Chest Pain Evaluation: When to Go to the Emergency Department

When your chest hurts, it’s easy to panic. Is it heartburn? A pulled muscle? Or something serious like a heart attack? The truth is, chest pain isn’t always what it seems-but when it is, every minute counts. Around 6 to 8 million people in the U.S. show up at emergency departments each year with chest pain. Only about 1 in 10 will have a heart attack. But missing the other 9%? That’s where things go wrong.

What Counts as Chest Pain?

Chest pain isn’t just a sharp stab or crushing pressure in the center of your chest. It can show up as tightness, heaviness, burning, or even just a weird ache that won’t go away. And it doesn’t even have to be in your chest. You might feel it in your jaw, shoulder, arm, neck, or upper belly. Some people get shortness of breath, nausea, cold sweats, or sudden fatigue instead of pain at all. These are called anginal equivalents-and they’re just as dangerous.

Women, older adults, and people with diabetes are more likely to have these atypical symptoms. If you’re over 50, have high blood pressure, smoke, or have a family history of heart disease, don’t wait to see if it “goes away.”

When to Call 9-1-1 Right Now

Don’t drive yourself. Don’t wait for a ride. Call emergency services immediately if you have:

• Chest pain that lasts more than 5 minutes and doesn’t change with rest or position
• Pain that spreads to your arm, jaw, neck, or back
• Shortness of breath, dizziness, or fainting along with the pain
• Breaking out in a cold sweat for no reason
• Nausea or vomiting that comes with chest discomfort
• Heart rate over 100 beats per minute or breathing faster than 20 times a minute
• Low blood pressure (below 90 systolic)
• Crackling sounds when you breathe or a new heart murmur

These aren’t just signs-they’re red flags for heart attack, pulmonary embolism, or aortic dissection. Every minute without treatment increases the chance of permanent damage or death. Emergency Medical Services (EMS) can start life-saving care before you even reach the hospital. They can give you aspirin, monitor your heart, and alert the ER team. Driving yourself increases your risk of sudden cardiac arrest on the way by 25-30%.

What Happens When You Get to the ER

The first thing they do? Get an ECG within 10 minutes. This is non-negotiable. A 12-lead electrocardiogram can show if your heart is being starved of oxygen right now. It’s fast, cheap, and the single most important test in chest pain evaluation. If the ECG shows ST-elevation, you’re having a STEMI-a full-blown heart attack-and they’ll rush you to the cath lab. The goal? Get a balloon open in your blocked artery within 90 minutes of arriving.

While the ECG runs, they’ll draw blood for a high-sensitivity troponin test. Troponin is a protein released when heart muscle dies. Modern assays can detect tiny amounts, and with a second test 1-2 hours later, doctors can rule out a heart attack in 70-80% of patients within two hours. That’s huge. It means you might not spend the night if your pain is from something else.

They’ll also check your vitals: heart rate, blood pressure, oxygen levels, breathing rate. If you’re unstable-low BP, fast heart rate, trouble breathing-they won’t wait for tests. They’ll treat you like a cardiac emergency, because you are.

What If It’s Not a Heart Attack?

Most chest pain isn’t from a heart attack. But that doesn’t mean it’s harmless. Other common causes include:

• GERD (acid reflux)
• Costochondritis (inflamed rib cartilage)
• Pulmonary embolism (blood clot in the lung)
• Pneumonia or pleurisy
• Pericarditis (inflamed heart lining)
• Anxiety or panic attacks

But here’s the catch: some of these look exactly like heart problems. That’s why doctors use tools like the HEART score to help decide your risk. It looks at your History, ECG findings, Age, Risk factors, and Troponin level. A score of 0-3? Low risk. You can go home with a follow-up appointment. A score of 7-10? High risk. You’re going to the cath lab.

If your ECG and troponin are normal, and you’re stable, they might send you for a CT angiogram (CCTA). This scan shows your heart arteries in detail. It’s more accurate than a stress test for spotting blockages-especially if you’re under 65 and have no prior heart disease. Stress tests are still used, but only if you can’t have a CT scan due to kidney problems or an allergy to contrast dye.

Why You Shouldn’t Try to Tough It Out

I’ve seen too many people wait. “It’s probably just gas.” “I had this last week and it went away.” “I don’t want to waste the ER’s time.”

Here’s the reality: heart attacks don’t always come with dramatic movie scenes. Sometimes they start as mild discomfort. Sometimes they come and go. And sometimes, they kill before you get to the hospital.

Studies show that patients who delay seeking care for more than two hours after symptoms start have significantly higher death rates. The sooner you get treated, the more heart muscle you save. And if you’re having a non-ST-elevation heart attack (the most common type), getting a heart catheter within 24 hours cuts your risk of another heart attack or death by nearly half.

What You Can Do Before You Go

If you’re unsure whether to go:

• Stop what you’re doing. Sit down. Rest.
• Don’t take nitroglycerin unless you’ve been prescribed it and know how to use it.
• Chew one 325mg aspirin (not enteric-coated) if you’re not allergic. It helps thin the blood and can reduce damage.
• Call 9-1-1. Don’t call a friend or family member first. EMS is faster and better equipped.
• Have your medications and ID ready. They’ll ask about your history, allergies, and what you’re taking.

Don’t wait for someone else to decide for you. If you’re worried, you’re probably right.

The Future of Chest Pain Evaluation

Hospitals are getting smarter. By 2025, 75% of U.S. emergency departments will use AI to analyze ECGs. These systems can spot tiny changes in heart rhythm that even experienced doctors miss-like early signs of ischemia that show up before chest pain starts. This could cut diagnosis time by 15-20 minutes, which means more lives saved.

But technology doesn’t replace judgment. The most important tool is still the doctor’s gut feeling. The Society for Academic Emergency Medicine calls it “Sick vs Not Sick.” Is the person pale? Sweating? Looking like they’re about to collapse? That matters more than any number on a screen.

Right now, the guidelines are clear: if you have chest pain with any red flags, go to the ER. Don’t second-guess. Don’t wait. Don’t hope it’s nothing. Your heart doesn’t care if you’re embarrassed, busy, or scared. It only cares if you act.