Sudden Sharp Throbbing Upper Left Chest Pain
You need immediate emergency evaluation to rule out life-threatening cardiac and vascular causes—call 911 or go to the emergency department now, as this presentation requires an ECG within 10 minutes and immediate cardiac troponin measurement. 1
Immediate Life-Threatening Causes That Must Be Excluded
Acute Coronary Syndrome (ACS) is the primary concern despite the "sharp" quality of your pain, because sharp or stabbing chest pain does NOT exclude cardiac ischemia, particularly in women, elderly patients, and those with diabetes. 1 The pain waking you from sleep suggests occurrence at rest, which typically indicates ACS rather than stable angina. 1
Aortic dissection must be considered if your pain had sudden, abrupt onset with severe intensity, especially if you have hypertension, known aortic valve disease, or connective tissue disorders. 1 However, the "throbbing" quality makes this somewhat less likely than the classic "ripping" or "tearing" description. 1
Pulmonary embolism presents with sharp chest pain in over 90% of cases, typically accompanied by tachycardia and dyspnea, with pain worsening on inspiration. 1
Pneumothorax causes sharp pain with dyspnea and pain on inspiration, with unilateral absence of breath sounds on examination. 1
Critical Actions Required Immediately
Transport to the ED by EMS rather than driving yourself, as patients with acute chest pain should be transported urgently by emergency medical services. 1
ECG must be obtained within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI), new ischemic changes, or other abnormalities. 1
Cardiac troponin measurement should occur as soon as possible after presentation to detect myocardial injury. 1
Serial ECGs should be performed if the initial ECG is nondiagnostic but clinical suspicion remains high. 1
High-Risk Features Requiring Urgent Evaluation
You should seek immediate emergency care if you have any of these accompanying features:
- Associated symptoms: Diaphoresis, dyspnea, nausea, vomiting, lightheadedness, syncope, or palpitations 1
- Age >75 years with accompanying dyspnea, syncope, or acute delirium 2
- Known cardiovascular disease, diabetes, or renal insufficiency 2
- Hemodynamic instability including hypotension or tachycardia 2
Less Likely But Important Differential Diagnoses
Acute pericarditis presents with sharp chest pain that increases with inspiration and lying supine, typically improving when sitting forward—this is positional pain that distinguishes it from ischemic causes. 1 However, pericarditis can also present with fever and a friction rub on examination. 1
Musculoskeletal pain (costochondritis) would be reproducible with palpation of the chest wall and localized to a very limited area, but this diagnosis can only be considered after excluding life-threatening causes. 1
Critical Pitfalls to Avoid
Do not assume sharp pain means "not cardiac"—the 2021 ACC/AHA guidelines explicitly state that sharp, stabbing pain can occur with myocardial ischemia, especially in women, elderly patients, and those with diabetes. 1
Do not delay seeking care based on pain severity alone, as severity is a poor predictor of imminent complications like cardiac arrest. 3
Do not use nitroglycerin response as a diagnostic criterion, as relief with nitroglycerin does not confirm cardiac ischemia (esophageal spasm can respond similarly). 1
Do not wait for "classic" symptoms—examination may be completely normal in uncomplicated myocardial infarction cases. 1
What to Tell Emergency Providers
When you arrive at the ED, emphasize:
- Exact time of onset and whether it was sudden or gradual 1
- Pain characteristics: Sharp, throbbing, severity on 0-10 scale 1
- What you were doing when it started (at rest while sleeping) 1
- Any radiation to arm, jaw, neck, or back 1
- Associated symptoms including shortness of breath, sweating, nausea 1
- Cardiovascular risk factors: Hypertension, diabetes, smoking, family history of heart disease, known heart conditions 1