What could be causing my palpitations and chest pain, given that I'm an adult under significant stress?

Stress-Related Palpitations and Chest Pain: Evaluation and Management

Immediate Action Required

You must call 9-1-1 immediately if your chest pain is accompanied by diaphoresis (sweating), nausea, vomiting, shortness of breath, lightheadedness, or if the pain interrupts your normal activities—these symptoms require emergency evaluation to rule out life-threatening cardiac conditions. 1

Understanding Your Symptoms

While stress can certainly cause palpitations and chest pain, the initial evaluation must focus on excluding life-threatening cardiac causes including acute coronary syndrome (heart attack), aortic dissection, and pulmonary embolism before attributing symptoms to stress alone. 1, 2

Why This Matters

• Cardiac causes account for 20-69% of chest pain presentations depending on the clinical setting, with acute coronary syndrome representing 40-66% of emergency calls for chest pain 2
• Palpitations can indicate ventricular arrhythmias, which may occur with or without underlying heart disease 1
• The severity of your symptoms does not necessarily reflect the seriousness of the underlying condition—some patients with serious cardiac disease have minimal symptoms 1

Essential Immediate Evaluation

You Need These Tests Urgently:

1. 12-lead ECG within 10 minutes of medical evaluation to identify ST-segment elevation, dangerous arrhythmias, or other acute cardiac changes 1, 2

2. Cardiac troponin blood test as soon as possible to detect heart muscle damage 1, 2

3. Focused cardiovascular examination to identify signs of heart failure, valve problems, or aortic dissection 1

Critical Red Flags Requiring Emergency Care:

• Sudden onset of severe "ripping" chest pain radiating to your back (suggests aortic dissection) 1
• Chest pain with diaphoresis, cold sweats, or feeling faint (suggests acute coronary syndrome) 1, 2
• Palpitations with syncope (passing out) or near-syncope (suggests dangerous arrhythmia requiring hospitalization) 1
• Chest pain that gradually builds over minutes rather than fleeting seconds (more concerning for cardiac ischemia) 1

Differential Diagnosis: What Could Be Causing Your Symptoms

Life-Threatening Cardiac Causes (Must Rule Out First):

Acute Coronary Syndrome:

• Presents as retrosternal pressure, tightness, or discomfort that may radiate to arms, jaw, or neck 1, 2
• May be accompanied by shortness of breath, nausea, or diaphoresis 1
• Can occur at rest or with minimal exertion in unstable presentations 1
• Important caveat: Women, elderly patients, and diabetics frequently present with atypical symptoms including sharp or positional pain 1, 3

Ventricular Arrhythmias:

• Palpitations may feel like skipped beats, extra beats, or sustained rapid heartbeat 1
• Can be triggered by emotional stress or exercise 1
• May cause chest pain, shortness of breath, dizziness, or syncope 1

Pericarditis:

• Sharp, pleuritic chest pain that worsens when lying flat and improves when leaning forward 1, 2, 3
• May be accompanied by fever 1
• ECG shows widespread ST-elevation and PR depression 2

Other Cardiac Causes:

Stress Cardiomyopathy (Takotsubo):

• Can present identically to acute coronary syndrome 1
• Often triggered by significant emotional or physical stress 1
• Requires the same urgent evaluation as ACS 1

Non-Cardiac Causes (Only After Cardiac Causes Excluded):

Anxiety/Panic Disorder:

• Accounts for 5-11% of chest pain presentations 2
• Can cause palpitations, chest tightness, shortness of breath, and sense of impending doom 2
• Critical pitfall: Never assume anxiety is the cause without proper cardiac evaluation first 1

Musculoskeletal:

• Most common cause in general practice (43%) but only 5-14% in emergency settings 2, 4
• Pain is reproducible with palpation of chest wall or costochondral joints 1, 4
• Important caveat: Approximately 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome 4

Gastroesophageal Reflux:

• Accounts for 10-20% of outpatient chest pain 2
• Burning retrosternal discomfort, often worse after meals or when lying flat 2
• Do not use nitroglycerin response as a diagnostic test—esophageal spasm also responds to nitroglycerin 3

Risk Factors That Increase Cardiac Probability

Your evaluation should assess for: 1

• Hypertension, diabetes, high cholesterol, smoking
• Known coronary artery disease, prior heart attack, or heart failure
• Family history of sudden cardiac death or premature coronary disease in first-degree relatives
• Medications that prolong QT interval or stimulants (including caffeine, cocaine, amphetamines)
• Thyroid disease or electrolyte abnormalities

Recommended Evaluation Algorithm

Step 1: Emergency Assessment (If Not Already Done)

• Call 9-1-1 for transport to emergency department if any red flag symptoms present 1
• ECG within 10 minutes and cardiac troponin measurement 1, 2
• Focused cardiovascular examination 1

Step 2: If Initial Tests Are Normal

• Ambulatory ECG monitoring (24-48 hour Holter monitor) to capture palpitations and correlate with symptoms 5, 6
• Consider stress testing if chest pain characteristics suggest possible angina 1
• Echocardiogram if examination suggests structural heart disease 1

Step 3: If Cardiac Evaluation Is Negative

• Consider gastroesophageal causes with trial of proton pump inhibitor 2, 7
• Evaluate for anxiety/panic disorder if symptoms fit the pattern 2, 7
• Musculoskeletal evaluation if chest wall tenderness is present 4

When Stress Is the Likely Cause

Only after thorough cardiac evaluation excludes dangerous causes can stress-related palpitations and chest pain be diagnosed. 1, 2

Stress can cause:

• Sinus tachycardia (normal fast heart rate) that feels uncomfortable 6
• Increased awareness of normal heartbeat 6
• Chest wall muscle tension causing discomfort 4
• Hyperventilation leading to chest tightness 2

Common Pitfalls to Avoid

1. Never dismiss cardiac causes based on age, sex, or stress history alone—women and elderly patients are at particular risk for underdiagnosis 1

2. Fleeting pain lasting only seconds is reassuring, but pain building over minutes is concerning for cardiac ischemia 1

3. Relief with nitroglycerin does not confirm cardiac cause—esophageal disorders also respond 3

4. Reproducible chest wall tenderness is reassuring but does not exclude cardiac disease in 7% of cases 4

5. Normal resting ECG does not exclude acute coronary syndrome—serial troponins and further testing may be needed 1