Retrosternal Chest Pain: Causes, Symptoms, and When to Worry

Retrosternal chest pain is any discomfort or pain felt behind the sternum (breastbone). Because this area is home to vital organs like the heart and esophagus, this symptom can be alarming. While it can be caused by something as simple as indigestion, it can also signal a life-threatening emergency like a heart attack.

This guide provides a comprehensive overview of retrosternal chest pain, its causes, symptoms, and when you should seek immediate medical help.

“Chest pain is a common symptom with many potential causes – some are life-threatening, and others are not. Prompt evaluation is essential to distinguish between the two.” — 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain

What is Retrosternal Chest Pain?

Retrosternal chest pain literally means “pain behind the sternum.” It is also referred to as substernal pain or central chest pain. This pain is a symptom, not a diagnosis, and can manifest in several ways:

• A dull ache, pressure, or squeezing sensation.
• A sharp, stabbing pain.
• A burning feeling, often called heartburn.
• A sense of tightness in the mid-chest.

The nature of the pain, its duration, and any accompanying symptoms are crucial clues to its underlying cause.

Common Causes of Retrosternal Chest Pain

Pain behind the breastbone can originate from the heart, esophagus, lungs, muscles, or bones in the chest.

1. Heart-Related (Cardiac) Causes

Cardiac causes are the most critical to identify quickly.

• Angina Pectoris: This is chest pressure or squeezing caused by reduced blood flow to the heart muscle, typically due to coronary artery disease. It is often triggered by exertion or stress and relieved by rest.
• Heart Attack (Myocardial Infarction): A heart attack occurs when blood flow to the heart is completely blocked. It causes severe, often crushing retrosternal pain that lasts for more than a few minutes and is not relieved by rest. It is a medical emergency.
• Pericarditis: This is an inflammation of the sac surrounding the heart. It typically causes a sharp, stabbing pain that worsens when lying down or taking a deep breath and improves when leaning forward.
• Aortic Dissection: A rare but life-threatening condition where the inner layer of the aorta (the main artery from the heart) tears. It causes sudden, severe "tearing" or "ripping" pain that may radiate to the back.

2. Gastrointestinal (GI) Causes

Problems with the esophagus and stomach are very common causes of retrosternal pain.

• Gastroesophageal Reflux Disease (GERD): Also known as acid reflux, GERD is a frequent cause of a burning pain behind the sternum (heartburn). It happens when stomach acid flows back into the esophagus. The pain often worsens after eating, when lying down, or bending over, and may be relieved by antacids.
• Esophageal Spasm: Sudden, powerful contractions of the esophageal muscles can cause intense, crushing chest pain that can be mistaken for a heart attack.
• Esophagitis: Inflammation of the esophagus can cause pain and difficulty swallowing.
• Peptic Ulcer: An ulcer in the stomach or duodenum can sometimes cause a gnawing or burning pain that is felt in the lower chest area.
• Hiatal Hernia: When part of the stomach pushes up through the diaphragm, it can cause pain and contribute to GERD.

3. Musculoskeletal Causes

Pain can also originate from the chest wall's bones, cartilage, or muscles.

• Costochondritis: Inflammation of the cartilage connecting the ribs to the sternum. It causes sharp, aching, or pressure-like pain that is often tender to the touch. The pain can be reproduced by pressing on the affected area and may worsen with movement or deep breaths.
• Muscle Strain: Overexertion from lifting, exercising, or severe coughing can strain the chest muscles, causing localized pain that worsens with movement.
• Sternal Injury: A direct blow to the chest from an accident or fall can bruise or fracture the sternum, causing significant pain.

4. Lung-Related (Pulmonary) Causes

While often causing pain on the sides of the chest, some lung conditions can cause central chest pain.

• Pulmonary Embolism (PE): A blood clot in the lungs is a medical emergency. It can cause sudden, sharp chest pain (often worse with deep breathing), severe shortness of breath, and a rapid heart rate.
• Pleurisy: Inflammation of the lining around the lungs, causing sharp pain with breathing or coughing.
• Pneumonia or Bronchitis: Lung or airway infections can cause a burning pain behind the sternum, especially with coughing, along with fever and other respiratory symptoms.

