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Symptom hub · Clinically reviewed

Chest pain, the causes to rule out first and the UK pathways that assess them.

From acute coronary syndrome to costochondritis. What the pattern means, when it is a 999 call and what tests come next.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE NG185, ESC and Resuscitation Council UK guidance you can see at the end.

  • 03

    Current for 2026

    Reflects current UK rapid-access chest pain pathways, high-sensitivity troponin and CT coronary angiography as a first-line test.

Key facts

Chest pain at a glance.

The essentials, in plain English. What it is, the big categories, and the five life-threatening causes to rule out first.

  • What it is

    A symptom, not a diagnosis. Pain, pressure, tightness or heaviness anywhere in the front or side of the chest, often radiating to the arm, jaw, back or upper abdomen.

  • The big categories

    Cardiac, pulmonary, gastrointestinal, musculoskeletal, neurological, psychogenic and other. The differential is broad and the priority is ruling out life-threatening causes.

  • Life-threatening five

    Acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax and oesophageal rupture. All can present with chest pain and all need urgent care.

  • When to call 999

    New, severe, crushing or pressure-like chest pain lasting more than 15 minutes, especially with sweating, breathlessness, nausea or radiation to arm, jaw or back.

  • First test

    A 12-lead ECG within 10 minutes of arrival, followed by high-sensitivity troponin. NICE NG185 sets this standard for suspected cardiac chest pain.

  • Common but benign

    Costochondritis, reflux and muscular strain make up a large share of chest pain seen in primary care once the serious causes are excluded.

Why this guide matters

Sort the serious from the common, quickly.

Chest pain has a wide differential and a small, urgent core. The three points below shape everything else on this page.

  • Time is muscle in ACS

    The sooner an ECG is done and troponin is drawn, the sooner a heart attack can be treated with PCI or thrombolysis. Delay costs heart muscle.

  • Dissection and PE hide in plain sight

    Tearing pain, blood-pressure differences, sudden breathlessness or a swollen calf change the pathway completely. They are missed if not actively considered.

  • Most chest pain is not sinister

    Once the serious causes are excluded, costochondritis, reflux and muscular pain make up most of what remains. Reassurance is a treatment in itself.

How chest pain is assessed

From first pain to a clear pathway.

The steps a UK emergency team, GP or rapid-access chest pain clinic will normally follow, in order, so you know what to expect and why.

  1. 01

    Triage

    Immediate safety triage

    Any red flag pattern (crushing pain, sweating, syncope, tearing back pain, haemodynamic compromise) means calling 999 first and asking questions later.

  2. 02

    Triage

    SOCRATES history

    Site, onset, character, radiation, associated features, timing, exacerbating and relieving factors, plus severity. Add cardiovascular risk factors and medications.

  3. 03

    Triage

    Focused examination

    Blood pressure in both arms (a difference above 20 mmHg raises dissection suspicion), heart sounds, lung fields, pericardial rub, JVP, peripheral oedema and calf swelling.

  4. 04

    Investigate

    12-lead ECG within 10 minutes

    The single most time-critical test. Looks for ST elevation, depression, T-wave changes, new left bundle branch block and pericarditis patterns.

  5. 05

    Investigate

    Bloods and biomarkers

    High-sensitivity troponin (0 and 1 to 3 hour protocol), D-dimer if PE is possible, BNP for heart failure, FBC, U&Es and inflammatory markers.

  6. 06

    Investigate

    Imaging first line

    Chest X-ray for most, point-of-care ultrasound of lung and heart where available, and CT pulmonary angiogram or CT aorta when PE or dissection are suspected.

  7. 07

    Specialist

    Cardiac work-up as indicated

    CT coronary angiography (first-line under NICE NG185 for stable chest pain of suspected cardiac origin), stress imaging or invasive angiography where the picture demands it.

Typical timeline: acute ACS work-up in hours, stable chest pain clinic in days to weeks.

Causes and patterns

What chest pain can actually be.

Cardiac, pulmonary, gastrointestinal, musculoskeletal, neurological and psychogenic causes each carry a typical fingerprint. The pattern shapes the pathway.

