Chest Pain: When to Worry and When to Call for Help
Chest pain that feels like pressure, heaviness or squeezing in the centre of the chest, lasts more than a few minutes, and comes with sweating, breathlessness, nausea, or pain spreading into one or both arms, the jaw, the neck or the back is a heart attack until proven otherwise. Call Rescue 1122 or get to the nearest emergency department immediately — do not drive yourself, and do not wait to see whether it passes. Most chest pain seen in a clinic is not from the heart; acidity, muscle strain, anxiety and inflammation of the chest wall are all commoner. But nobody can tell the difference from the outside, an ECG and a troponin blood test take minutes and settle it, and the treatment that saves heart muscle only works in the first hours. Heart attack pain can be mild, can feel exactly like indigestion, and in people with diabetes and in older women may appear as breathlessness or overwhelming tiredness with no chest pain at all.
Health writers · Aslam Clinic
Why chest pain is treated differently
In almost every other part of medicine it is reasonable to wait and see. Chest pain is the exception, for one reason: a heart attack destroys muscle continuously from the moment the artery blocks, and that muscle does not grow back. Reopening the artery in the first hour saves most of it. At six hours much of it is already gone. There is no way to make up the lost time later, and there is no test you can do at home that tells you which kind of pain you have.
This matters more here than in the countries most guidelines are written for. Ischaemic heart disease is the leading cause of death in Pakistan, and South Asians develop it around a decade earlier than European populations — a heart attack at 45 is not unusual, and "too young for a heart attack" is not a category that exists in this population. Add to that a national habit of treating chest pain as gas and reaching for an antacid, and the commonest reason people here arrive at hospital too late is not distance. It is delay at home.
What heart pain typically feels like
The classic description is a heaviness or a band across the centre of the chest, as though something is sitting on it, rather than a pain you can point to with one finger. People often describe it with a closed fist held over the breastbone. It usually builds over a minute or two rather than arriving instantly, lasts more than a few minutes, and may spread outwards to the arms, jaw or back.
is the same discomfort brought on predictably by effort — climbing stairs, walking uphill, carrying shopping, or the first cold morning of winter — and relieved within a few minutes by rest. Angina that has been stable for months and follows its usual pattern is managed with an appointment. Angina that is new, that is coming on at rest, that is lasting longer, or that is being triggered by less effort than last month is called unstable and is treated as an emergency.
| Feature | More likely the heart | Less likely the heart |
|---|---|---|
| What it feels like | Pressure, heaviness, tightness, a band, a weight | Sharp, stabbing, or a spot you can cover with one fingertip |
| Where it is | Centre of the chest, spreading to arms, jaw, neck, back or upper abdomen | One small fixed point, or wandering around the chest |
| How long it lasts | More than a few minutes, steady while it lasts | A few seconds, or unchanged for days on end |
| What brings it on | Effort, emotional stress, cold air, a heavy meal | Twisting, pressing on the spot, a deep breath, bending or lying down after food |
| What comes with it | Sweating, nausea, breathlessness, a sense of dread | Burning behind the breastbone, acid taste, belching, tingling round the mouth and fingers |
| What relieves it | Rest, or a nitrate spray under the tongue, within minutes | An antacid, a change of position, slow breathing, a burp |
The commoner, harmless causes
Acid reflux and gastritis
Acid is the most frequent cause of chest pain in a general clinic. It burns rather than presses, sits behind the breastbone, is worse lying down or bending over, is often worse after a late or fried dinner, and may come with an acid or bitter taste at the back of the throat. It has nothing to do with effort. and a hiatus hernia produce a similar picture.
Chest wall and muscle pain
Costochondritis is of the joints where the ribs meet the breastbone. It is sharp, well localised, reproduced exactly when you press on the spot, and worse on twisting or taking a deep breath. Muscle strain from lifting, coughing or an unfamiliar workout behaves the same way. If pressing a finger on the painful point recreates the pain precisely, the heart is an unlikely source — though pressing on the chest of someone with the emergency features above is not a test worth performing instead of calling for help.
Anxiety and panic
A panic attack produces genuine chest tightness, a pounding heart, breathlessness, tingling in the fingers and around the mouth, and a powerful fear of dying. The symptoms are real, not imagined. But panic is a diagnosis made after the heart has been excluded, not instead of excluding it, and a first episode in an adult over 40 deserves an .
Lung and airway causes
Pneumonia, pleurisy and can all produce chest pain. The pattern is usually pain on breathing in, with cough, fever or , and it is sharper and more clearly related to the breath than cardiac pain is.