5. Anxiety and Panic Attacks

Psychological distress can cause very real physical symptoms.

• Panic Attack: A panic attack can cause sharp chest pain, a racing heart, shortness of breath, and a feeling of impending doom. This is due to muscle tension, hyperventilation, and a heightened awareness of bodily sensations. The pain often peaks within 10 minutes and subsides as the panic attack resolves.

Differentiating Symptoms: Heart Attack vs. Heartburn vs. Musculoskeletal Pain

Feature	Heart Attack	Heartburn (GERD)	Musculoskeletal Pain
Sensation	Pressure, squeezing, heaviness	Burning, rising sensation	Sharp, achy, sore
Triggers	Can occur at rest or with exertion	Eating, lying down, bending over	Movement, deep breaths, pressing on the area
Relief	Not relieved by rest or antacids	Antacids, standing up, belching	Rest, heat, anti-inflammatories
Associated Symptoms	Shortness of breath, sweating, nausea, pain in arm/jaw	Sour taste in mouth, regurgitation	Pain is localized and reproducible with touch

⚠️ When to Seek Immediate Medical Help

Call emergency services (911) if you experience chest pain that is:

• Severe, crushing, or feels like heavy pressure, especially if it lasts more than five minutes.
• Accompanied by other symptoms, such as:
  • Shortness of breath or difficulty breathing
  • Cold sweats
  • Nausea or vomiting
  • Dizziness, lightheadedness, or fainting
  • Pain that radiates to the jaw, neck, back, shoulders, or arms (especially the left arm)
  • A feeling of impending doom
• Described as a "tearing" or "ripping" sensation that spreads to your back.

Do not try to drive yourself to the hospital. Call for an ambulance, as emergency medical personnel can begin treatment on the way.

"Any new, unexplained chest pain lasting more than a few minutes should be treated as a medical emergency until proven otherwise. When in doubt, check it out.” — American Heart Association

How Doctors Diagnose the Cause of Chest Pain

A doctor's primary goal is to rule out life-threatening conditions. The evaluation process typically includes:

1. Medical History: You'll be asked detailed questions about the pain, your activities, your personal and family medical history, and risk factors for heart disease.
2. Physical Exam: The doctor will check your vital signs, listen to your heart and lungs, and press on your chest wall to check for tenderness.
3. Diagnostic Tests:
   • Electrocardiogram (ECG or EKG): Records the heart's electrical activity to detect signs of a heart attack or other cardiac issues.
   • Blood Tests: To check for cardiac enzymes (like troponin), which are released when the heart muscle is damaged.
   • Chest X-ray: To view the lungs, heart, and major blood vessels.
   • CT Scan: May be used to diagnose a pulmonary embolism or aortic dissection.
   • Echocardiogram: An ultrasound of the heart to see how it is functioning.
   • Stress Test: If a heart attack is ruled out, a stress test may be done later to check for coronary artery disease.
   • Endoscopy: If a GI cause is suspected, a thin tube with a camera is used to examine the esophagus and stomach.

Treatment and Management

Treatment depends entirely on the underlying cause.

• Heart Attack: Emergency treatment aims to restore blood flow to the heart quickly using clot-busting drugs or a procedure called coronary angioplasty and stent placement.
• Angina: Managed with lifestyle changes, medications (like nitroglycerin, beta-blockers), and sometimes angioplasty or bypass surgery.
• GERD: Treated with lifestyle changes (avoiding trigger foods, not lying down after eating) and medications like antacids, H2 blockers, or proton pump inhibitors (PPIs).
• Musculoskeletal Pain: Typically managed with rest, heat, and over-the-counter anti-inflammatory drugs (like ibuprofen).
• Pulmonary Embolism: Requires immediate treatment with blood thinners and sometimes clot-dissolving medications.
• Anxiety/Panic Attacks: Managed with therapy (like CBT), stress-reduction techniques, and sometimes anti-anxiety medications.

