Chest pain that isn't your heart: when the results are normal but the fear stays

Before you read anything else: if your chest hurts right now, suddenly and badly, if the pain is crushing or spreads to your arm, jaw or back, or if it comes with difficulty breathing, sweating, nausea or dizziness, stop reading and call 112 immediately (the emergency number in Slovenia and across the EU). Do not drive yourself to A&E and do not wait to see whether it passes. This piece is for afterwards — once a doctor has already checked your heart.

It is half past two in the morning. In A&E they have done an ECG, taken blood, and you have waited for the results. A young doctor comes round the curtain, looks at the papers and says: “Your heart is fine. You can go home.” The relief lasts as far as the car park. In the car something tightens under your breastbone again, and when you lie down at home you count the beats with your palm on your chest. If your heart is fine, why does it still hurt?

A lot of people hear that question in their own heads, but few ask it out loud. It feels ungrateful — after all, you have just been given good news. But good news that something isn’t there does not tell you what is. In this piece I will try to describe what chest pain that is not the heart can be, why it so often comes back, and what psychotherapy can do about it — and what it cannot.

The heart first — and this is not a formality

I want to be very clear here, because everything else depends on it. Nobody should explain chest pain away on their own. Not with experience (“it’s happened lots of times before”), not with anxiety (“it’s just panic again”), and not with age (“at my age it can’t be the heart”). A heart attack does not always announce itself the way films show it. In women, older people and people with diabetes it more often shows up with less obvious signs — such as breathlessness, nausea, unusual tiredness, or pain in the upper abdomen, back or jaw.

The American cardiology guidelines from 2021 therefore recommend that doctors stop describing chest pain as “atypical”, because the word reassures people at the wrong moment. Pain is either likely cardiac, possibly cardiac, or likely non-cardiac — and that is decided by an examination, not by a feeling.

Once the examination is done and the heart has been ruled out, a different story begins. I have written in more detail about what the doctor checks — the ECG, the thyroid, a blood count — in Panic or the heart? What to check with a doctor before starting therapy, so I won’t repeat it here.

“Your heart is fine” is not the end of the story

Chest pain that has no cardiac cause is known in medicine as non-cardiac chest pain. It sounds like a leftover, something that remains once the important things have been removed. In fact it is very common. In a 2011 review of the research, Ronnie Fass and Sami Achem wrote that, according to estimates from different countries, somewhere between roughly one in eight and one in three adults experience it at some point in their lives — and many of them never see a doctor about it.

Among those who do, the story is often similar. In 1996 the Canadian researcher Richard Fleet and his colleagues systematically assessed people who had come to an emergency department with chest pain. About a quarter of them met the criteria for panic disorder. The second finding was even more important: the emergency doctors had recognised it in only very few of them. People went home with results saying their heart was not to blame, without a word about what was.

That is how a gap opens up. You know what you don’t have, but not what you do have. And fear feels very much at home in that gap.

Where the pain can come from, if not the heart

There is a great deal more in the chest than the heart. Once a doctor has ruled out a cardiac cause, a few common sources remain — and they often overlap.

• The oesophagus. Research shows that the single most common cause of non-cardiac chest pain is reflux — acid coming back up into the oesophagus. The pain can be burning, but also squeezing, which is why it is so easy to mistake for heart pain. Less often, the cause is spasms of the oesophagus.
• Muscles, ribs and cartilage. The muscles between the ribs, the chest muscles and the cartilage that joins the ribs to the breastbone can all hurt because of strain, posture, coughing or long-lasting tension.
• Breathing. When someone breathes shallowly and quickly for a long time, high up in the chest, the muscles that help with this become tired and cramped. A tightness appears, along with the feeling of not being able to get enough air.
• The nervous system’s alarm. A panic attack and long-term stress can both trigger a pounding heart, tightness in the chest and the fear that you are dying. How that happens, step by step, is the subject of Why a panic attack is not dangerous, even when it feels like a heart attack.

