Chest Pain Evaluation: When to Go to the Emergency Department

When your chest hurts, it’s natural 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 it’s also not something to ignore. Every year in the U.S., millions of people show up at emergency departments with chest discomfort. Only about 1 in 10 of them are having a heart attack. But that 10%? That’s the group that can’t afford to wait. Knowing when to call 9-1-1 instead of driving yourself to the hospital could save your life.

What Counts as Chest Pain?

Chest pain isn’t just a sharp stab or squeezing feeling in the middle of your chest. It can show up as pressure, tightness, burning, or even just a strange heaviness. And it doesn’t even have to be in your chest at all. You might feel it in your left arm, jaw, neck, back, or upper belly. Some people describe it like an elephant sitting on their chest. Others just feel really tired, short of breath, or nauseated - especially women and older adults.

The American Heart Association defines chest pain broadly: any discomfort in the chest, shoulders, arms, neck, jaw, or upper abdomen that’s new, unusual, or doesn’t go away. If you’re unsure whether it’s serious, treat it like it is. Don’t try to tough it out. Don’t wait to see if it gets better. If you’re experiencing this for the first time - or it’s worse than usual - get help now.

When to Call 9-1-1 Immediately

Don’t drive yourself. Don’t wait for a ride. Call 9-1-1 right away if you have chest discomfort and any of these symptoms:

• Sweating (diaphoresis) - cold, clammy skin, even if it’s not hot
• Shortness of breath that doesn’t improve with rest
• Nausea, vomiting, or sudden dizziness
• Heart rate over 100 beats per minute or very low blood pressure
• Feeling faint, lightheaded, or like you’re about to pass out

These aren’t just random symptoms. They’re red flags that your heart might be under severe stress. Emergency responders are trained to start treatment the moment they arrive. They can give you aspirin, monitor your heart, and even begin life-saving interventions before you reach the hospital. Driving yourself delays care by 25-30 minutes on average. That’s time you can’t afford to lose.

The ECG Is Your First Line of Defense

When you arrive at the emergency department, the first thing they’ll do is hook you up to an electrocardiogram (ECG). This test takes less than a minute and shows how your heart is electrically firing. It’s the single most important tool in the first 10 minutes of evaluation.

According to the 2021 AHA/ACC guidelines, every hospital must get and interpret an ECG within 10 minutes of your arrival. Why? Because if you’re having a STEMI - a type of heart attack where a major artery is completely blocked - that ECG will show it right away. And if it does, the clock starts ticking. The goal is to open that artery within 90 minutes of your arrival. Every minute counts. Delayed treatment means more heart muscle dies.

Even if your first ECG looks normal, don’t assume you’re safe. Some heart attacks don’t show up on the first test. That’s why doctors often repeat the ECG every 15-30 minutes if your symptoms persist. A subtle change over time can be more telling than a single normal result.

Troponin Tests: The Blood Marker That Tells the Truth

Along with the ECG, doctors will draw blood to check for cardiac troponin - a protein released when heart muscle is damaged. Modern high-sensitivity troponin tests can detect even tiny amounts of damage. In fact, with these newer tests, doctors can rule out a heart attack in 70-80% of chest pain patients within just 1-2 hours.

But here’s the catch: these tests only work if they’re the right kind. Older troponin assays can’t pick up early damage. If your hospital is still using outdated equipment, the results may be misleading. Most U.S. hospitals switched to high-sensitivity troponin by the end of 2022, so this isn’t usually an issue anymore - but it’s something to be aware of if you’re in a rural or under-resourced area.

Doctors don’t rely on troponin alone. They combine it with your symptoms, ECG, age, risk factors, and other signs to make a full picture. That’s where tools like the HEART score come in. It’s a simple checklist: History (what you’re describing), ECG findings, Age, Risk factors (like smoking or diabetes), and Troponin level. A score of 0-3? You’re likely low risk and may go home. A score of 7-10? You’re in the high-risk zone and need immediate action.

What About Chest Pain That’s Not a Heart Attack?

Not every chest pain is cardiac. In fact, most aren’t. Other common causes include:

• Acid reflux or GERD - burning that gets worse after eating or lying down
• Muscle strain or costochondritis - pain that worsens with movement or pressing on the chest
• Lung issues like pneumonia or pulmonary embolism - sharp, stabbing pain with breathing
• Anxiety or panic attacks - often accompanied by hyperventilation and tingling in hands or feet

But here’s the problem: some of these conditions - like pulmonary embolism - are just as dangerous as a heart attack. That’s why doctors don’t just assume it’s “just heartburn.” They rule out the deadly stuff first. If your ECG and troponin are normal but you’re still in pain, they might order a CT scan to check for a blood clot in your lungs or an echocardiogram to look at your heart’s function.

There’s also a growing group of patients called INOCA - those with ischemia (reduced blood flow) but no blocked arteries. This is more common than people think, affecting 5-10% of chest pain cases. It’s often missed by standard tests and requires specialized evaluation. If you’ve had multiple negative tests but still get chest pain with exertion, talk to a cardiologist about this possibility.

Why Not Just Go to Urgent Care?

It’s tempting to skip the ER and head to urgent care. But if your chest pain could be cardiac, urgent care isn’t equipped to handle it. They don’t have the 24/7 cardiac monitoring, the rapid lab turnaround, or the immediate access to cath labs that emergency departments do. If you’re having a heart attack and go to urgent care, you’ll likely be transferred to the ER anyway - and by then, time has passed.

The 2021 AHA/ACC guideline is clear: patients with unstable vital signs, ongoing pain, or abnormal ECG findings must be evaluated in an emergency department. No exceptions. If you’re unsure, err on the side of caution. It’s better to be evaluated and told you’re fine than to wait and risk a preventable tragedy.

What Happens After the Emergency?

If you’re cleared and sent home, you’re not done. Even low-risk patients need follow-up. Your doctor will likely schedule a stress test, echocardiogram, or coronary CT angiography to check for underlying heart disease. Don’t ignore these appointments. Many people who survive a heart attack didn’t realize they had coronary artery disease until it was too late.

And if you’ve been diagnosed with INOCA or microvascular disease, your treatment plan will be different. You might need medications like nitrates, beta-blockers, or calcium channel blockers - not just lifestyle changes. These conditions are real, underdiagnosed, and can significantly impact your quality of life.

What You Can Do Now

You don’t have to wait for chest pain to act. Here’s how to prepare:

• Know your risk factors: high blood pressure, diabetes, smoking, obesity, family history of early heart disease
• Keep a list of your medications and allergies handy - keep it on your phone or in your wallet
• Teach your family what signs to look for - especially if you live alone
• Make sure your phone is charged and you know how to call 9-1-1 quickly
• Don’t keep aspirin in the bathroom cabinet - keep it by your bed or in your car

And if you ever feel uncertain - call 9-1-1. Emergency medical services exist for exactly this reason. They’re not there to judge you. They’re there to make sure you’re okay. Even if it turns out to be indigestion, you’ll walk away knowing you did the right thing.

Final Thought: Better Safe Than Sorry

Every second matters when your heart is in trouble. The tools we have today - fast ECGs, high-sensitivity troponin tests, AI-assisted interpretation - make it easier than ever to rule out life-threatening causes quickly. But none of that matters if you don’t act. Don’t second-guess yourself. Don’t worry about “bothering” anyone. Emergency departments are built for this. They see thousands of chest pain cases every day. They’re not going to think you’re overreacting. They’ll be glad you came.

If you’re ever in doubt - call 9-1-1. It’s the single best decision you can make when your chest hurts.