  • Cardiac (ACS and angina)

    Central, pressing or heavy pain, often radiating to the arm, jaw or back, worse on exertion, with sweating, nausea or breathlessness.

  • Aortic dissection

    Sudden, severe, tearing pain between the shoulder blades, often with a blood-pressure difference between arms and pulse or neurological changes.

  • Pulmonary embolism

    Sharp, pleuritic chest pain with breathlessness, sometimes haemoptysis, calf swelling or recent immobility. See our blood-clots guide.

  • Pneumothorax and pleurisy

    Sudden one-sided pleuritic pain with breathlessness in pneumothorax; sharp pain worse with breathing in pleurisy and pneumonia.

  • Gastrointestinal

    Burning retrosternal pain from reflux, cramping pain from oesophageal spasm, and epigastric pain that radiates upward from a peptic ulcer or gallbladder.

  • Musculoskeletal

    Reproducible tender pain over a costochondral joint (costochondritis), a rib, or muscles between the ribs, often after coughing or exertion.

  • Neurological

    Band-like burning or tingling pain in a dermatomal pattern, sometimes preceding a shingles rash by days, or from a thoracic nerve root.

  • Red flag pattern

    Crushing central pain, radiation to arm or jaw, sweating, syncope, tearing back pain, sudden severe breathlessness or haemodynamic compromise. Call 999.

Treatment

How chest pain is treated in the UK.

Treatment follows the cause. The eight below cover the vast majority of chest pain presentations seen in NHS and private practice.

  • Acute coronary syndrome

    Aspirin 300 mg, a P2Y12 inhibitor, oxygen only if hypoxic, nitrate for symptom relief, morphine for ongoing pain and urgent PCI or thrombolysis per pathway.

  • Aortic dissection

    Rapid blood-pressure and heart-rate control (target systolic around 100 to 120 mmHg), pain control and immediate cardiothoracic surgical assessment.

  • Pulmonary embolism

    Therapeutic anticoagulation for most, systemic thrombolysis for massive PE with haemodynamic instability, and inpatient care until stable.

  • Pneumothorax

    Observation, needle aspiration or intercostal chest drain depending on size and symptoms. Tension pneumothorax needs immediate decompression.

  • Pericarditis and myocarditis

    High-dose NSAIDs plus colchicine for pericarditis, cardiology-led supportive care for myocarditis, with steroids reserved for selected cases.

  • GORD and oesophageal causes

    Proton pump inhibitor trial, lifestyle changes and, where symptoms persist, endoscopy or pH studies. See our acid reflux guide for detail.

  • Musculoskeletal chest pain

    Reassurance, NSAIDs or paracetamol, relative rest and physiotherapy for costochondritis, Tietze syndrome and muscular strain.

  • Psychogenic and panic

    Once life-threatening causes are excluded, cognitive behavioural therapy, breathing retraining and treatment of underlying anxiety or panic disorder.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

If you have chest pain that concerns you, please get seen. In the UK, call 999 for any suspected acute coronary syndrome, dissection or pulmonary embolism.

  • NICE. Chest pain of recent onset: assessment and diagnosis (NG185).

  • NICE. Acute coronary syndromes (NG185 and related quality standards).

  • European Society of Cardiology. Guidelines on acute coronary syndromes and aortic diseases.

  • Resuscitation Council UK. Advanced Life Support guidance.

  • British Thoracic Society. Guidelines on pleural disease and pulmonary embolism.

Red flags

When chest pain needs a 999 call.

Most chest pain is manageable. These are the patterns that are not, and where every minute counts.

  • Suspected acute coronary syndrome

    Central, crushing, pressure or heavy pain lasting more than 15 minutes, especially with sweating, nausea, breathlessness or radiation to arm, jaw or back. Call 999.

  • Suspected aortic dissection

    Sudden, severe, tearing pain between the shoulder blades, a blood-pressure difference between arms, or focal neurological signs. Call 999 immediately.

