From the Guidelines
For patients presenting with sternal pain, it is crucial to first rule out life-threatening causes, such as cardiac issues, by immediately acquiring and interpreting a 12-lead ECG within 10 minutes of arrival to a medical facility, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. When evaluating sternal pain, considerations should include the full extent of clinical data to identify life-threatening causes, determine clinical stability, and assess the need for hospitalization versus outpatient evaluation and management. The causes of chest pain, including sternal pain, can be categorized into four types: STEMI, NSTE-ACS, stable angina, and noncardiac, according to the ACC/AHA STEMI and NSTE-ACS guidelines 1. Key steps in managing sternal pain include:
- Identifying and triaging patients with STEMI to urgent coronary reperfusion
- Prompt evaluation in a hospital setting for patients with other ST-T abnormalities consistent with possible ischemia
- Managing patients with stable angina or noncardiac chest pain that is not life-threatening as outpatients It is essential to note that patients with severe pain, shortness of breath, pain radiating to the jaw or arms, or associated with sweating or nausea should seek emergency medical attention immediately, as these symptoms could indicate a heart attack. Additionally, persistent sternal pain lasting more than a week, pain following trauma, or pain with fever requires medical evaluation to determine the underlying cause and appropriate treatment.
From the Research
Sternal Pain Management
- Sternal pain can be a symptom of various conditions, including musculoskeletal injuries or acute coronary syndrome 2
- The management of sternal pain depends on the underlying cause, and a thorough evaluation is necessary to determine the appropriate treatment
Pharmacologic Therapy
- For acute mild to moderate pain, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment options 3
- Topical NSAIDs can be used for non-low back, musculoskeletal injuries, while acetaminophen is well tolerated but requires lower doses in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 3
- Ibuprofen/acetaminophen fixed-dose combination is an alternative to opioids in the management of common pain types, including sternal pain, with potential benefits of reduced need for rescue opioid medication 4
Diagnostic Evaluation
- For patients presenting with acute chest pain, including sternal pain, a skilled assessment of symptoms, history, and physical examination is necessary, often followed by serial recording of electrocardiograms and measurement of serum biochemical markers 2
- Computed tomography angiography, including the "triple rule-out" protocol, can be used to detect life-threatening causes of chest pain, such as coronary artery disease, acute aortic syndrome, and pulmonary emboli, but should not be used as a routine screening procedure 2