Medically Reviewed By: Dr Paul Lim – MBBS, M.Med (Int Med), MRCP (UK), FAMS (Cardiology)
Chest pain is any pain, pressure, tightness, burning, or discomfort felt in the chest. It is a symptom, not a diagnosis. The heart is only one of its causes — muscles and ribs, acid reflux, the lungs, and anxiety all cause chest pain, and they can feel remarkably similar. Most chest pain is not a heart attack, but because the two cannot be told apart from the feeling alone, severe or sustained chest pain is always treated as an emergency first and explained afterwards.
Senior Consultant Cardiologist & Cardiac Electrophysiologist
Dr Paul Lim is a Senior Consultant Cardiologist who assesses chest pain to establish whether the heart is the cause — using ECG, echocardiography, treadmill stress testing, and CT coronary imaging — and who subspecialises in heart rhythm disorders. He completed advanced fellowship training at Barts Heart Centre, London under Singapore’s HMDP award.
Chest pain is any discomfort felt between the neck and the upper abdomen. People describe it as pain, pressure, tightness, burning, aching, or simply “something not right” in the chest. The chest is a crowded space: the heart, the large blood vessels, the lungs and their lining, the oesophagus, the stomach, the ribs, the muscles between them, and the nerves that serve them all sit within a few centimetres of each other, and they share nerve pathways. That shared wiring is why a problem in the gullet can feel like the heart, and why pain from the heart can be felt in the jaw or the arm rather than the chest at all.
Two facts sit side by side here, and both matter. The first is that most chest pain is not caused by the heart. The second is that you cannot tell from the sensation alone which chest pain is which. A heart attack can feel like indigestion. Reflux can feel like a heart attack. This is why doctors approach chest pain by first excluding the causes that can kill quickly, and only then working through the many that will not.
The good news is that this is usually straightforward. An ECG takes a few minutes, a blood test can detect heart muscle injury, and where needed a stress or perfusion test, or a CT coronary angiogram, can assess whether blood flow to the heart is adequate. Either the heart is the cause and treatment starts, or it is not — and you can be pointed towards the cause that actually explains your symptoms.
Chest pain is the one symptom where it is better to over-react than under-react. Use the traffic-light guide below, but if you are ever in doubt, treat it as the red category.
Do not drive yourself, and do not wait to see if it passes. Chest pain is an emergency if it is:
See a cardiologist promptly — without waiting for it to worsen — if your chest pain is:
These patterns point away from the heart, though none of them excludes it:
Not sure which category you fall into? Speak to a cardiologist — and if the pain is happening right now and is severe, call 995 instead.
Chest pain that keeps coming back? Find out whether your heart is the cause.
Chest pain has causes in five broad groups. Cardiac causes are the ones that must be excluded first, but they are not the most common. In many people more than one factor is at play — reflux and anxiety often travel together, and both are more noticeable when you are already worried about your heart.
Note: this is not an exhaustive list. If you are experiencing symptoms, consult a doctor for a proper evaluation.
Anxiety-related chest pain is real pain, and it deserves treatment rather than dismissal. But anxiety does not protect anyone from heart disease, and the two frequently coexist. Chest pain should only be attributed to anxiety after cardiac causes have been properly considered — not instead of considering them.
Patients often assume that left-sided pain means the heart and right-sided pain does not. That is one of the most common misconceptions about chest pain — and it is not reliable.
The heart does sit slightly to the left, which is why left chest pain causes the most alarm. In practice, most left-sided chest pain is not cardiac: chest wall strain, costochondritis, reflux, anxiety, and pleurisy are all more common. What matters is not the side but the character and company the pain keeps. Left-sided pain that is a pressure or tightness, comes on with exertion, or arrives with sweating, breathlessness, or pain spreading into the arm or jaw, needs emergency assessment regardless of how mild it seems.
Pain behind the breastbone is the classic site for pain from the heart, and also for reflux and oesophageal spasm — which is precisely why the two are so often confused. A central pressure, tightness, or heaviness that lasts minutes and comes on with exertion suggests angina until proven otherwise. A central burning that rises towards the throat after meals suggests reflux. Both descriptions are common, and neither is reliable enough to act on without testing.
Right-sided chest pain is less commonly cardiac, and more often comes from the chest wall, the lung and its lining, or the gallbladder. It is not, however, a guarantee — pain from the heart can be felt on the right, and an aortic dissection often causes right-sided or back pain. Right-sided pain with breathlessness, fever, or a cough needs assessment for a lung cause.
