Chronic chest pain: causes, red flags and how it is investigated

There is no strict cut-off, but doctors tend to use the word chronic or recurrent for chest pain that keeps coming back over weeks or months, or that has been present most days. It is a different problem from the sudden, crushing pain of a heart attack, although both deserve respect. People with long-standing chest pain often live for months with uncertainty about whether it comes from the heart, the gullet, the lungs, the chest wall or anxiety.

The first job of any assessment is to decide whether the pain could be cardiac, because that is the cause that changes treatment most. The next is to find the most likely non-cardiac cause so the pain can be treated rather than endured. The questions below follow the order a clinician is likely to take.

The NHS chest pain page pairs symptoms with likely causes, and it stresses that you should not self-diagnose. The table combines that guidance with the NHS pages on angina and heartburn.

Pain that feels like tightness, squeezing, pressure or a dull ache, appears with exertion or emotion, and comes with breathlessness, sweating, sickness or dizziness is more suggestive of angina. The NHS adds that you are more likely to have a heart cause if you are older or have risk factors for coronary heart disease: smoking, living with obesity, high blood pressure, diabetes or high cholesterol, and close relatives who had heart attacks or angina under 60.

Microvascular and vasospastic angina are less familiar forms in which small or reactive vessels cause the same pain even when large arteries look open. They are one reason why a normal-looking scan does not always end the investigation, and the NHS points to the British Heart Foundation for more detail.

Even if you have had chest pain for months, a change in its character is a warning. The NHS advice splits into the following levels.

• Call 999 if you get sudden pain or discomfort in the chest that does not go away, whether it feels like squeezing, pressure, burning or indigestion.

• Call 999 if the pain spreads to the left or right arm, the neck, jaw, shoulder, stomach or back.

• Call 999 if chest pain comes with sweating, feeling sick, light-headedness or shortness of breath: you could be having a heart attack and need treatment in hospital.

• If you have diagnosed angina and the pain does not stop after resting or after medicine, the NHS says to take a second dose after 5 minutes, and call 999 if you still have symptoms 5 minutes after the second dose.

• Get help from NHS 111 if you have chest pain that comes and goes, or diagnosed angina that is getting worse, happening more often, lasting longer or occurring at rest.

• Pain with sudden breathlessness, coughing blood, or a swollen painful leg may point to a clot in the lungs, which also needs emergency care.

• Do not drive yourself to A&E.

Expect detailed questions: where the pain sits and whether it spreads, what it feels like, what brings it on, how long it lasts, what relieves it, and whether it varies with breathing, eating, posture or movement. The clinician will ask about breathlessness, palpitations, fainting, cough, fever, heartburn, difficulty swallowing and mood, and about smoking, blood pressure, diabetes, cholesterol and family history.

The examination typically includes pulse, blood pressure, oxygen level, listening to the heart and lungs, pressing the chest wall to see whether it reproduces the pain, and looking for leg swelling. A normal examination does not exclude angina, so further tests are often needed if the story fits.

If a GP thinks you may have angina the NHS says you will be referred to a cardiologist, with tests that can include blood tests, an electrocardiogram (ECG) to check the electrical activity of the heart, checking the level of oxygen in your blood, and scans such as an angiogram, MRI scan or CT scan.

For suspected reflux, a GP may try a proton pump inhibitor trial, and if medicines do not help or symptoms are severe the NHS says a referral for gastroscopy may follow. For possible lung causes, a chest X-ray and breathing tests may be used. If anxiety seems likely, the assessment focuses on its pattern after heart and lung causes have been reasonably excluded.

For reflux-type pain the NHS suggests smaller, more frequent meals, avoiding trigger foods, not eating within 3 or 4 hours of bed, not smoking, moderating alcohol and, if overweight, losing weight. It also suggests raising the head of the bed by about 10 to 20cm rather than stacking extra pillows.

For angina, the NHS advises avoiding triggers such as stress, cold and large meals, always carrying prescribed medicine, giving up smoking, keeping to a healthy weight and cutting alcohol if above 14 units a week. Keeping a note of when pain occurs, how long it lasts and what helped can speed up the next consultation.

Recurrent pain is first assessed by the GP, who can organise an ECG and blood tests and arrange a rapid cardiology route if angina is suspected. Gastroenterology, respiratory or musculoskeletal teams are involved if the picture points that way. Private cardiology clinics offer quick access to ECG, echo and CT coronary angiography, which some people choose to shorten uncertainty; any sudden change in pain should still be handled through emergency services.