What is causing my intermittent sharp left chest pain?

Intermittent Sharp Left Chest Pain: Evaluation and Causes

Sharp, intermittent left chest pain is most likely noncardiac in origin—particularly musculoskeletal, pleuritic, or gastrointestinal—but you must systematically exclude life-threatening cardiac causes (acute coronary syndrome, pericarditis) and other emergencies (pulmonary embolism, aortic dissection) before attributing symptoms to benign conditions. 1, 2

Why Sharp Pain Suggests Lower Cardiac Risk

• Sharp chest pain that is fleeting (lasting only seconds), positional, or increases with inspiration (pleuritic) suggests a lower likelihood of myocardial ischemia. 1
• Pain that can be localized to a very limited area (point tenderness) makes ischemia less likely, as cardiac pain is characteristically deep, diffuse, and difficult to localize. 1
• Cardiac ischemia typically presents as substernal pressure, heaviness, or squeezing that gradually builds over minutes—not sharp, stabbing sensations. 1

Critical Red Flags Requiring Immediate Emergency Evaluation

Despite the "sharp" quality making cardiac causes less likely, you must still evaluate for these emergencies:

Acute Coronary Syndrome (ACS)

• Even though sharp pain is atypical, ACS can present with varied symptoms, particularly in women, elderly patients, and those with diabetes. 1, 2
• Associated features that increase ACS likelihood include: diaphoresis, nausea, vomiting, radiation to arm/jaw/neck, symptoms interrupting normal activity, dyspnea, or lightheadedness. 1, 2
• If any concern for ACS exists, activate 9-1-1 immediately for EMS transport to obtain an ECG within 10 minutes of arrival and measure cardiac troponin. 1, 2

Acute Pericarditis

• Sharp chest pain that increases with inspiration and lying supine, relieved by sitting forward, strongly suggests acute pericarditis rather than ischemic heart disease. 1
• This is a cardiac cause that presents with sharp pain and requires ECG evaluation for characteristic diffuse ST-segment elevation and PR depression. 3

Pulmonary Embolism

• Pleuritic sharp chest pain with dyspnea and tachycardia (present in >90% of PE patients) requires consideration. 1, 2
• Peripheral pulses remain intact in PE, so their presence does not exclude this diagnosis. 2

Aortic Dissection

• Sudden onset of severe "ripping" or "tearing" sharp pain radiating to the back suggests aortic dissection, particularly in hypertensive patients. 1, 2
• The absence of pulse differential does NOT rule out aortic dissection, especially Type B dissections. 2

Most Likely Noncardiac Causes of Sharp Left Chest Pain

Musculoskeletal Pain (Most Common)

• Chest wall pain or costochondritis presents as sharp, localized pain that worsens with movement, palpation, or specific positions. 4
• Point tenderness on examination strongly suggests musculoskeletal origin. 1

Pleuritic Pain

• Sharp pain that worsens with deep breathing suggests pleural irritation from pneumonia, pleuritis, or pneumothorax. 1

Gastrointestinal Causes

• Esophageal spasm, gastroesophageal reflux disease, or rarely esophageal rupture can cause sharp chest pain. 4, 5
• Gastrointestinal disorders account for approximately 10-20% of chest pain cases. 6

Immediate Diagnostic Approach

You must obtain the following to safely exclude life-threatening causes:

1. Detailed history focusing on:

   • Exact pain characteristics (onset, duration, quality, location, radiation) 1
   • Precipitating factors (exertion, position, inspiration, meals) 1
   • Associated symptoms (dyspnea, diaphoresis, palpitations, syncope) 1, 2
   • Cardiovascular risk factors and family history 1

2. Physical examination including:

   • Vital signs (tachycardia, hypotension, tachypnea suggest emergency) 1, 2
   • Cardiovascular examination (murmurs, S3, pulse differentials) 1
   • Chest wall palpation for reproducible tenderness 1
   • Lung examination for decreased breath sounds or crackles 1

3. 12-lead ECG should be obtained unless a clearly noncardiac cause is evident. 1, 2

   • If unavailable in office setting, refer to ED for ECG. 1

4. If any concern for ACS exists, measure cardiac troponin as soon as possible. 1, 2

Critical Pitfalls to Avoid

• Do not rely on pain severity or character alone to determine urgency—severity is a poor predictor of imminent complications like cardiac arrest. 2
• Do not use nitroglycerin response as a diagnostic criterion, as relief with nitroglycerin does not confirm ischemia. 1
• Do not delay transfer to ED if cardiac causes cannot be confidently excluded in the outpatient setting. 1, 2
• Do not assume sharp pain automatically means "benign"—elderly patients and those with diabetes may present with atypical symptoms despite severe disease. 1, 2

When Noncardiac Diagnosis Is Appropriate

Only after systematically excluding life-threatening causes through history, examination, and ECG (with troponin if indicated) can you confidently attribute sharp chest pain to musculoskeletal, pleuritic, or gastrointestinal causes. 1, 4, 5