Chest pain does not always mean a heart attack
Chest pain is among the most terrifying symptoms a person can experience. As soon as that unpleasant pressure or stabbing sensation appears in the chest area, most people's minds immediately jump to the worst possible scenario – a heart attack. But the reality is considerably more complex and, in many cases, far less dramatic. Experts in cardiology and general practice repeatedly point out that a large proportion of patients who come to the emergency room with chest pain ultimately leave with a diagnosis that has nothing to do with the heart. This does not mean the pain should be dismissed – quite the opposite. But understanding what is truly behind it can be the key to faster and more accurate treatment.
According to data published in the medical journal American Family Physician, cardiac causes of chest pain account for only a minority of cases – approximately 15 to 18 percent. The remainder falls across a wide range of other conditions, from digestive problems and muscle inflammation to anxiety disorders. Yet the fear of a heart attack becomes so paralysing for many people that they either seek unnecessary emergency care, or – the more dangerous alternative – ignore the pain and wait too long. So how can you tell what is actually happening?
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When is it the heart and when is it not?
Before we run through the most common non-cardiac causes, it is important to understand how doctors approach chest pain. At the first visit, they always try to rule out the so-called "big four" – heart attack, pulmonary embolism, aortic dissection, and tension pneumothorax. Only after these life-threatening conditions have been excluded does the search for less serious causes begin. Heart attack pain is typically constricting, radiates to the left arm, jaw, or back, and is accompanied by a feeling of breathlessness, cold sweats, or nausea. Pain of non-cardiac origin, by contrast, tends to have a different character – it is sharp, stabbing, localised, changes with movement or breathing, and may come and go without any obvious connection to physical exertion.
Of course, even this rule is not absolute. There are patients who have had a heart attack without any pain at all, and conversely people with intense burning pain caused by nothing more than heartburn. This is why the golden rule applies: for any new, severe, or recurring chest pain, it is always appropriate to seek medical attention. But what happens in those cases where the heart is not the culprit?
Gastroesophageal reflux and heartburn
One of the most common conditions mistaken for a heart attack. Acidic stomach contents flowing back into the oesophagus can cause a burning pain behind the breastbone so intense that people call an ambulance. Gastroesophageal reflux disease, abbreviated as GERD, affects approximately 20 percent of the adult population, and its symptoms overlap so significantly with cardiac complaints that even experienced physicians must perform an ECG to distinguish them. The pain is typically burning, worsens after eating, when lying down, or when bending forward, and subsides after antacids. If such symptoms recur, it is advisable to consult a gastroenterologist and consider dietary changes.
Costochondritis – inflammation of the cartilage of the chest
A less well-known but surprisingly common condition. Costochondritis is an inflammation of the cartilaginous joints between the ribs and the breastbone. The pain can be sharp, stabbing, and very unpleasant – and localised precisely where people imagine the heart to be. A characteristic feature is that the pain worsens when the chest is pressed or when the upper body moves. Doctors diagnose it through simple physical examination – pressing a finger on the affected area is enough for the patient to immediately identify where the pain is coming from. Treatment consists of rest, anti-inflammatory medications, and physiotherapy.
Panic attack and anxiety
People who have never experienced a panic attack can hardly imagine how physically real it can feel. Racing heart, tightness in the chest, shortness of breath, tingling in the hands, a sense of impending doom – these are all symptoms that appear during an anxiety attack completely without warning and can last for several minutes. Panic attacks are one of the most common causes of emergency room visits with a diagnosis of "chest pain of non-cardiac origin." Research shows that up to a third of patients admitted with suspected cardiac problems actually suffer from an anxiety disorder. An accurate diagnosis is crucial in these cases – these patients do not need cardiological care, but psychotherapy and possibly pharmacological support.
Pleuritis – inflammation of the pleura
The pleura is the thin membrane surrounding the lungs, and when it becomes inflamed – most commonly as a result of a viral infection, pneumonia, or an autoimmune disease – the pain it causes is unmistakable. It is sharp, stabbing, and markedly worsens with inhalation or coughing. This dependence on breathing is an important diagnostic clue: pain that changes with breathing almost never originates from the heart. Treatment depends on the cause of the inflammation – from simple anti-inflammatory drugs to antibiotics or corticosteroids.
Muscle pain and chest wall injury
Overuse or strain of the intercostal muscles, a direct blow to the chest, or even excessive coughing or unusual physical activity can cause pain that initially appears to be cardiac. A classic example is the situation after an intense workout – someone starts exercising after a long break, wakes up the next day with chest pain, and immediately thinks something serious has happened. In reality, it is simply muscle fatigue. Chest muscle pain tends to be dull or cramping, localised, and responds to movement, compression, or stretching. Heat, gentle massage, and an over-the-counter analgesic if needed are all helpful.
Less obvious causes that doctors do not overlook
Sometimes chest pain has causes that a layperson would never identify on their own. Herpes zoster, commonly known as shingles, can cause intense burning pain on one side of the chest before the characteristic blisters appear on the skin. People at this stage of the illness very often head to the emergency room with suspected heart attack. Only a few days later, when the rash appears, does everything fall into place. Treatment with antivirals is most effective precisely in the early stage, so timely diagnosis has a direct impact on the course of the illness.
Another less obvious culprit may be gallbladder disease. Gallstones or inflammation of the gallbladder cause pain in the right upper abdomen that can radiate to the right shoulder or even into the chest area. The pain typically comes on after a fatty meal and can be very intense. Similarly, oesophageal spasm can also be a source of problems – a sudden cramp of the oesophagus that causes a constricting pain behind the breastbone almost identical to that of a heart attack, and which moreover subsides after nitroglycerin, a medication otherwise intended for cardiac patients. This, of course, complicates the situation even further.
Finally, it is also worth mentioning pericarditis, i.e. inflammation of the pericardium – the sac surrounding the heart. Although this involves a cardiac structure, pericarditis is not a heart attack and is treated in an entirely different way. The pain is typically sharp, worsens when lying down, and eases when leaning forward. It is diagnosed using an ECG, echocardiography, and blood tests.
The story of a forty-year-old teacher from Brno who came to the emergency room with severe chest pain after a stressful week at work illustrates this very well. The ECG was normal, troponins negative. After a thorough examination, doctors found she was suffering from a combination of GERD and panic disorder, which had fully manifested for the first time during this period. She left with a referral to a gastroenterologist and a psychologist – and without any heart medication.
As American cardiologist and popular health author Dean Ornish says: "The heart is an incredibly resilient organ. Many things that look like its failure are actually calls for attention from other systems of the body."
It is precisely this perspective that should change the way we approach chest pain. The point is not to dismiss the fear – it serves a purpose, and in the case of a real heart attack it can save a life. The point is to understand that the body is a complex system in which various organs and structures overlap, mutually influence one another, and sometimes even "take the floor" from their neighbours. Chest pain is a signal that deserves attention – but it does not always mean the worst. An accurate diagnosis, patience on the part of both doctor and patient, and a willingness to look for the cause beyond the first suspicion are what ultimately lead to relief and genuine recovery. And that is a message worth remembering.
