Chest pain that appears during physical activity, known as exertional chest pain, is a symptom that should always prompt attention. Exercise increases the body’s demand for oxygen, forcing the heart to work harder and faster. While the underlying cause is often benign, the pain may signal a serious underlying cardiovascular issue related to insufficient blood flow to the heart muscle. This guide outlines the immediate steps to take and explores the various origins of this discomfort, from muscular strain to cardiac concerns.
Immediate Action: Recognizing Emergency Warning Signs
Chest pain that begins during exercise requires immediate cessation of the activity and observation. If the pain is severe, sudden, or lasts longer than a few minutes after stopping the exertion, it may be a medical emergency. Seek emergency medical attention if the pain is accompanied by severe symptoms, as these often point toward an acute cardiac event.
An immediate call for emergency services is necessary if the pain radiates from the chest to other parts of the body, such as the jaw, neck, back, or down one or both arms. Simultaneously experiencing shortness of breath that does not improve with rest, severe dizziness, or a sudden fainting episode (syncope) are highly concerning signs. Cold sweats, nausea, or an intense feeling of anxiety accompanying the chest discomfort also elevate the concern for a serious condition.
A key distinction for unstable cardiac issues is pain that persists despite resting or worsens over time. Any new or unexplained chest discomfort, particularly a heavy pressure or squeezing sensation, requires urgent evaluation to rule out acute coronary syndrome. Treating exertional chest pain as a potential cardiac event until proven otherwise is the safest course of action.
Non-Cardiac Reasons for Exercise-Related Chest Pain
Not all exertional chest pain originates from the heart; many common causes are related to the musculoskeletal, respiratory, or gastrointestinal systems. Musculoskeletal pain is a frequent, non-cardiac source of chest discomfort, often resulting from muscle strain or inflammation. This type of pain is typically localized, sharp, and may be easily reproduced by pressing on the affected area of the chest wall.
Muscle strains, particularly in the pectoral or intercostal muscles, can occur during lifting weights, intense pushing movements, or overexertion. These strains cause pain that worsens with specific movements of the torso or deep breaths, differentiating it from the diffuse pressure of cardiac pain. Another common musculoskeletal cause is Costochondritis, which involves inflammation of the cartilage connecting the ribs to the breastbone. The hallmark of Costochondritis is tenderness when palpating the costochondral junctions, which are the points where the ribs meet the sternum.
Gastroesophageal Reflux Disease (GERD), or acid reflux, is a leading non-cardiac cause of chest pain, sometimes exacerbated by physical activity. When exercising, increased abdominal pressure can push stomach acid back into the esophagus, causing a burning sensation that mimics heart pain. This discomfort may worsen when bending over or lying down.
Respiratory issues can also contribute to exertional chest pain, with exercise-induced bronchoconstriction being a primary example. This condition, sometimes called exercise-induced asthma, involves the temporary narrowing of the airways triggered by physical activity, leading to chest tightness and shortness of breath. Hyperventilation, which is rapid or deep breathing, can also cause chest wall discomfort and lightheadedness due to changes in blood carbon dioxide levels.
When Chest Pain Signals a Cardiac Concern
When chest pain occurs with exertion and subsides with rest, it is the classic presentation of angina, which is the body’s signal of reduced blood flow to the heart muscle. This pain, often described as a squeezing, heaviness, or pressure in the chest, is caused by myocardial ischemia—a lack of oxygen reaching the heart tissue. The increased oxygen demand during exercise cannot be met due to underlying vascular restriction, triggering the pain response.
The most common underlying cause for exertional angina is Coronary Artery Disease (CAD), where plaque buildup, known as atherosclerosis, narrows the coronary arteries. As the arteries narrow, blood flow is restricted. While this may be sufficient at rest, the body cannot supply enough oxygenated blood when the heart rate and workload increase during exercise. This predictable pattern of pain that starts with activity and resolves with rest is characteristic of stable angina.
Unstable angina represents a more dangerous progression, characterized by pain that is less predictable, may occur at rest, and is often more severe or prolonged. This change indicates a potentially worsening obstruction or damage to the plaque within the coronary artery. Other, less common cardiac causes include pericarditis, inflammation of the sac surrounding the heart, or specific arrhythmias. A different form, microvascular angina, is caused by spasms in the smallest coronary arteries, restricting blood flow despite larger arteries appearing clear.
Diagnostic Process and Prevention Strategies
A medical evaluation for exertional chest pain begins with a thorough physical examination and detailed patient history. Initial diagnostic tests often include an Electrocardiogram (ECG) to assess the heart’s electrical activity and blood tests to check for elevated cardiac enzymes, such as troponin, which signal damage to the heart muscle. A chest X-ray may also be used to evaluate the lungs and the size and shape of the heart, helping to rule out pulmonary causes.
If cardiac causes remain a concern, further testing is required, with a stress test being a common next step. This involves monitoring the heart with an ECG while the patient exercises on a treadmill or stationary bike, or sometimes using medications to simulate the effects of exercise. More advanced imaging, such as Coronary Computed Tomography Angiography (CCTA) or a stress echocardiogram, helps physicians visualize the coronary arteries or assess blood flow to the heart muscle. These tests help differentiate between ischemic pain and non-cardiac causes.
Once a diagnosis of a non-cardiac issue is confirmed, prevention strategies focus on modifying exercise habits and managing the root cause:
- For musculoskeletal pain, ensure a proper warm-up before exercise and gradually increasing the intensity of training can prevent muscle strain.
- Managing GERD-related pain involves avoiding large meals or known trigger foods for at least two to three hours before beginning a workout.
- Individuals with exercise-induced bronchoconstriction can often prevent symptoms by using a prescribed inhaler before starting their activity.
- Performing a longer, gentler warm-up in appropriate environmental conditions can also help prevent symptoms.