The important thing is this: none of it is “all in your head”. Reflux is real, a cramped muscle is real, hyperventilation changes your blood chemistry. Fear isn’t imagination either — it is a bodily state. The question is not whether the pain is real, but what drives it and what keeps it going.

Why the alarm rings louder in the chest

If your knee hurts, you tell yourself you have probably overdone it. If you feel a stab in your chest, something different happens. The chest is not just any part of the body. That is where the heart is — the organ we link with life itself, and an organ we all know a story about: the neighbour who died suddenly, the father who had a heart attack at fifty.

The brain responds to this sensibly. A signal from the chest takes priority over others. The way we perceive the inner state of the body — the heartbeat, the breath, tension in the stomach — is called interoception. In people who have once had a real fright about their heart, this perception often sharpens: they notice every skipped beat, every twinge, every change in their breathing. Not because they are imagining things, but because the nervous system is now keeping a close watch on the place where it detected danger. This state of tense watchfulness is called hypervigilance.

And here something sneaky happens. Attention directed at the chest doesn’t only pick up more sensations — it amplifies them. When you watch something anxiously, the muscles around it tighten, your breathing becomes shallower and your pulse quickens. A body searching for a sign of danger often ends up creating one.

The loop that closes after the test results

The most exhausting part of non-cardiac chest pain is not always the pain itself. It is the checking. Taking your pulse. The smartwatch you glance at twenty times a day. Searching online at three in the morning. Another visit to the doctor, another ECG, another wave of relief — which lasts a day or two.

Every check brings a brief moment of calm. But at the same time it tells the brain something important: that was worth checking, so it must have been dangerous. Next time the fear arrives faster and louder. This is how a one-off pain slowly turns into a habit in which worry about your health feeds itself. When that fear grows into constant worry about every symptom, we speak of health anxiety, which I wrote about in Health anxiety: when every symptom means the worst.

When the heart is a story in the family

In relational family therapy, which I am training in, we always ask one more question: what does this symptom mean in the family’s story? With chest pain the answer is often surprisingly concrete. The people most afraid for their heart often have someone in the family who fell ill or died because of their heart. Then the fear is not irrational — it is a memory. The body knows this has already happened in the family, and it pays special attention.

Christian Gostečnik describes how a family passes on feelings for which there was no room in a form that isn’t verbal — in the atmosphere, in tension, in the body. It doesn’t happen to everyone. But it is worth looking at when the pain first appeared and what was going on at the time. A conversation in a session might go something like this (a composite, not a real person):

“When did you first feel this pain?”
“Last autumn. A few weeks after I took over my father’s business.”
“How old was your father when he had his heart attack?”
“Fifty-two. The age I am now.” (a long pause) “I hadn’t connected those two things.”

A connection like that doesn’t mean the pain disappears the moment you put it into words. But it does mean the fear gains a shape and a name. A fear that has a name can be carried differently from one that comes out of nowhere. If you would like to explore such connections more systematically, that is what the longer genogram session is for, A Look into the Past.

What research says about help

The good news is that non-cardiac chest pain is not a dead end. A 2015 Cochrane review led by Steve Kisely brought together studies of psychological approaches in people with chest pain and normal coronary arteries. The conclusion was cautious but encouraging: psychological help, particularly cognitive behavioural approaches, reduced how often the pain occurred and improved wellbeing in the first months. The evidence was not strong, because there were few studies and they were small — which is only fair to say.

Psychotherapy is not the only route here, and often it is not the first. If the cause is reflux, a doctor treats it. If it is muscles and posture, a physiotherapist can do a lot. Psychotherapy comes in mainly when fear has woven itself around the pain — when checking, avoidance and worry take up more and more space — or when the pain coincides with a period that has been too much emotionally.

Breathing helps too, but not in the way people often expect. It isn’t about deep breaths — those can sometimes increase the tension in the chest. It is about a slower, longer out-breath. How to do it is described in the exercise breathing with a longer out-breath, and more about what genuinely helps with breathing in Breathing during panic: what actually helps and why a paper bag is not the answer.