Prevention

While not all causes of chest pain are preventable, you can reduce your risk of serious conditions:

• Maintain a Heart-Healthy Lifestyle: Don't smoke, eat a balanced diet, exercise regularly, and manage blood pressure, cholesterol, and blood sugar.
• Manage GERD: Identify and avoid trigger foods, eat smaller meals, and avoid lying down for 2-3 hours after eating.
• Reduce Stress: Practice relaxation techniques like meditation, yoga, or deep breathing to manage stress and anxiety.
• Exercise Safely: Warm up properly and use correct form to avoid straining chest muscles.
• Get Regular Check-ups: Proactively manage health conditions that are risk factors for heart disease.

Frequently Asked Questions (FAQs)

Q: What does “retrosternal chest pain” feel like? A: Retrosternal chest pain refers to any pain felt behind the breastbone in the center of your chest. The sensation can vary widely depending on the cause. It might feel like pressure or squeezing (common with heart-related pain), a burning sensation (common with acid reflux), a sharp or stabbing pain (from pericarditis or chest wall issues), or a general ache. It is the location of the pain, not a specific feeling.

Q: Is retrosternal chest pain always a heart attack? A: No, not always. While a heart attack is a serious potential cause, many other conditions can cause pain behind the sternum, including benign issues like heartburn (GERD) or muscle strain. However, because a heart attack is a life-threatening possibility, it's crucial to have any new, severe, or unexplained chest pain evaluated by a medical professional to rule it out.

Q: How can I tell the difference between heartburn and a heart attack? A: This can be difficult as symptoms can overlap. Heartburn is typically a burning pain that may worsen after eating or when lying down and might improve with antacids. Heart attack pain is more often a pressure, tightness, or squeezing sensation that may radiate to the arm, jaw, or neck and is often accompanied by shortness of breath, sweating, or nausea. If you are ever in doubt, seek emergency medical care immediately.

Q: When should I go to the ER for chest pain? A: Call 911 or go to the ER immediately if your chest pain is severe, lasts more than a few minutes, or is accompanied by warning signs like shortness of breath, cold sweats, nausea, fainting, or pain radiating to the jaw, neck, or arms. Sudden, tearing pain that radiates to the back is also an emergency. If you are worried the pain might be serious, it is always safer to get it checked out.

Q: Can anxiety or panic attacks really cause chest pain? A: Yes, absolutely. A panic attack can trigger a 'fight or flight' response, leading to a rapid heart rate, muscle tension in the chest wall, and hyperventilation, all of which can cause real, significant chest pain. While it feels very alarming, it is not physically dangerous like a heart attack. However, a doctor must first rule out physical causes before attributing chest pain to anxiety.

Q: What tests might the doctor do for my chest pain? A: To diagnose the cause of chest pain, a doctor will likely start with an electrocardiogram (ECG/EKG) and blood tests (like troponin) to check for heart damage. A chest X-ray is also common. Depending on the initial findings, further tests might include a CT scan (to check for blood clots or aortic issues), an echocardiogram (heart ultrasound), a stress test, or an endoscopy (to examine the esophagus for reflux).

Q: Can GERD (acid reflux) cause chest pain that feels like a heart problem? A: Yes. GERD is a very common cause of non-cardiac chest pain. The esophagus is located near the heart, and the shared nerve pathways can cause the brain to misinterpret the source of the pain. Reflux can cause a severe burning or pressure-like sensation under the sternum that can mimic a heart attack, which is why a medical evaluation is essential to distinguish the two.

Q: I have chest pain only when I press on my chest. Is that serious? A: Pain that is reproducible when you press on a specific spot on your chest wall or worsens with certain movements is most likely musculoskeletal, such as costochondritis (inflamed rib cartilage) or a muscle strain. This type of pain is generally not a sign of a heart attack, which typically causes a deep, internal pressure that is not affected by touch. While likely benign, a doctor can confirm the diagnosis.

Q: I get chest pain when I exercise, but it goes away with rest. What should I do? A: Chest pain that occurs with exertion and is relieved by rest is a classic symptom of angina, which is caused by reduced blood flow to the heart due to blocked arteries. This requires a prompt medical evaluation. Your doctor will likely recommend a stress test or other cardiac imaging to investigate the cause. Do not ignore this symptom.