  • Suspected pulmonary embolism

    Sudden pleuritic pain with breathlessness, tachycardia, calf swelling, recent surgery, immobility or a known clotting tendency. Urgent assessment needed.

  • Tension pneumothorax

    Sudden severe one-sided chest pain with breathlessness, tracheal deviation and low blood pressure. A time-critical emergency.

  • Oesophageal rupture (Boerhaave)

    Severe chest pain after forceful vomiting, often with surgical emphysema. Rare but life-threatening and needs surgical review.

  • Haemodynamic compromise

    Any chest pain with low blood pressure, fast or slow pulse, pale clammy skin or loss of consciousness needs a 999 response.

  • Exertional chest pain

    New chest pain that comes on with exertion and settles with rest is angina until proven otherwise and needs same-day medical assessment.

  • Not relieved by GTN

    Chest pain that fails to settle with a glyceryl trinitrate spray, or that returns quickly, should be treated as suspected ACS until proven otherwise.

  • Chest pain with focal neurology

    Chest or back pain with new weakness, numbness or speech disturbance can signal dissection with stroke and needs a 999 response.

Living with it

A common symptom, with a clear playbook.

Four things that make the biggest difference if you live with angina, have had a heart attack or carry cardiovascular risk factors.

A quiet reminder

Never drive yourself to hospital with new severe chest pain.

Call 999. Ambulance crews can start treatment on the way and take you to a hospital equipped for primary PCI if you are having a heart attack.

  1. 01 Know

    Learn your pattern

    If you have known angina, know what your usual pain feels like, what triggers it and what settles it, so you spot change early.

  2. 02 Plan

    Have a GTN plan

    Carry your GTN spray, know the sit-down-and-spray routine and know when a persisting attack becomes a 999 call.

  3. 03 Reduce

    Lower cardiovascular risk

    Stop smoking, keep blood pressure and cholesterol in target range, treat diabetes well and stay active. Small changes reduce future events.

  4. 04 Recover

    Use cardiac rehab

    After a heart attack or PCI, cardiac rehabilitation improves fitness, mood and long-term outcomes. Ask to be referred if not already offered.

Frequently asked

Everything we get asked about chest pain.

Quick answers on when to call 999, what the tests do and how the common non-cardiac causes are treated.

  • When is chest pain a 999 call?

    Call 999 for chest pain that is new, severe, pressure-like, crushing or heavy, lasts more than 15 minutes, spreads to the arm, jaw or back, or comes with sweating, nausea, breathlessness or a feeling of faintness. Do not drive yourself.

  • What is the difference between angina and a heart attack?

    Angina is chest pain from reduced blood supply to the heart, usually brought on by exertion and relieved by rest or a GTN spray within a few minutes. A heart attack is when a coronary artery blocks off, the pain does not settle and heart muscle starts to die. Any prolonged or new pattern needs to be treated as a heart attack until proven otherwise.

  • Can chest pain come from stress or anxiety?

    Yes. Panic attacks and anxiety can cause tight, heavy or sharp chest pain, often with hyperventilation, tingling in the hands and a sense of doom. But this is a diagnosis of exclusion, made only after serious causes have been ruled out with an ECG, examination and appropriate blood tests.

  • What tests will I have for chest pain?

    A 12-lead ECG within 10 minutes, high-sensitivity troponin blood tests, a chest X-ray and, depending on the picture, a D-dimer, CT pulmonary angiogram, CT of the aorta or CT coronary angiography. NICE NG185 makes CT coronary angiography a first-line test for stable chest pain of suspected cardiac origin.

  • How is costochondritis different from a heart attack?

    Costochondritis usually produces a sharp, well-localised pain over a costochondral joint that is reproduced by pressing on the area or by twisting and deep breathing. It is not associated with sweating, breathlessness or radiation to the arm or jaw. Any diagnostic doubt still needs an ECG and clinical review.

  • What should I do while I wait for the ambulance?

    Sit down and rest. If you have been prescribed a GTN spray, use it. Chew a 300 mg aspirin unless you are allergic or told not to. Unlock the front door if you are alone, and stay on the phone with the 999 operator until help arrives.

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