What should I do if I have substernal chest pain?

Management of Substernal Chest Pain

If you experience substernal chest pain, you should immediately call 911 (emergency services) for urgent transport to the nearest emergency department, as this could indicate a life-threatening condition requiring immediate medical attention. 1, 2

Initial Assessment and Triage

Substernal chest pain requires immediate evaluation as it may represent acute coronary syndrome (ACS) or other life-threatening conditions. The approach should follow this algorithm:

1. Call emergency services (911) - Do not drive yourself to the hospital or delay seeking care 1
2. Emergency medical services will:
   • Perform an ECG within 10 minutes of arrival
   • Transport you urgently to the emergency department
   • Begin appropriate initial treatment (oxygen if needed, aspirin, IV access)

Potential Causes of Substernal Chest Pain

Substernal chest pain can indicate several serious conditions:

• Acute Coronary Syndrome - Characterized by pressure, heaviness, tightness, or squeezing in the chest that may radiate to arms, jaw, or back 1
• Aortic Dissection - Sudden onset of severe, ripping pain, often described as "worst pain of life" 1
• Pulmonary Embolism - Associated with dyspnea, tachycardia, and pain that worsens with inspiration 1
• Esophageal Rupture - Associated with vomiting, subcutaneous emphysema 1
• Pericarditis - Pain that worsens when lying flat and improves when leaning forward 1, 2
• Pneumothorax - Sudden onset of sharp pain with dyspnea 1

Warning Signs Requiring Immediate Medical Attention

Seek emergency care immediately if your substernal chest pain is accompanied by:

• Shortness of breath
• Diaphoresis (sweating)
• Nausea or vomiting
• Radiation of pain to jaw, neck, arms, or back
• Dizziness or lightheadedness
• Pain occurring with exertion or emotional stress
• Pain in someone with risk factors for heart disease (hypertension, diabetes, smoking, high cholesterol)

What to Expect in the Emergency Department

The emergency department will perform:

1. Immediate ECG - To look for signs of heart attack or ischemia 1
2. Cardiac biomarker testing (troponin) - To check for heart damage 1
3. Physical examination - To help identify the cause of chest pain 1
4. Additional testing based on initial findings:
   • Chest X-ray
   • Additional ECGs
   • Cardiac stress testing
   • CT scan or other imaging if non-cardiac causes are suspected

Common Pitfalls to Avoid

• Delaying medical care - "Wait and see" approaches can be dangerous with substernal chest pain 2
• Self-diagnosing as "just indigestion" - Cardiac pain can mimic gastrointestinal symptoms 2
• Assuming pain must be severe to be serious - Even mild chest discomfort can indicate a serious condition 1
• Relying on nitroglycerin response to diagnose - Relief with nitroglycerin is not diagnostic of cardiac pain 1, 2

Key Point

The American Heart Association and American College of Cardiology guidelines emphasize that the initial evaluation of substernal chest pain should focus on rapidly identifying life-threatening causes 1. Time is critical - minutes lost can result in permanent heart damage or death. When in doubt, seek emergency medical care immediately.