Exercise: two minutes instead of checking

This exercise is only for pain that a doctor has already examined and that feels the same as before. If the pain is new, different or stronger, or comes with breathlessness, sweating, nausea or dizziness — don’t do the exercise; call 112.

1. Name the sensation, not its meaning. Instead of “something’s wrong with my heart”, say to yourself: “I feel a stabbing on the left, under my collarbone.” Where exactly is it? How big is it? Is it sharp, dull, burning?
2. Put off checking for two minutes. Don’t take your pulse, don’t look at your watch, don’t go online. Just two minutes — you can still check later if you need to.
3. Drop your shoulders and lengthen your out-breath. Breathe in through your nose as you naturally would, and breathe out slowly through your mouth, a little longer than the in-breath. Repeat six to eight times.
4. Write down what happened half an hour earlier. Had you eaten? Were you sitting hunched over? Did you have an unpleasant conversation? Did something come to mind?
5. After two minutes, rate the sensation from 0 to 10 and write it down. After a week, look back at your notes. A pattern often appears that you can’t see in the moment of fear.

The aim of the exercise isn’t to make the pain go away. It is to put some space between the sensation and the fear — and to let your nervous system learn that the story can end without checking.

Where this explanation does not apply

Because the subject is so sensitive, it would be irresponsible of me not to set out the limits too.

Anxiety and heart disease do not rule each other out. Someone with panic disorder can also have heart disease — and people with heart disease often develop anxiety. A test result that was fine two years ago is not valid forever. If the pain changes, appears in different circumstances, or your risk factors change, go back to the doctor.

“It’s just stress” can be a premature label. Sometimes a doctor or someone close to you puts the pain down to nerves too quickly — more often with women and younger people. If you feel you haven’t been heard, you are allowed to ask for a second opinion. That isn’t mistrust; it is looking after yourself.

Psychotherapy does not replace medical treatment. Untreated reflux can damage the oesophagus. Inflamed cartilage needs its own time and sometimes medication. Talking about fear does not remove a physical cause — but it can help you not to fight it alone, and keep the fear from taking the wheel.

And one last thing: if the pain, the fear or the exhaustion bring thoughts that you can’t go on, or thoughts of suicide, call Klic v duševni stiski (01 520 99 00 in Slovenia, every day from 7 pm to 7 am) or the Samaritans helpline (116 123 in Slovenia, 24 hours a day). In an emergency, call 112.

When the fear doesn’t go, even though the results say otherwise

Many people with non-cardiac chest pain take a long time to come to therapy, because it feels as though doing so would mean admitting they are making the pain up. I’d like to turn that around. You don’t come to therapy because the pain isn’t real. You come because it is real, and because a fear has grown around it that steals your quiet nights, your trust in your body and sometimes even the courage to go for a walk up a hill.

I have written more broadly about what psychotherapy knows about physical symptoms without a clear cause in “The tests are normal, but it still hurts”: what therapy knows about psychosomatics; you will find a short explanation of the term in the knowledge base under psychosomatics. What happens with chest pain happens elsewhere too — why pain sometimes persists after the body has healed is the subject of Chronic pain and the nervous system: why pain stays after the wound has healed, and the link between digestion and stress is explored in Irritable bowel syndrome and stress: the axis between the gut and the brain.

If English is the language you feel most at home in, you are welcome to come to sessions in English; they take place in person in Ljubljana.

What to remember

• Acute, new or severe chest pain = call 112 straight away. Never explain it away yourself, even if you are an anxious person.
• Once a doctor rules out the heart, common sources remain: the oesophagus, muscles and ribs, breathing and the nervous system’s alarm — often intertwined.
• Pain that isn’t cardiac is not “all in your head”. It is real, but it is often kept going by a loop of fear and checking.
• Research suggests psychological help can reduce pain and fear, but it does not replace treatment of physical causes.
• If the pain changes, go back to the doctor — even if your earlier results were normal.