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How to Differentiate Between Anxiety, Intercostal Muscle Spasms, and Heart Attack

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Dr. William H. Frishman, Director of Medicine, Westchester Medical Center

How can you tell the difference between types of chest pain?

How can you tell the difference between types of chest pain?

Are You Experiencing Chest Discomfort?

People often can't tell if they are having a heart attack or one of many other chest problems. There are two problems that people often confused with a heart attack:

  • Anxiety
  • Strains, cramps, or spasms of the intercostal muscles in the wall of the chest (these are the muscles between the ribs)

This confusion is understandable, as symptoms of these other conditions resemble the symptoms of a heart attack.

Of course, the only surefire way to know is to go to the hospital where different types of diagnostics will be used to evaluate your condition, find out if you had a heart attack and if so, determine how much damage was done. Nevertheless, there is not always a hospital close by, and knowing the symptoms of these three conditions can help you prepare for whatever may follow.

Although symptoms of anxiety and intercostal muscle spasms closely resemble those of a heart attack, there are notable differences. Again, if you are in doubt, have had a heart attack before, are elderly, diabetic, or are otherwise at increased risk of a heart attack, you should consult a doctor immediately.

Decoding Chest Pain: Heart Attack vs. Anxiety vs. Muscle Spasms

Additional sources used: "Chest Pain Anxiety Symptoms" from and "Chest Pain: A Heart Attack or Something Else" from Harvard Health Publications

 Type of PainTimelineAreaOther Symptoms

Heart Attack

Pressure, tightness, squeezing, or burning; pain is diffuse, not sharp

Onset is gradual and may last for over 30 minutes

Pain can extend to left arm, neck, back, or jaw

Pain or pressure is accompanied by other symptoms, like difficulty breathing, nausea, or cold sweat

Anxiety or Panic Attack

Chest pain that can be sharp and shooting, can feel like muscle spasm or twitching; can take different forms

Can vary person to person — may come and go, be persistent, occur frequently, or occur rarely

Can move around in the chest or affect one area only

Chest pain is common in people with anxiety; may be accompanied by other symptoms of anxiety

Muscle Spasm or Strain

Severe stabbing pain

Sudden onset, lasts for anywhere from five minutes to an hour

Localized pain, usually around the ribs

Usually happens after physical exertion of some kind

Anatomy of the Lungs and Heart (detail), Quain's Plates

Anatomy of the Lungs and Heart (detail), Quain's Plates

Symptoms of a Heart Attack

A heart attack can be caused by multiple factors related to poor cardiovascular health, or by trauma, electric shock, or infection. An attack occurs when the blood supply to the heart muscle is impaired, usually by a clot in a blood vessel, causing the heart muscle to die and lose some of its pumping ability. The amount of damage depends on the size of the area that is blocked from receiving blood and how long it takes to get treatment.1

Most heart attacks begin with subtle symptoms that are not usually described as pain — terms commonly used include squeezing or tightness. If you have a very sudden onset of sharp pain, it is likely not a heart attack.

Symptoms of a heart attack include:2

  • Chest discomfort or pain that can feel like a mild ache, pressure, fullness, or squeezing that may last for more than a few minutes and may come and go. This may feel like heartburn.
  • Upper body pain or discomfort that may spread beyond your chest to other parts of your body, like your shoulders, arms, back, neck, teeth, or jaw. You could also just have upper body pain without chest discomfort. These sensations may also feel like numbness, pinching, or prickling
  • Shortness of breath, which usually happens before chest pain (if you have it). You might pant for breath or be unable to take deep breaths.
  • Anxiety and feeling a sense of doom for no apparent reason
  • Irregular heartbeat, or a sudden onset of a racing heart
  • Light-headedness, usually accompanied by headaches
  • Nausea or vomiting
  • Sweating or breaking into a sweat with clammy skin
  • Unusual fatigue

Symptoms of a heart attack last for 30 minutes or longer and don't go away with nitroglycerin under the tongue.1 The symptoms of a heart attack also differ from person to person. If you are over 50, diabetic, or have had a cardiovascular problem before, consult the doctor immediately when in doubt about whether you have had a heart attack.

It is very important to treat heart attacks quickly. If not treated in time, a person having a heart attack may suffer irreversible damage to heart muscles or even die.

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Solution: If experiencing heart attack symptoms, get immediate emergency help.

In the long term, lifestyle changes can reduce symptoms of heart disease and make further attacks less likely: eating a healthy diet, exercising, and avoiding risky habits such as excessive smoking or drinking. Medications may also play a role in reducing risk of heart attack.