Where chest pain travels is often more informative than where it starts. Pain spreading to the left arm, both arms, the jaw, the neck, the shoulders, or the back raises the likelihood of a cardiac cause considerably and should be treated as an emergency when it is new or severe. Pain radiating through to the back in a sudden, tearing fashion suggests an aortic dissection. Pain that follows a band around one side of the chest suggests a nerve cause such as shingles.
The character of the pain is one of the most useful clues a doctor has — more useful than its location. None of these descriptions is diagnostic on its own, but each shifts the odds.
This is the question everyone wants answered. The table below shows the patterns doctors weigh up — but read the caveat underneath it before you use it on yourself.
| Feature | More typical of the heart | More typical of a non-cardiac cause |
|---|---|---|
| Character | Pressure, tightness, squeezing, heaviness | Sharp, stabbing, pinpoint, or burning |
| Location | Central, over a broad area — often shown with a whole fist | A small spot you can point to with one fingertip |
| Spread | To the left arm, both arms, jaw, neck, shoulders, or back | Stays in one place, or follows a band around the ribs |
| Brought on by | Exertion, emotional stress, or a heavy meal | Posture, twisting, pressing the spot, deep breaths, or lying flat after eating |
| Duration | A few minutes, settling with rest (angina). Pain lasting longer, coming and going, or not settling needs emergency care | Seconds, or a constant ache over hours to days |
| Relieved by | Rest, or a GTN spray within minutes (angina) | Changing position, antacids, or simple pain relief |
| Company it keeps | Sweating, nausea, breathlessness, light-headedness | Belching, acid taste, local tenderness, cough, or rash |
Important: this table describes tendencies, not rules, and every row has exceptions. A heart attack can feel like ordinary indigestion, and can occur with little or no chest pain at all — this is more common in people with diabetes and in older adults. Reflux can produce pain indistinguishable from angina. Chest wall tenderness makes a cardiac cause less likely but does not exclude one — in one emergency department study, 6% of patients whose chest pain could be reproduced by pressing were nonetheless having a heart attack. And relief from a GTN spray does not confirm that pain came from the heart: guidelines specifically advise against using the response to GTN as a diagnostic test. Use the table to understand what your doctor is weighing up, not to rule your own heart in or out.
Stable angina follows a predictable pattern: it appears at a similar level of exertion — the same hill, the same flight of stairs — lasts a few minutes, and settles with rest or a GTN spray. It reflects a narrowed coronary artery that can supply enough blood at rest but not under load. It should be assessed, but it is not an emergency in itself.
Unstable angina is angina that is new, occurs at rest, lasts longer, comes on with less and less effort, or no longer responds to a GTN spray as it used to. It signals a coronary artery at risk of blocking completely, sits on the same spectrum as a heart attack, and is an emergency. If your usual angina pattern changes, do not wait for your next appointment — go to A&E.
Stop guessing from a table. Get your chest pain properly assessed.
Chest pain tends to arrive in recognisable situations. Here is what is usually going on — and when each one is worth checking.
Pain that clearly worsens when you breathe in is called pleuritic pain, and it usually points away from the coronary arteries. The common causes are chest wall strain, costochondritis, and chest infection. The serious ones are pleurisy, pneumonia, a collapsed lung, and a clot on the lung. Pericarditis is the cardiac exception — it worsens on breathing in and on lying flat, and eases when sitting forward. Sudden sharp pain with breathlessness is an emergency, especially after long-haul travel, surgery, or a period of immobility.
If pressing on a spot reproduces exactly the pain you have been feeling, the pain is likely coming from the chest wall — the ribs, the joints where they meet the breastbone, or the muscles between them. Costochondritis is the classic example: tender, worse on movement or a deep breath, and often lasting days to weeks. This is genuinely reassuring, and it is one of the more useful things you can tell your doctor. It is not, however, absolute proof: chest wall tenderness can coexist with heart disease, so exertional symptoms still deserve assessment.
Burning chest pain after meals, worse on lying down or bending over and often with an acid taste or belching, usually indicates acid reflux. Large, fatty, or spicy meals, late dinners, alcohol, and coffee are common triggers. But there is a catch that catches people out: a heavy meal also increases the heart’s workload, so angina can appear after eating too. Chest pain after meals that also occurs when you walk uphill is not a reflux story, and needs a cardiac assessment.
Chest pain that comes on at night is most often reflux, because lying flat allows acid to travel up the gullet. Musculoskeletal pain also feels worse when you lie on it, and anxiety tends to surface when distractions fall away. However, chest pain that wakes you from sleep, or that occurs at rest, is one of the features of unstable angina — and breathlessness on lying flat can indicate heart failure. Night-time chest pain that is new or recurrent should not be dismissed as indigestion without assessment.
