chest pain,  heart

Is it a heart attack? The top five signs your chest pain is the real deal

You’re minding your own business when – wham! – your chest feels like it just met the business end of a baseball bat. As the chest pain intensifies, you imagine the worst. It’s a heart attack. This is how it ends for me. I should have exercised more. I could have found time. Why wasn’t I vegan?

You have two important decisions to make. First, are you going to blow this off and hope for the best, or are you going to seek medical attention? And second, should you make an appointment for after work, or just call an ambulance?

Of course, not all chest pain is a heart attack. The other possibilities range from the benign – like a muscle strain, irritation of a rib joint, or acid reflux – to the alarming – like pneumonia, pulmonary embolism (blood clot in the lungs), or aortic dissection (tear in the large blood vessel arising from the heart).

So if you’re experiencing chest pain, how do you know if it’s time to call 911?

You have chest pressure at rest that gets worse with exertion.

Even though the heart is always full of blood, the muscular walls need their own dedicated supply of oxygen-rich blood. In a heart attack, the arteries that feed the heart muscle get blocked, causing the heart to suffocate and malfunction. The main symptom is crushing, pressure-like pain, which may sometimes travel down the arms or up to the jaw. During exertion, the heart beats faster and harder, making it even thirstier for oxygen and intensifying your pain.

You also feel short of breath.

If your heart starts failing, blood can back up into your lungs and make you feel breathless. Another possible explanation is that you’ve developed a blood clot in your lungs (pulmonary embolism), which can cause both pain and shortness of breath. This condition is more likely if you take oral contraceptives, have an immobilized leg (e.g., in a cast), or have cancer.

You’ve had an abnormal stress test.

A stress test determines if your heart muscle gets adequate blood flow during exertion. An abnormal result indicates the supply is at least partially blocked, increasing the chances that chest pain is from your heart. (In contrast, a normal test makes chest pain less likely to be from the heart.)

The pain doesn’t change with deep breathing or changes in position.

Pain originating from the heart doesn’t usually change with deep breathing, raising your arms, or twisting your torso. In these cases, more likely explanations include:

  • muscular injuries or irritated rib joints (costochondritis)
  • infection of the lung (pneumonia), particularly if you also have fever and cough
  • irritation of the lining around the lungs (pleurisy), especially if you have lupus or other autoimmune diseases
  • irritation of the lining around the heart (pericarditis), especially if the pain is mostly relieved by sitting forward

The pain came on suddenly and feels like a sharp, ripping sensation in your chest and back.

You may have a tear in the lining of the aorta, the main vessel that receives blood from the heart and distributes it to the rest of the body. You’re at increased risk for this dangerous condition if you’re really tall (since you could have a connective tissue disease known as Marfan’s), or if you have a long history of high blood pressure.

Christopher Kelly, M.D., M.S.

Christopher Rehbeck Kelly, M.D., M.S., is a cardiology fellow at NewYork-Presbyterian Hospital / Columbia University Medical Center.