Physical Symptoms of Anxiety

Anxiety, stress, and worry can have physical effects on the body.3 When worry becomes excessive, it can trigger a stress response in your body which has two elements. The first involves recognizing the challenge, and the second is an automatic physiological reaction called the "fight or flight response." This response sends adrenaline and other hormones into your body and puts you in a state of high alert.3

The physical symptoms of this heightened state of stress include:

  • Heavy breathing, difficulty breathing through the nose, shortness of breath
  • Constriction of throat muscles, making it hard to swallow saliva, or a sensation of having something stuck in the throat
  • Dry mouth
  • Increased heart beat
  • Confusion, light-headedness, inability to concentrate, irritability
  • Heightened senses — a person may become extremely sensitive to sound, touch, taste, or anything that happens in the body. A person may become unduly concerned about these sensations. The most common example is a person listening to their own heart beat, and getting the sense that it is fading away, skipping, or stopping, when in fact their heart is okay.
  • Chest pain, especially towards the ribs or sternum (middle of the chest). This is usually caused by the heavy breathing. The pain increases when inhaling or exhaling.
  • Muscle aches, muscle tension
  • Nausea
  • Nervous energy
  • Sweating
  • Twitching and trembling

When a person is experiencing strong emotions, like stress or anger, they may well focus on their thoughts or on their surroundings, rather than on how they are feeling physically. When a person finally pays attention to their bodily sensations, these sensations may seem to have started suddenly, when in fact they have been going on all day, along with the unpleasant thoughts that cause them.

In a panic attack, the feelings of anxiety can come on quite strongly and suddenly. Panic attacks are sudden feelings of terror that can strike without warning.4 If you're having a panic attack, you may feel like you're going crazy, that you're having a heart attack, or that you are dying.

According to WebMD, you may experience the following symptoms:

  • Feeling a loss of control
  • Breathing difficulties
  • Chest pains
  • Feeling sweaty or having chills
  • Chest pains
  • Sense of terror or impending doom
  • Tingling or numbness in the hands and fingers
  • Feeling weak, faint or dizzy
  • A "racing" heart

These attacks usually only last for around 10 minutes, though some of the symptoms may last for a longer time.

Solution: There are many solutions, mostly involving relaxation techniques (e.g. meditation) or distraction (e.g. exercise, talking to a friend). If anxiety often causes physical symptoms, counseling or therapy may lead to a long-term solution. If you're experiencing panic attacks frequently, you should see a doctor to find out what kind of solutions are available to you. These may include different kinds of medication.

Intercostal muscles go from rib to rib.

Intercostal muscles go from rib to rib.

Symptoms of Intercostal Muscle Strain or Spasm

At some point or another, most people experience a muscle spasm or cramp somewhere in their body. A muscle cramp is a sudden and involuntary contraction of a muscle or several muscles.5 Often, muscle cramps happen in the leg muscles — especially the calf — though they can happen anywhere in the body. Though they are usually harmless, they can be quite painful.

Several factors can lead to a muscle cramp, including:5

  • Long periods of exercise or physical labor, especially in hot weather
  • Some types of medication or medical conditions, such as inadequate blood supply or mineral depletion
  • Overuse of a muscle
  • Dehydration
  • Muscle strain
  • Holding a physical position for a prolonged period of time

The intercostal muscles run from rib to rib, and enable a person to breathe by expanding and contracting the chest wall. A spasm can happen when a person constricts their lower chest muscles for a long time and then suddenly extends the same muscles.

For example, a spasm can happen when a person bends or hunches forward for some time and then suddenly straightens their upper body. A spasm can also be caused by lifting heavy objects or abruptly twisting the body. They can occur during simple, regular household work as well as more difficult physical labor or exercise.

Symptoms of intercostal muscle spasms include:

  • Severe stabbing pain in the lower left or right chest, that persists and usually worsens with an attempt to move or straighten the upper body
  • The pain is localized at one single point, usually around the ribs or in the middle lower area of the chest
  • If the person is not anxious, the heart beat is usually steady.
  • Pain increases with heavy breathing
  • Pain may last from five minutes to an hour or more

Solution: Lie flat with arms straightened out above the head to stretch the muscle, or simply wait out the problem. Eventually the spasm will resolve by itself. You should see a doctor if it doesn't resolve itself, if the spasm happens frequently, or if the spasm is not connected to an obvious cause.5

Do You Need to Get Help?

Hopefully this article has helped you understand whether or not what you're experiencing is a medical emergency. Remember that the only way to know for sure if you're having a heart attack is to see a doctor for tests. If you are still unsure or if you are at increased risk for heart problems, please consider seeing a doctor as soon as possible.