Chest pain brought on by exertion and relieved by rest is the textbook description of angina, and it is the single most important pattern to recognise on this page. It means the heart’s blood supply is adequate at rest but not under load. In a younger person, exertional chest pain or fainting during exercise can point to structural conditions such as hypertrophic cardiomyopathy. Exercise-related chest pain at any age warrants prompt specialist assessment, and you should stop exercising until you have been seen.
You may have read that women do not get chest pain with a heart attack, or that their symptoms are “atypical”. Current guidance moves away from both ideas, because they lead women to dismiss genuine symptoms. Chest pain is the most common heart attack symptom in women, just as it is in men. What differs is that women are more likely to also have accompanying symptoms — breathlessness, nausea, sweating, unusual fatigue, or pain in the jaw, neck, back, or shoulder. Women are also recognised to be at risk of underdiagnosis, so cardiac causes should always be considered. Risk rises after menopause. Central chest pain in a woman deserves exactly the same urgency as in a man, and should not be assumed to be muscular or hormonal without assessment.
In people under 40, chest pain is usually caused by the chest wall, reflux, or anxiety, and coronary artery disease is uncommon. That is a reason for reassurance, not dismissal. Pericarditis and myocarditis affect young people, often after a viral illness. A collapsed lung typically affects tall, slim young men. Inherited conditions such as hypertrophic cardiomyopathy can present with chest pain or fainting on exertion. A family history of sudden cardiac death before 50, or symptoms during exercise, changes the picture entirely and needs specialist review.
Chest pain is not a symptom to manage at home until you know what is causing it. These steps apply only once serious causes have been excluded, or while you are waiting for help to arrive.
If the pain is severe, lasts more than a few minutes, comes and goes, or comes with sweating, breathlessness, or fainting, stop reading and call 995. Sit down and rest while you wait. Do not drive yourself to hospital, and do not wait to see whether it passes — in a heart attack, treatment delay is what causes lasting damage.
Stop what you are doing and sit upright. Slow, controlled breathing — in for four, out for six — settles the adrenaline and overbreathing that drive anxiety-related chest pain. If the pain eases within a couple of minutes of rest, note that: it is exactly the sort of detail your doctor needs.
Note what you were doing when it started, how long it lasted, what the pain felt like, where it went, and what made it better or worse. This history is what a cardiologist reasons from — it carries more weight than any single test, and it is easily forgotten by the time of the appointment.
Taking antacids and finding partial relief does not prove the pain is not cardiac. Do not start, stop, or borrow medication for chest pain, and do not use someone else’s GTN spray. If you have been prescribed a GTN spray, follow the instructions you were given — and if the pain persists after using it as directed, call 995.
Once the heart has been ruled out, the cause of your chest pain still deserves a name — reflux, costochondritis, and anxiety all have effective treatments. “Nothing wrong with your heart” is the start of the answer, not the whole of it.
The aim is to answer one question first — is this the heart? — and then to find what else it might be. Testing is tiered: it starts simple, and goes further only when the story or the findings warrant it.
Dr Lim will ask what the pain feels like, where it sits and spreads, what brings it on and relieves it, how long it lasts, and what else comes with it — alongside your risk factors and family history. In chest pain, the history is the most informative part of the assessment, and it directs everything that follows.
A 12-lead ECG takes a few minutes and can show a heart attack in progress, past damage, or rhythm problems. Importantly, a normal ECG does not exclude a heart attack or coronary disease — it records only that moment, which is why guidelines advise repeating it when suspicion is high or symptoms persist. It is interpreted alongside the history, never on its own.
Troponin is a protein released when heart muscle is injured. It is the key blood test when a heart attack is suspected. It is measured more than once, a few hours apart, because what matters is the pattern — a rising or falling level — rather than any single reading. A first result taken early can be normal in a heart attack. This test belongs in an emergency department, not a routine clinic visit.
An echocardiogram is an ultrasound scan of the heart. It shows the pumping function, the valves, the muscle thickness, and fluid around the heart. It can identify structural heart disease and may show complications or associated findings of conditions such as pericarditis or previous myocardial injury.
If your chest pain comes on with exertion, a treadmill stress test reproduces the trigger under ECG and blood pressure monitoring, showing how the heart behaves under the load that provokes your symptoms. It suits patients whose resting ECG can be interpreted and who can walk to a reasonable level of exertion; where it is unsuitable or inconclusive, imaging tests are used instead.
