cause chest pain?
Anxiety and panic attacks commonly cause chest tightness, rapid heartbeat and shortness of breath, and the symptoms are real. We diagnose anxiety as the cause only after checking the heart, lungs and other physical causes. When anxiety is the driver, treating it directly usually improves the chest symptoms.