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Tightness in the chest – understanding what lies behind it.
Pressure, tightness or burning behind the breastbone, often during exertion, sometimes radiating to the arm, neck, jaw or back – this is how angina pectoris presents, literally “tightness of the chest”. The most common cause is coronary artery disease (CAD – the gradual narrowing of the coronary arteries by deposits). But not every chest tightness comes from narrowed vessels, and not every one comes from the heart. Many patients come to us with a diagnosis – but without a clear answer. With ECG, echocardiography, cardiac CT and stress MRI we clarify the cause in one place and discuss the result with you in detail.
Angina pectoris – also called chest tightness or chest pain on exertion – is a symptom, not a disease in itself. Typical signs are a feeling of pressure or tightness in the chest that occurs with physical or emotional stress, in the cold or after a heavy meal and subsides at rest within a few minutes. The causes range from narrowed coronary arteries (CAD) and disorders of the smallest heart vessels to vascular spasms (vasospastic angina); some symptoms that resemble angina have entirely different causes. Which treatment is right therefore depends on a precise assessment.
If climbing stairs, walking briskly or excitement triggers a feeling of pressure or tightness in the chest or unusual breathlessness that goes away again at rest, we clarify whether the coronary arteries are behind it.
You have been diagnosed with angina pectoris or CAD – or the cardiac catheterisation was unremarkable, but the symptoms persist? Then we take a closer look: at the large coronary arteries, at the blood flow to the heart muscle down to the smallest vessels – and at possible other causes. Also as a second opinion.
Every day, around 550 people in Germany die from the consequences of calcified coronary arteries – in the Munich region around 7,000 a year.1 This calcification (coronary artery disease, CAD) usually develops unnoticed over years. Which test detects it early is therefore no minor matter.
A large analysis using data from 2,920 patients compared the methods directly: the exercise ECG detected only about 55 % of relevant narrowings, cardiac CT about 95 %.9 A normal exercise ECG therefore does not rule out CAD.
The European Society of Cardiology (ESC) recommends cardiac CT to confirm or rule out CAD – with class I and level of evidence A, the highest grade of its rating system.2 This applies when the likelihood of CAD is estimated beforehand as low to intermediate.
A Danish study analysed all 54,028 deaths of one year: around 45 % of the people who died of sudden cardiac death had no previously known cardiovascular disease.10 For them, death was the first sign. The most common cause of sudden cardiac death in adults is CAD – in up to 80 % of cases.15
That is how the Deutsches Ärzteblatt (German Medical Journal) put it on 2 October 2026.11 In 2024, 771,234 catheter examinations of the coronary arteries (coronary angiographies) were recorded in Germany, but only 309,634 catheter interventions such as stent placement.12 Most cardiac catheterisations were therefore purely diagnostic – a question that cardiac CT can often answer as well, without a catheter.
“In the long run, CCTA will prevail – not only as a replacement for many cardiac catheterisations to detect stenoses, but also because only it makes early detection of CAD possible.”
Because the usual baseline tests do not see the vessel wall. Resting and exercise ECG measure the heart's electrical signals; cardiac ultrasound shows the heart muscle and pumping function. They usually only become abnormal once a narrowing already restricts blood flow. The deposits themselves grow for a long time without symptoms: in the REACT study, 57 % of symptom-free adults aged 18 to 70 already had deposits in their arteries.13 In the PROMISE study, the stress test was normal in 78 % of those examined, cardiac CT in only 33 % – and over half of the later serious cardiac events in the CT group affected people with deposits that did not yet narrow the vessel.14 Only cardiac CT makes these deposits directly visible. This is no criticism of ECG and ultrasound – they answer a different question.
In cardiology with ultrasound and ECG – and radiologically, if there are signs of CAD, with CT and MRI. We discuss the findings with you in person.
Two forms are distinguished. The difference determines how quickly action is needed.
The symptoms occur only during exertion, follow a consistent pattern and go away at rest – or after a nitroglycerin spray – within a few minutes. This is not an emergency, but a clear signal. Call us promptly: +49 89 5527 9560.
The symptoms occur suddenly, for the first time, at rest or ever more frequently and severely – or last longer than a few minutes. A heart attack may then be imminent or already under way. Please call the emergency services on 112 immediately – not us – and do not drive yourself.
Reduced blood flow to the heart does not show the same way in everyone. The differences between women and men are well documented – and important so that symptoms are correctly interpreted.
On cardiac catheterisation the large vessels then often look unremarkable – this is called INOCA, reduced blood flow without narrowed coronary arteries. The symptoms are nevertheless real: stress MRI can provide evidence of such a circulatory disorder. More on our page Cardiology for women.
Cardiac CT shows narrowed vessels and deposits directly and without a catheter; stress MRI shows whether a narrowing actually restricts blood flow to the heart muscle. More on our page Cardiac CT.
For women and men alike: breathlessness during exertion can be the only sign – a so-called angina equivalent, especially with diabetes and in older age. What matters is not whether the symptoms are “typical”, but whether they are new, recur or increase with exertion.