A CT coronary angiogram gives detailed, non-invasive images of coronary plaque and narrowing and is useful for assessing selected patients with suspected coronary artery disease. A CT calcium score measures calcified plaque and is primarily a cardiovascular risk-assessment tool; it is not a substitute for evaluating acute symptoms. Where clinically appropriate, these tests will be recommended.
If chest discomfort comes with palpitations, a Holter monitor records the rhythm during daily life. Blood tests for cholesterol, diabetes, and anaemia complete the risk picture and identify contributing causes.
Not everyone needs every test. For many patients, a consultation, an ECG, and an echocardiogram give a clear answer. The purpose of the tiered approach is to reach a confident conclusion using the fewest tests that will settle the question — and a heart screening can establish your baseline risk if you have no symptoms but a family history.
Chest pain happening right now that is severe, sustained, or comes with sweating, breathlessness, or fainting is not a clinic problem — call 995 or go to A&E. A clinic appointment is the right route for chest pain that has settled, that keeps returning, that appears on exertion, or that has never been properly explained.
It is particularly worth booking a review if your chest pain is brought on by exertion and eased by rest, if you have risk factors such as high blood pressure, high cholesterol, diabetes, or smoking, if there is a family history of heart disease or sudden cardiac death before 50, or if you have been treated for reflux or muscle strain and the pain has not gone away. As a cardiologist, Dr Lim’s role is to determine whether your heart is responsible — and if it is not, to say so clearly, so the real cause can be identified and treated.
Contact us to schedule a consultation or to find out more about our cardiac services.
Answers to the most common questions about what causes chest pain, when to worry, how to tell heart pain from muscle, gastric, or anxiety causes, and how it is diagnosed.
Call 995 immediately if chest pain is severe or crushing, lasts more than a few minutes, or comes and goes — and do not drive yourself. The same applies if it comes with sweating, nausea, severe breathlessness, fainting, or pain spreading to the arm, jaw, neck, back, or stomach. Pain that starts during exertion and eases with rest suggests angina and needs prompt specialist review. Sudden tearing pain radiating to the back, or sudden sharp pain with breathlessness, are also emergencies. Chest pain that is brief, pinpoint, reproduced by pressing on the chest, or clearly linked to posture is less likely to be cardiac — but no pattern is reliable enough to diagnose yourself, so see a doctor if you are unsure.
Muscular or chest wall pain is typically sharp and localised, can often be pointed to with one finger, is tender when you press on the spot, and changes with movement, posture, or a deep breath. Pain from the heart is more often a central pressure, tightness, or heaviness, is brought on by exertion or stress, may spread to the arm, jaw, neck, or back, and can come with sweating or breathlessness. These are patterns, not rules. Pain that is reproduced by pressing on the chest makes a cardiac cause less likely but does not exclude it, so the distinction should be confirmed with an ECG and, where needed, further tests rather than assumed.
Left-sided chest pain worries people because the heart sits slightly to the left, but most left-sided chest pain is not cardiac. Common causes include chest wall and muscle strain, costochondritis, acid reflux, anxiety, and lung conditions such as pleurisy. Cardiac causes including angina and heart attack are important but are more often felt as central pressure that may spread to the left arm or jaw. The side of the pain alone does not tell you the cause — left-sided pain with exertion, sweating, breathlessness, or spread to the arm or jaw needs emergency assessment.
Yes. Anxiety and panic attacks are a common cause of chest pain and the pain is genuine, not imagined. Adrenaline, rapid shallow breathing, and chest muscle tension can produce a tight, sharp, or aching chest, often with palpitations, breathlessness, tingling, and light-headedness. The difficulty is that the symptoms overlap with those of heart problems, and anxiety does not protect you from heart disease. Chest pain should therefore not be attributed to anxiety until cardiac causes have been considered and, where appropriate, excluded with an ECG and further tests.
Chest pain is a symptom; a heart attack is one specific and serious cause of it. A heart attack happens when blood flow to part of the heart muscle is blocked, and it typically causes central chest pressure, tightness, or heaviness lasting more than a few minutes — or coming and going — often with sweating, nausea, breathlessness, or pain spreading to the arm, jaw, neck, or back, and it does not ease with rest. Most chest pain is not a heart attack, but the symptom alone cannot tell the two apart, which is why sustained or severe chest pain is treated as an emergency until proven otherwise.
Acid reflux is one of the most common non-cardiac causes of chest pain, and it can closely mimic pain from the heart. Reflux pain is often burning, rises behind the breastbone towards the throat, is worse after meals or when lying down or bending over, and may come with an acid taste or belching. Cardiac pain is more often a pressure or tightness brought on by exertion. However, the overlap is substantial — reflux can cause pain that feels like angina, and a heart attack can feel like indigestion. Responding to an antacid does not prove the pain is not cardiac, so new, severe, or exertional chest pain should be assessed medically.
