I’ve been experiencing shortness of breath and chest tightness; what could be causing this and how should I manage it?

Shortness of Breath and Chest Tightness: Evaluation and Management

You need immediate medical evaluation to distinguish between life-threatening cardiac causes (like angina or heart attack) and respiratory conditions (like asthma or exercise-induced bronchoconstriction), as chest tightness with breathing difficulty can represent either emergency. 1, 2

Immediate Priorities: Rule Out Life-Threatening Causes

Do not assume this is anxiety or a benign condition without objective testing—serious causes like pulmonary embolism, acute coronary syndrome, and pneumonia can present with shortness of breath and chest tightness as primary symptoms. 3, 4

Critical Red Flags Requiring Emergency Evaluation

• Chest tightness provoked by exertion and relieved by rest suggests cardiac ischemia (angina), especially if cold weather worsens symptoms 1
• Sudden onset with unilateral leg swelling or recent immobilization raises concern for pulmonary embolism, which can present without chest pain 3, 5
• Fever accompanying dyspnea requires evaluation for pneumonia or other infectious causes 4
• Persistent symptoms at rest or worsening over days demands urgent workup 2, 6

Initial Diagnostic Approach

First-Line Testing (Obtain These Immediately)

• Chest radiography is the appropriate first imaging test for chronic dyspnea to identify consolidations, infiltrates, or structural abnormalities 5, 7
• Electrocardiogram (ECG) to assess for cardiac ischemia, arrhythmias, or conduction abnormalities 1, 7
• Oxygen saturation and vital signs including blood pressure and respiratory rate 4, 7
• Complete blood count to exclude anemia as a cause 7, 2
• Basic metabolic panel for baseline assessment 7

Second-Line Testing Based on Initial Results

• Brain natriuretic peptide (BNP) or NT-proBNP is the single most important test when initial cardiac and pulmonary workup is unrevealing, with BNP <100 pg/mL having 96-99% sensitivity for ruling out heart failure 2
• Spirometry before and after bronchodilator to establish baseline lung function and rule out asthma or COPD 1, 7
• D-dimer testing may help rule out pulmonary embolism if clinical suspicion exists 7, 3

Understanding Your Symptoms: Three Distinct Sensations

The American Thoracic Society identifies three mechanistically distinct breathing sensations that help narrow the diagnosis 5:

1. Chest Tightness

"Tightness" is the hallmark sensation of bronchoconstriction and is commonly experienced during asthma attacks or exercise-induced bronchoconstriction. 5

• Tightness arises from stimulation of airway receptors (pulmonary afferents), not from increased work of breathing 5
• Cold air is a potent trigger for bronchospasm in susceptible individuals 1
• Tightness responds rapidly to nebulized albuterol, whereas work/effort sensations respond more slowly 5
• This sensation is dominant in early stages of asthma attacks 5

2. Work/Effort of Breathing

• Sensations of increased work or effort arise from respiratory muscle afferents and perceived cortical motor command 5
• Can be produced by external resistive loads, weakened respiratory muscles, or increased ventilatory demand 5
• Much greater in patients with cardiopulmonary disease and frequently limits exercise 5

3. Air Hunger/Unsatisfied Inspiration

• Perception of not getting enough air, induced by increased inspiratory drive when capacity to satisfy ventilatory demand is limited 5
• Common in patients with cardiopulmonary disease, restrictive lung disease, or when dynamic hyperinflation restricts inspiratory capacity 5

Specific Diagnostic Pathways

If Symptoms Are Exercise-Related and Resolve at Rest

This pattern is classic for either exercise-induced bronchoconstriction (EIB) or cardiac ischemia—both require objective testing for diagnosis. 5, 1

For Suspected Exercise-Induced Bronchoconstriction:

• Perform exercise challenge test using treadmill or cycle ergometry, achieving heart rate ≥85% of maximum for 6 minutes 5, 1
• A fall in FEV1 ≥10% from baseline confirms EIB 1
• Self-reported symptoms without objective testing are not diagnostic 5, 1
• Do not initiate therapeutic trials without establishing a diagnosis—this leads to unnecessary medication use and missed alternative diagnoses 1

For Suspected Cardiac Ischemia:

• Do not assume a negative stress test excludes all cardiac causes—it primarily rules out obstructive coronary disease but not heart failure with preserved ejection fraction (HFpEF), valvular disease, or pulmonary hypertension 2
• If BNP is elevated (≥100 pg/mL), proceed to echocardiography to assess for diastolic dysfunction, valvular disease, or pulmonary hypertension 2
• Women often present with atypical angina (chest tightness without crushing pain), making cardiac evaluation essential in your demographic 1

If Initial Testing Is Normal

When chest radiography, ECG, spirometry, and basic labs are unrevealing, obtain BNP/NT-proBNP as the next step. 2

• If BNP is normal (<100 pg/mL), consider cardiopulmonary exercise testing (CPET) to identify exercise-induced limitations, deconditioning, exercise-induced bronchoconstriction, or exercise-induced arterial hypoxemia 2
• CPET distinguishes between cardiac limitation, pulmonary limitation, and deconditioning when resting tests are normal 2
• Deconditioning is a common cause of exertional dyspnea in patients with normal resting cardiac and pulmonary function 2

If Symptoms Persist Despite Normal Initial Workup

• Chest CT without contrast is appropriate as second-line imaging for conditions of unclear etiology, suspected COPD, small airways disease, or to evaluate for interstitial lung disease 5, 2
• Consider inspiratory/expiratory CT to evaluate for air trapping on expiratory images, associated with small airways disease 5

Common Diagnostic Pitfalls to Avoid

• Never diagnose based on self-reported symptoms alone—objective testing with bronchoprovocation or cardiac stress testing is mandatory 1
• Never dismiss pulmonary embolism based solely on absence of classic symptoms—it can present with shortness of breath as the major symptom without chest pain 3, 4
• Never label symptoms as "anxiety" or "panic" before excluding serious causes—pulmonary embolism, cardiac ischemia, and pneumonia must be ruled out first 3
• Clinical evaluation alone has low sensitivity (59%) for cardiac causes, making biomarker testing essential 2
• A negative cardiac stress test does not exclude HFpEF, which is particularly common in middle-aged women and may present with normal systolic function but diastolic dysfunction 2

When to Refer to Specialists

• Refer to cardiology if echocardiography reveals valvular disease, HFpEF, or if cardiac etiology remains suspected despite negative initial testing 2
• Refer to pulmonology for consideration of interstitial lung disease, pulmonary vascular disease, or if CPET suggests pulmonary limitation 2

Treatment Considerations (Only After Diagnosis)

Treatment depends entirely on the underlying cause identified through objective testing. 5

If Exercise-Induced Bronchoconstriction Is Confirmed:

• Inhaled short-acting β2-agonists (SABAs) are effective for 2-4 hours when used before exercise 5, 1
• Caution against daily use of β2-agonists alone—this can lead to tolerance, manifesting as reduced duration and magnitude of protection 5
• Leukotriene modifiers can be used daily or intermittently without tolerance development 5
• Inhaled corticosteroids (ICS) taken alone or in combination can decrease frequency and severity of EIB but do not eliminate it in all subjects 5

If Cardiac Cause Is Identified:

• Treatment directed at underlying condition (heart failure, ischemia, valvular disease) per cardiology recommendations 2

The presence of dyspnea is a potent predictor of mortality, often surpassing common physiological measurements in predicting clinical course—do not delay evaluation. 5, 2