Can a patient with a coronary stent and shoulder and back pain undergo hyperbaric oxygen therapy?

Can a Patient with a Coronary Stent and Shoulder/Back Pain Undergo Hyperbaric Oxygen Therapy?

Yes, a patient with a coronary stent can safely undergo hyperbaric oxygen therapy (HBOT), and emerging evidence suggests it may actually provide cardiovascular benefits, though the shoulder and back pain etiology must first be evaluated to ensure it's not cardiac in origin.

Initial Critical Assessment

Before proceeding with HBOT, you must first determine whether the shoulder and back pain represents:

• Cardiac ischemia (referred pain from angina or acute coronary syndrome)
• Musculoskeletal pain (non-cardiac origin)

If the pain is cardiac in nature with evidence of ischemia or acute coronary syndrome, the patient requires urgent cardiac evaluation and management per standard guidelines 1, not HBOT as a primary intervention.

Safety Profile of HBOT in Stented Patients

Evidence Supporting Safety and Efficacy

HBOT appears safe and potentially beneficial in patients with coronary stents:

• Multiple studies have evaluated HBOT specifically in post-stent patients without reporting stent-related complications 2, 3, 4, 5
• A 2021 randomized pilot study of STEMI patients post-PCI showed HBOT improved myocardial perfusion (affected SPECT segments decreased from 47.1% to 33.7%, p=0.039) and ejection fraction (44% to 57.2%, p=0.011) 2
• A 2019 retrospective study of 55 patients post-stent implantation demonstrated improved vascular endothelial function with HBOT, including increased flow-mediated dilation and nitric oxide levels 3
• A 2004 trial showed major adverse cardiac events occurred in only 4% of HBOT patients versus 35% in controls at 8 months post-PCI 5

Potential Complications to Monitor

The main risks of HBOT are not stent-related but rather general HBOT complications 6:

• Middle ear barotrauma (17% experience ear discomfort; 3.8% have documented tympanic membrane injury)
• CNS oxygen toxicity (generalized seizures in <1% of patients)
• Pulmonary complications (rare, but documented in thoracic trauma patients 7)
• Myopia and cataract progression (with prolonged therapy)

Critical caveat: A 2025 study in thoracic trauma patients found 20% developed respiratory or cardiac symptoms during HBOT, including dyspnea, chest pain, and arrhythmias 7. While these patients had severe trauma, this underscores the need for cardiac monitoring during sessions.

Clinical Decision Algorithm

Step 1: Rule Out Cardiac Etiology

• Obtain ECG immediately
• Check troponin levels
• If any evidence of ischemia or ACS → manage per cardiology guidelines 1 before considering HBOT

Step 2: Assess HBOT Candidacy

Proceed with HBOT if:

• Pain is confirmed non-cardiac (musculoskeletal)
• Patient is on appropriate dual antiplatelet therapy (DAPT) per guidelines 1
• No contraindications to HBOT exist (untreated pneumothorax, severe COPD with CO2 retention)

HBOT protocol used in cardiac studies:

• Pressure: 2.4 ATA (atmospheres absolute) 7
• Duration: 90-120 minutes per session 2
• Frequency: 15 sessions over several weeks 2

Step 3: Monitoring During HBOT

• Continuous cardiac monitoring during sessions
• Blood glucose checks in diabetics (to exclude hypoglycemia as seizure cause) 6
• Pressure equalization assessment (especially critical in first session)
• Stop immediately if chest pain, dyspnea, or arrhythmias develop

Antiplatelet Therapy Considerations

Do not interrupt DAPT for HBOT. Current guidelines mandate 1:

• Aspirin 75-100 mg daily indefinitely
• P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) for 12 months post-stent

HBOT studies have not reported increased bleeding complications in patients on DAPT 2, 3, 4, 5, suggesting the therapy is compatible with standard antiplatelet regimens.

Practical Recommendations

For musculoskeletal shoulder/back pain in a stable stented patient:

• HBOT is safe and may provide additional cardiovascular benefits
• Ensure patient is compliant with DAPT
• Perform pre-HBOT cardiac assessment (ECG, clinical evaluation)
• Use multiplace chamber with medical supervision
• Monitor for barotrauma symptoms (ear pain is most common)

For unclear or potentially cardiac pain:

• Defer HBOT until cardiac workup is complete
• Consider stress testing or coronary angiography if indicated
• Treat any identified ischemia per standard revascularization guidelines 1, 8

Key Pitfall to Avoid

Do not assume shoulder/back pain is musculoskeletal without cardiac evaluation. Referred cardiac pain commonly presents in these locations, particularly in women and diabetics. Missing acute coronary syndrome while pursuing HBOT would be catastrophic. Always obtain ECG and troponin first.

The evidence suggests HBOT is not only safe but potentially beneficial for cardiovascular outcomes in stented patients 2, 3, 4, 5, making it a reasonable adjunctive therapy once cardiac causes of pain are excluded.