What could be causing a pricking pain on my left chest?

Evaluation of Pricking Pain on Left Chest

Your pricking pain on the left chest requires immediate evaluation to exclude life-threatening cardiac causes, particularly acute coronary syndrome, before considering more benign explanations like musculoskeletal pain. 1

Immediate Actions Required

Call 9-1-1 or go to the emergency department immediately if you experience any of the following: 1

• Diaphoresis (sweating), tachycardia, or feeling faint 1
• Pain radiating to your left arm, jaw, neck, or back 1
• Shortness of breath or difficulty breathing 1
• Nausea, vomiting, or lightheadedness 1
• Sudden onset of severe "ripping" or "tearing" quality pain 1
• Pain that occurs at rest or with minimal exertion 1

Characteristics That Suggest Your Pain May Be Less Urgent

Sharp, pricking chest pain that increases with inspiration and lying supine is unlikely to be related to ischemic heart disease and more commonly suggests pericarditis or musculoskeletal causes. 1

• Fleeting chest pain lasting only a few seconds is unlikely to be cardiac 1
• Pain that can be localized to a very limited area and reproduced by palpation is more likely musculoskeletal 1
• Positional chest pain (changes with body position) is usually nonischemic 1

Critical Differential Diagnoses to Exclude

Life-Threatening Causes

Acute Coronary Syndrome (ACS): Typically presents as retrosternal pressure, heaviness, or tightness that gradually builds over minutes, often with diaphoresis, nausea, or dyspnea 1

Aortic Dissection: Sudden onset of severe "ripping" pain radiating to the back, especially if you have hypertension or connective tissue disorders 1, 2

Pulmonary Embolism: Tachycardia and dyspnea occur in >90% of patients, with pain that may worsen with inspiration 1, 2

Pneumothorax: Dyspnea and pain on inspiration with unilateral absence of breath sounds 1

Other Cardiac Causes

Pericarditis: Sharp chest pain that increases with inspiration and lying supine, may have fever and friction rub 1

Myocarditis: Fever, chest pain, and signs of heart failure 1

Non-Cardiac Causes

Costochondritis: Tenderness of costochondral joints reproducible by palpation 1

Pneumonia: Fever, localized chest pain that may be pleuritic, with regional dullness to percussion 1

Herpes Zoster: Pain in dermatomal distribution, triggered by touch, with characteristic unilateral rash 1

What You Should Do Now

If you are not currently experiencing alarming symptoms, you should still see a healthcare provider urgently (within 24 hours) for proper evaluation. 1

Required Initial Evaluation

• ECG should be obtained within 10 minutes if you present to an emergency department 1
• Cardiac troponin should be measured as soon as possible if ACS is suspected 1
• Focused cardiovascular examination to identify serious causes 1
• Chest radiograph to evaluate cardiac, pulmonary, and thoracic causes 2

If Seen in Office Setting

Unless a noncardiac cause is evident, an ECG should be performed; if unavailable, you should be referred to the emergency department 1

Patients with clinical evidence of ACS or other life-threatening causes should be transported urgently to the ED, ideally by EMS 1

Important Caveats

Do not use relief with nitroglycerin as a diagnostic criterion for cardiac vs. non-cardiac pain—this is unreliable 1, 2

Women are at particular risk for underdiagnosis of cardiac disease and may present with atypical symptoms including sharp or stabbing pain 1, 3

If you are >75 years old, ACS should be considered even with atypical presentations like isolated shortness of breath or confusion 1

Patients with diabetes may have atypical presentations of cardiac ischemia 1, 3

A normal physical examination does not exclude ACS—the examination may be completely normal in uncomplicated cases 1, 2

Bottom Line

While pricking pain can be benign (especially if reproducible by palpation and positional), you must be evaluated by a healthcare provider to systematically exclude life-threatening causes before attributing your symptoms to a benign cause 1, 4, 2. The evaluation should include at minimum an ECG and focused cardiovascular examination 1.