Chest Pain but a Normal EKG: Should You Get an Echocardiogram?
Chest pain is one of the most common—and anxiety-provoking—reasons people seek medical care. While an electrocardiogram (EKG or ECG) is often the first test ordered, many patients are surprised (and sometimes confused) when their EKG comes back normal despite ongoing symptoms.
So what does a normal EKG really mean—and should you still consider an echocardiogram?
Important Safety Note
Active or severe chest pain is a medical emergency.
If you are experiencing new, worsening, or ongoing chest pain, chest pressure, shortness of breath, dizziness, nausea, or pain radiating to the arm, jaw, neck, or back, call 911 or seek emergency care immediately.
This article is for educational purposes only and is not a substitute for emergency medical evaluation. Do not delay urgent care based on online information or normal test results.
What a Normal EKG Can (and Can’t) Tell You
An EKG records the electrical activity of the heart at a single point in time. It’s excellent for detecting:
Active heart attacks
Dangerous heart rhythm abnormalities
Prior myocardial injury
Conduction system issues
However, a normal EKG does not rule out all heart problems.
An EKG does not show:
Heart muscle strength
Valve structure or function
Wall motion abnormalities
Pericardial disease
Structural heart disease
This is why some patients continue to experience chest pain even when their EKG looks reassuring.
Common Causes of Chest Pain With a Normal EKG
Chest pain can come from many cardiac and non-cardiac sources. When the EKG is normal, providers often consider:
Cardiac causes that may not appear on EKG:
Valvular heart disease (mitral valve prolapse, aortic stenosis)
Cardiomyopathy
Heart failure (early or diastolic dysfunction)
Pericardial effusion or inflammation
Structural abnormalities
Non-cardiac causes:
Acid reflux (GERD)
Musculoskeletal pain
Anxiety or panic attacks
Lung-related conditions
This overlap is where imaging becomes critical.
How Echocardiography Helps Answer the Next Question
An echocardiogram is a non-invasive ultrasound that allows providers to see the heart in motion—not just its electrical signals.
Echocardiography can evaluate:
Heart pumping function (ejection fraction)
Valve anatomy and severity of regurgitation or stenosis
Wall motion abnormalities
Chamber size and thickness
Fluid around the heart (pericardial effusion)
Signs of elevated pressures or heart failure
For patients with persistent chest pain, shortness of breath, or unexplained symptoms, an echocardiogram often provides the missing piece of the diagnostic puzzle.
When an Echocardiogram Is Often Recommended
Your provider may suggest an echocardiogram if you have chest pain with a normal EKG and:
Ongoing or recurrent symptoms
Shortness of breath or fatigue
A new heart murmur
History of hypertension, diabetes, or heart disease
Abnormal findings on physical exam
Family history of cardiomyopathy or valve disease
In these cases, imaging helps rule out structural causes that an EKG alone cannot detect.
The Bottom Line
A normal EKG is reassuring—but it’s not the full story.
If chest pain persists or symptoms don’t add up, an echocardiogram can provide crucial insight into how the heart is functioning structurally and mechanically. Early imaging can lead to earlier answers, better treatment decisions, and peace of mind.
If you’re experiencing chest pain and have questions about whether an echocardiogram is appropriate, speak with your healthcare provider about the next best step.