Chest pain that is clearly worse on breathing in or coughing is called pleuritic pain and usually points away from the heart. Common causes include chest wall and rib muscle strain, costochondritis, and a chest infection. More serious causes are pleurisy, pneumonia, a collapsed lung (pneumothorax), and a blood clot on the lung (pulmonary embolism). Pericarditis, an inflammation of the sac around the heart, is a cardiac cause that also worsens on breathing in and often eases on sitting forward. Sudden sharp chest pain with breathlessness needs emergency assessment.
Duration is a useful clue. Pain lasting only a few seconds, or a sharp catch that passes quickly, is rarely cardiac. Angina usually lasts less than 10 minutes and settles with rest or a GTN spray. Chest pain that lasts more than a few minutes, or that comes and goes, may indicate a heart attack and is an emergency — call 995 rather than waiting to see whether it passes. Chest pain that comes and goes is not automatically harmless — angina comes and goes by definition, and pain that returns with exertion and eases with rest is a pattern that needs prompt assessment. Constant pain lasting days is more often musculoskeletal or reflux-related, but should still be reviewed.
A normal ECG is reassuring but does not rule out coronary artery disease or a heart attack. An ECG records the heart’s electrical activity at that moment, so it can be normal between episodes of angina, and it can be normal in the early stages of a heart attack. If chest pain persists or the story is suggestive, further tests are used — a troponin blood test, an echocardiogram, a treadmill stress test, or a CT coronary angiogram. A normal ECG also raises the possibility of non-cardiac causes such as reflux, chest wall pain, or anxiety, which is why assessment considers the whole picture rather than one test.
Central chest pain in women has the same broad range of causes as in men — acid reflux, chest wall and costochondritis pain, anxiety, and cardiac causes including angina and heart attack. Chest pain is the most common heart attack symptom in women just as it is in men, and the older idea that women do not get chest pain is now discouraged because it leads women to dismiss real symptoms. Women are more likely to also have accompanying symptoms such as breathlessness, nausea, sweating, fatigue, or pain in the jaw, neck, or back, and are recognised to be at risk of underdiagnosis. Central chest pain in women should therefore be taken as seriously as in men, and risk rises after menopause. Breast and musculoskeletal causes are also common and can be identified on assessment.
Chest pain in young adults is usually not caused by coronary artery disease, and the common causes are chest wall and muscle pain, costochondritis, acid reflux, and anxiety. It should still not be dismissed. Important conditions that affect younger people include pericarditis and myocarditis (often after a viral illness), a collapsed lung, and inherited heart conditions such as hypertrophic cardiomyopathy. Chest pain during exercise, fainting during exertion, or a family history of sudden cardiac death before the age of 50 are red flags in a young person and need prompt specialist assessment.
Assessment begins with a clinical history and examination, which carry more weight than any single test. A 12-lead ECG is done first. A troponin blood test detects heart muscle injury and is used when a heart attack is suspected. An echocardiogram shows the heart’s structure and pumping function. A treadmill stress test looks for reduced blood flow during exertion, and a CT coronary angiogram gives detailed pictures of the coronary arteries and can rule out significant disease. A CT calcium score assesses risk. Blood tests for cholesterol, diabetes, and anaemia are used to build the overall risk picture.
There is no single medicine for chest pain, because treatment depends entirely on the cause — the right treatment for reflux is wrong for angina, and self-medicating can delay the diagnosis of a serious problem. Angina from coronary artery disease is treated with medication that reduces the heart’s workload and lowers cardiovascular risk, and a GTN spray is prescribed to relieve episodes. Reflux-related pain is treated with acid-suppressing medication. Chest wall pain often settles with simple pain relief and rest. Do not start or stop any medication for chest pain without medical advice, and never delay emergency care to try a remedy at home.
For sudden, severe, or ongoing chest pain, go to A&E or call 995 rather than waiting for an appointment. For chest pain that is recurrent, exertional, or unexplained, a cardiologist can determine whether the heart is the cause. Dr Paul Lim is a Senior Consultant Cardiologist and Electrophysiologist in Singapore, with clinics at Orchard and Jurong. A consultation typically includes an ECG and, depending on the findings, an echocardiogram, a treadmill stress test, or a CT coronary angiogram. Where chest pain proves to be non-cardiac, that is a useful result — it redirects you to the right treatment.