Chest tightness, palpitations, breathlessness and declining exercise capacity are typical symptoms of stable angina pectoris – but they also occur in other conditions. Since the coronavirus pandemic this particularly concerns people in whom such symptoms persist after an infection. The distinction matters: treatment and course are fundamentally different, and not infrequently several causes exist side by side. The timing pattern often gives a first clue.
Long COVID refers to symptoms that persist for more than four weeks after an infection, post-COVID to symptoms lasting more than twelve weeks. Common complaints are exhaustion, breathlessness, chest pain, palpitations and difficulty concentrating. The coronary arteries are usually unremarkable; less often the infection leaves inflammation of the heart muscle or pericardium – cardiac MRI can make it visible.
In post-exertional malaise (PEM), the core symptom of ME/CFS, symptoms worsen not during exertion but with a delay – often only hours to days afterwards – and usually last for days. This distinguishes it from stable angina pectoris, which occurs during exertion and subsides at rest within a few minutes. Important for people with PEM: in stress MRI the exertion is replaced by a medication – physical effort is not required.
In postural orthostatic tachycardia syndrome (POTS), a dysregulation of the autonomic nervous system (dysautonomia), the pulse rises by more than 30 beats per minute within ten minutes of standing, without a drop in blood pressure. Palpitations, chest tightness, dizziness and breathlessness then occur on standing up and during prolonged standing and improve when lying down – regardless of physical exertion. The heart itself is usually structurally healthy; an active stand test (Schellong test) or a tilt-table test clarifies the diagnosis.
Here the boundary with angina pectoris is fluid: if the inner vessel wall (endothelium) or the smallest heart vessels do not work properly, the heart muscle receives too little blood during exertion – even though the large coronary arteries are open. This affects women more often, as well as people with high blood pressure or diabetes, and has also been described after viral infections. Cardiac CT then shows unremarkable large vessels; stress MRI can provide evidence of the circulatory disorder of the small vessels.
| Condition | Typical pattern |
|---|---|
| Stable angina pectoris | during exertion, cold or excitement; gone at rest within a few minutes |
| Unstable angina pectoris | sudden, new, at rest or increasing – call 112 immediately |
| Microvascular angina / INOCA | during exertion, but also at rest or under stress; cardiac catheterisation often unremarkable |
| PEM (post-exertional malaise) | delayed, often hours to days after exertion; usually lasts for days |
| POTS / dysautonomia | on standing up and while standing, markedly raised pulse; better lying down |
| Long/post-COVID | after an infection, over weeks to months; fluctuating, often with exhaustion |
How we proceed: First we clarify whether the heart is involved – whether the coronary arteries are narrowed (cardiac CT), whether the heart muscle receives enough blood under stress and whether there is inflammation or scarring (stress MRI, cardiac MRI). If the heart shows no pathological finding, that is reliable and important information – for you and for further treatment, for example by your GP, a neurologist or a specialised post-COVID clinic. Conversely, a past infection does not rule out coronary artery disease – both can exist side by side.
The European guideline (ESC 2024) recommends non-invasive imaging as the first step when coronary artery disease is suspected – cardiac CT or a stress test with imaging such as stress MRI – even before cardiac catheterisation. Cardiac ultrasound (echocardiography) and an ECG alone are not sufficient for this: they can neither reliably confirm nor rule out CAD. Certainty is what is needed here. We offer cardiac CT and stress MRI under one roof – complemented by ECG and echocardiography.
The basis: the ECG records the rhythm and signs of circulatory disorders or old scars; cardiac ultrasound shows pumping function, wall motion and valves – without radiation.
CT coronary angiography shows narrowings and deposits (plaque) directly – including soft, non-calcified plaque – without a catheter. The calcium score classifies the risk. With modern dual-source technology, the radiation dose is as low as is currently technically possible.
Stress MRI shows whether the heart muscle receives enough blood under medication-induced stress – including evidence of disorders of the smallest vessels – and makes scars and inflammation visible. Without radiation and without physical exertion.
We discuss images and findings with you in detail – clearly and with time for your questions. Also if you already bring findings and would like a second opinion.
Conveniently online or by phone – you will receive a timely appointment through our friendly reception.
ECG and echocardiography, then – depending on the question – cardiac CT or stress MRI. Cardiology and radiology evaluate the results together.
You receive a detailed report and a personal consultation about the further course of action.
Specialised in echocardiography, ECG diagnostics and cardiological assessment – in close cooperation with radiology.
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Coronary artery disease – together with its sequelae – is the most common cause of death in Germany;¹ angina pectoris is its most common warning sign. The 2024 European guideline recommends non-invasive imaging – cardiac CT or stress MRI – as the first diagnostic step when CAD is suspected.² In the SCOT-HEART trial, people with chest pain whose assessment included cardiac CT had fewer heart attacks or coronary deaths over five years (2.3 % versus 3.9 %).³ A considerable proportion of people with angina – more often women – have no narrowed large coronary arteries but a disorder of the smallest vessels or vascular spasms (INOCA).⁴ At the same time, long and post-COVID, post-exertional malaise as well as POTS and other forms of dysautonomia can cause similar symptoms;⁵ ⁶ ⁷ ⁸ careful differentiation is therefore part of every assessment. Whether and which examination makes sense in your case, we decide together based on your individual risk profile.