Dangerous causes that are not a heart attack
Three other emergencies present as chest pain, and each needs the same immediate response:
- A clot on the lung (pulmonary embolism). Sudden breathlessness with sharp pain on breathing in, sometimes coughing blood, often after a long journey, surgery, a fracture, a recent pregnancy, or a swollen painful calf.
- A tear in the main artery (aortic dissection). A sudden, severe, tearing pain that starts at maximum intensity and moves through to the back, often in someone with long-standing high . The pain is usually far more dramatic than a heart attack's.
- A collapsed lung (pneumothorax). Sudden one-sided chest pain with breathlessness, classically in a tall thin young person or someone with existing lung disease.
How doctors work it out
The assessment of chest pain is fast and well rehearsed, and most of it happens within the first half hour:
- An within ten minutes of arrival. It is painless, takes two minutes, and identifies the most dangerous kind of heart attack immediately.
- A troponin blood test. Troponin is a protein released when heart muscle is damaged. Modern high-sensitivity assays detect it within an hour or two of the event, and a second sample a few hours later shows whether it is rising.
- A chest , to look at the lungs and the outline of the great vessels.
- An , an of the heart, which shows whether a part of the muscle has stopped moving normally and how well the valves are working.
- A stress test or CT coronary angiogram later, for stable pain, to see whether the arteries narrow under load.
- A coronary angiogram where treatment is likely — a fine tube passed to the heart arteries that both shows the blockage and allows it to be opened in the same procedure.
A normal ECG does not exclude a heart attack, and this is worth knowing because people are sometimes reassured by one and go home. A meaningful proportion of heart attacks show nothing on the first tracing, which is exactly why the troponin is repeated and why hospitals keep people for a few hours rather than discharging on a single normal result.
What happens in hospital
If a major artery is blocked, the aim is to reopen it as fast as possible. The preferred method is primary angioplasty — a balloon and usually a stent passed through the wrist or groin — which is available in cardiac centres in Lahore, Rawalpindi and other large cities, and is why an ambulance may take someone past a nearer hospital to reach one that can perform it. Where angioplasty cannot be reached in time, a clot-dissolving drug given into a vein is used instead, and works best in the first few hours. Alongside that: aspirin and a second antiplatelet drug, pain relief, oxygen if levels are low, and monitoring for rhythm disturbance in the first day, when it is most likely.
After a heart attack most people leave hospital within a few days on four or five long-term medicines, and the great majority return to normal activity, including work and sex, within a few weeks. Cardiac rehabilitation — a supervised exercise and education programme — is one of the few interventions that measurably reduces the chance of a second event, and it is worth asking for by name.
What to do while waiting for help
- Call 1122 first, before anything else, and say the words "chest pain" so the call is prioritised.
- Stop and sit down, propped up rather than flat, and stay still. Do not walk to the vehicle if you can be brought to it.
- Loosen tight clothing and open a window or door.
- Chew one 300 mg aspirin — or three 100 mg tablets — unless the person is allergic to aspirin, has been told by a doctor not to take it, or has active bleeding from the stomach. Chewed rather than swallowed whole, because it acts faster.
- Take a nitrate spray or tablet under the tongue if one has already been prescribed for you, and repeat after five minutes if the pain persists. Do not use someone else's.
- Give nothing by mouth to anyone who is drowsy, confused or vomiting.
- Stay with the person. If they become unresponsive and are not breathing normally, start chest compressions in the centre of the chest, hard and fast, and do not stop until help arrives.
Reducing the risk
The factors that cause coronary disease are the same ones this clinic writes about constantly, because they are the ones that can actually be changed: stopping every form of tobacco, which halves the excess risk within a year; controlling ; controlling ; lowering , usually with a where risk is high; thirty minutes of brisk walking on most days; losing weight from around the waist; and treating kidney disease where it is present. None of these is dramatic and all of them are cumulative.
When to see a doctor
Call an ambulance, not a clinic, for any of the emergency features at the top of this page. Book an appointment within days for chest discomfort that comes on reliably with exertion and settles with rest, for chest pain in anyone with diabetes, known heart disease or several risk factors, and for pain that keeps returning even if each episode passes. Book a routine appointment for chest pain that is clearly positional, clearly related to food, or clearly reproduced by pressing on the spot — and go back sooner if the pattern changes. A pattern that changes is the single most useful warning the body gives.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