Sources Used

  1. Reviewed by James Beckerman, MD, FACC. "Heart Attacks and Heart Disease." April 17, 2017. WebMD. Accessed May 17, 2017.
  2. Mayo Clinic Staff. "Heart Attack Symptoms: Know What's a Medical Emergency." June 25, 2014. Mayo Clinic. Accessed May 17, 2017.
  3. Reviewed by Joseph Goldberg, MD. "How Worrying Affects the Body." August 15, 2015. WebMD. Accessed May 17, 2017.
  4. Reviewed by Joseph Goldberg, MD. "Panic Attack Symptoms." February 9, 2017. WebMD. Accessed May 17, 2017.
  5. Mayo Clinic Staff. "Muscle Cramp." February 16, 2016. Mayo Clinic. Accessed May 17, 2017.
  6. "Chest Pain: A Heart Attack or Something Else." Published May 2010, updated August 11, 2015. Harvard Health Publications. Accessed May 17, 2017.
  7. Folk, Jim and Marilynn Folk, BScN. "Chest Pain Anxiety Symptoms." (n.d.) Accessed May 17, 2017.

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.


Melanie on August 07, 2017:

Hi, just thought you could add esophageal spasms to this article - they mimic heart attack and can last for weeks.

TinaJ on May 27, 2017:

All my symptoms fitted the Heart Attack group.Including numbness of left side of face lips and arm and light headed ness. After going to hospital and having ecg, blood test & chest xray it was determined I had a muscle spasm possibly accompanied by anxiety ( which I don't generally suffer from) I was given a muscle relaxant and sent home. I;m glad I went to get checked though. The hospital staff were very good in Hereford A & E.

Pete on December 29, 2016:

I have had chest problems 8 months noe had sevral ecg blood tests x rays 2 weeks ago had angiogramme angioplasty they say my pain in chest and over my heart lightening bolt feeling is gerd also heart muscle and chest spasms the pains unreal terryfying have to take omprazole and gtn spray under my tongue when pain starts i live in the uk hospital been brilliant and caring

Aaron on December 29, 2016:

I have anxiety brought on by a spinal cord/neck injury and a tear in the intercostal muscles. It's good to have a list to lay out the basics between the three because I constantly worry about heart issues and I'm only 29. I've never had one but I get all the symptoms because of the injuries.

Ann Marie on November 08, 2016:

The explanation which you provider has really helped to reassure me that the pain I experienced last night after a couple of basic yoga moves was nothing more than a muscular spasm. It's just a pity that I didn't read it before Spending 6 hours in hospital having an ECG, chest X-ray etc.!!

Kathy on October 31, 2016:

I ran a 10km race in which I twisted my ankle and fell. The next day my chest muscles on the right up nearer the shoulder and armpit but on the chest hurt a bit. During the week I washed windows and the next day suffered severe spasms that I cold hardly breath or walk. My husband took me to the hospital where they gave me a small dose of morphine. I no longer get the spasms, but the moment I exert my self using my right arm I feel the pain getting stronger again, but no spasms. How long will it take for this muscle to heal and how can I speed up the process.

Rowena on March 02, 2016:

Thanks for this article. Just used it to convince my partner that I am NOT hsving a heart attack but a muscle spasm. He still made me a cup of tea. c:

Snakesmum on June 23, 2015:

It is difficult to distinguish between heart attacks and other problems. On one occasion I was taken to hospital with a suspected heart attack, but it turned out to be acute indigestion! Lucky for me. The symptoms were exactly the same.

Carol Houle from Montreal on October 02, 2014:

Very good separation of these symptoms. Thanks. I've taken note of spastic pain in the chest, and stiffness and numbness.

With atrial fibrillation, some of these same symptoms occur, so sadly, I am forever worried.

If one also has the sharp pain of sternum inflammation 1 or 2 days after heavy lifting or moving, you will find that it does recur each time one does heavy lifting. I've had it for longer than Michael Jackson had it.

Dan on May 04, 2013:

Thank you for this. I have scoured the internet for information on this and I feel that it is something that doctors would almost never diagnose. Having suffered from anxiety and recently having similar recurring symptoms without the triggers it occurred to me that there must be another explanation and now that I am aware of this injury it seems to have vanished! I am astonished and am laughing as I type this. It was like being made aware of it...well made it go away. It has been plaguing me for weeks or months on and off but now I know its just a muscle thing the anxiety phantom symptoms are gone and not compounding the muscular tension. Amazing...thankyou!

Manda on October 28, 2012:

I know this is a little older but thanks for posting! I looked up "intercostal muscle spasm" after being hunched over sitting and standing straight up and getting a pain from my lower floating rib up to and throughout my breast, which was worse when I took breaths. Your page was the first thing that came up! So thank you for the confirmation that that was all that happened :)

Chris k on August 10, 2012:

very informative and helpful. Thank you!

donna on June 01, 2012:

my daughter went to hospital with chest pain and burning in throut also pain in left elbow 2 blood test said she had a heart atack she has had 3 in 3 days what's happening/

Shasta Matova from USA on February 27, 2012:

This is very helpful to be able to tell the difference between these three conditions. Thank you.

riley on August 06, 2011:

Thanks montelka! This helped me a bunch...

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