Classic cardiac chest pain — angina — is described as pressure, squeezing, tightness, or heaviness in the center or left side of the chest. It may radiate to the jaw, left arm, or back. It is typically exertional (brought on by physical activity or emotional stress) and relieved by rest or nitroglycerin. It lasts minutes, not seconds, and not hours. These characteristics are taught as classic — but a significant proportion of MI presentations, particularly in women, elderly patients, and diabetics, are atypical.
Non-cardiac causes of chest pain are numerous: musculoskeletal (costochondritis, rib strain), gastrointestinal (GERD, esophageal spasm), pulmonary (pleuritis, pneumothorax, pulmonary embolism), anxiety and panic disorder, and herpes zoster before the rash appears. GERD is particularly common and can closely mimic angina — burning or pressure behind the sternum, sometimes with relief after antacids. Pulmonary embolism is a dangerous mimic that must be kept in mind with pleuritic pain and dyspnea.
The evaluation of chest pain involves ECG, cardiac biomarkers (troponin), chest X-ray, and clinical history. High-sensitivity troponin assays have transformed ED evaluation — a negative troponin at presentation and 1–3 hours later essentially rules out myocardial injury in most protocols. Stress testing and coronary CT angiography are used in intermediate-risk presentations for outpatient evaluation.
The principle for patients is simple: if you are uncertain whether your chest pain is serious, treat it as serious until proven otherwise. Unexplained new chest pain warrants same-day evaluation. Pain at rest, pain with exertion, pain with radiation, or pain accompanied by shortness of breath, sweating, nausea, or syncope warrants 911.