Chest Pain Evaluation: When to Go to the Emergency Department

When your chest hurts, your brain screams: heart attack. But not every chest pain is a heart attack. And not every heart attack looks like the movies show. The real danger isn’t the pain itself-it’s waiting too long to act when you should’ve gone straight to the emergency department.

What Chest Pain Really Means

Chest pain isn’t just a sharp stab or crushing weight in the middle of your chest. It can feel like pressure, tightness, burning, or even just a strange fullness. And it doesn’t even have to be in your chest. You might feel it in your jaw, down your left arm, in your back, or deep in your upper belly. Some people-especially women, older adults, and those with diabetes-don’t feel chest pain at all. Instead, they get sudden fatigue, nausea, dizziness, or shortness of breath with no obvious cause.

This isn’t guesswork. The 2021 American Heart Association and American College of Cardiology guidelines define chest pain as any discomfort in the chest, shoulders, arms, neck, jaw, or upper abdomen, especially when paired with sweating, nausea, or unexplained tiredness. These are called anginal equivalents-signs your heart is struggling, even if it doesn’t scream.

When to Call 9-1-1, Not Drive Yourself

If you’re experiencing chest discomfort that lasts more than a few minutes-or comes and goes over 15-20 minutes-don’t wait. Don’t text a friend. Don’t Google it. Don’t hope it’ll pass. Call emergency services right away.

Why? Because every minute counts. If your heart muscle is being starved of oxygen, the clock is ticking. Studies show that people who drive themselves to the hospital have a 25-30% higher risk of complications than those transported by EMS. Emergency crews can start monitoring your heart, give you aspirin, and even transmit your ECG to the hospital before you arrive. That’s a 20-30 minute head start on treatment.

Here’s the short list of red flags that mean you need an ambulance now:

• Chest pain or pressure lasting more than 5 minutes
• Pain that spreads to your arm, jaw, neck, or back
• Sudden sweating, especially cold, clammy sweat
• Nausea, vomiting, or sudden dizziness
• Shortness of breath without exertion
• Heart rate over 100 bpm or breathing faster than 20 times per minute
• Low blood pressure (below 90 mmHg)
• Feeling like you’re going to pass out

If you have even one of these, don’t debate it. Call 9-1-1. The hospital can send a team ready to act the moment you walk in.

What Happens When You Arrive at the ED

When you get to the emergency department, the first thing they do is check if you’re sick or not sick. It’s not about how you feel-it’s about what your body is telling them. Is your skin pale? Are you sweating? Is your heart racing? Are you struggling to breathe? That’s the clinical gestalt-your doctor’s gut feeling based on your appearance and vital signs.

Then, within 10 minutes of arrival, you’ll get a 12-lead ECG. No delays. No excuses. This test is the fastest, cheapest, and most powerful tool to spot a heart attack. It can show if you’re having a STEMI-the most dangerous kind-where a major artery is completely blocked. If it’s there, the hospital’s cath lab team springs into action. The goal? Get you to the catheterization table in under 90 minutes.

After the ECG, they’ll take a blood sample for a high-sensitivity troponin test. Troponin is a protein released when heart muscle is damaged. The new generation of tests can detect tiny changes within an hour. In fact, 70-80% of chest pain patients can be ruled out for a heart attack within 1-2 hours using this method.

They’ll also check your blood pressure, oxygen levels, and heart rhythm. If you have signs of heart failure-like crackles in your lungs or a third heart sound (S3 gallop)-they’ll act fast. If you’re stable, they might use the HEART score: a simple tool that looks at your history, ECG, age, risk factors, and troponin level to decide if you’re low, medium, or high risk.

When You Don’t Need the ED

Not every chest discomfort is an emergency. If you’ve had similar pain before, it’s been diagnosed as stable angina, and it goes away with rest or nitroglycerin, you’re likely okay to call your doctor the next day. But only if:

• The pain is predictable-happens with exertion, goes away with rest
• You’ve been diagnosed by a cardiologist before
• You have your prescribed medication on hand
• No new symptoms like sweating, nausea, or trouble breathing

If any of those conditions aren’t met, don’t risk it. Play it safe. Go to the ED.

Also, some chest pain has nothing to do with your heart. Acid reflux, muscle strain, panic attacks, lung infections, or even shingles can mimic cardiac pain. But here’s the catch: you can’t tell the difference alone. That’s why the ED exists-to rule out the life-threatening stuff fast.

What You’ll Be Told After Testing

If your ECG and troponin are normal and you’re low-risk, you might be sent home with follow-up instructions. That doesn’t mean you’re off the hook. About 5-10% of people who leave the ED with a "normal" workup later have a heart attack within 30 days. That’s why follow-up is non-negotiable.

You’ll likely be referred to a cardiologist for stress testing, a coronary CT angiogram (CCTA), or other imaging. CCTA is more accurate than a treadmill test for spotting blocked arteries, especially if you’re under 65 and have no prior heart disease. But if you have kidney problems or an allergy to contrast dye, stress testing is still the go-to.

Some patients are diagnosed with INOCA-Ischemia with Non-Obstructive Coronary Arteries. That means their heart isn’t getting enough blood, but their arteries aren’t clogged. It’s real, it’s serious, and it’s often missed. If you’ve had chest pain, normal angiograms, but still feel unwell, keep pushing for answers.

What’s Changing in 2025

By 2025, most U.S. hospitals will use AI to help read ECGs. These systems can spot subtle changes humans miss-like tiny ST-segment shifts or early T-wave inversions that signal a heart attack hours before it fully develops. Early tests show 98.5% accuracy. That means faster diagnosis, fewer missed cases, and better outcomes.

High-sensitivity troponin is now used in 90% of U.S. emergency departments. That’s a huge shift from just five years ago. It’s why you can now be ruled out for a heart attack in under two hours instead of waiting six to eight.

But the biggest change isn’t technology. It’s mindset. The guidelines now stress shared decision-making. Your doctor should explain your risk, the pros and cons of testing, radiation exposure from scans, and costs-not just tell you what to do. You have a right to understand why you’re being sent for a test or held overnight.

What to Do Next

If you’ve ever had chest pain-even once-talk to your doctor. Ask: "Could this have been a heart issue?" Get your risk factors checked: blood pressure, cholesterol, blood sugar, and family history. If you’re over 40, smoke, have diabetes, or have a family history of early heart disease, get a baseline ECG and lipid panel.

Keep aspirin (81 mg) in your medicine cabinet. If you ever suspect a heart attack, chew one tablet while waiting for EMS. It’s not a cure, but it can reduce damage.

And remember: if you’re unsure, go. Better to be safe than sorry. Every year, 6 to 8 million people go to the ED with chest pain. Only 1 in 10 has a heart attack. But if you’re that one person? Waiting could cost you your life.