Can a TENS (Transcutaneous Electrical Nerve Stimulation) unit or back stimulator be used to manage electrical chest pain?

Using TENS for Electrical Chest Pain Management

Transcutaneous electrical nerve stimulation (TENS) can be considered for patients with chest pain of cardiac origin when standard medical therapy has failed, particularly in patients with syndrome X (microvascular angina) who have persistent pain despite implementation of first-line measures. 1

Understanding Electrical Chest Pain

Chest pain with an "electrical" quality may arise from several causes:

• Cardiac causes (angina, syndrome X/microvascular angina)
• Musculoskeletal pain
• Neuropathic pain
• Non-cardiac causes (esophageal, pulmonary)

Initial Evaluation

Before considering TENS therapy, proper evaluation is essential:

1. Immediate assessment with ECG within 10 minutes of presentation 1, 2
2. Cardiac biomarker measurement (preferably high-sensitivity troponin) 1, 2
3. Focused cardiovascular examination to rule out acute coronary syndrome or other serious causes 1

TENS for Cardiac Chest Pain

Evidence for TENS in Cardiac Pain

TENS has demonstrated efficacy in specific cardiac pain scenarios:

• Syndrome X (microvascular angina): TENS is specifically mentioned in ACC/AHA guidelines as a Class IIb recommendation (Level of Evidence: B) for patients with syndrome X who have continued pain despite implementation of first-line measures 1

• Refractory angina: TENS has shown benefit in patients with angina pectoris refractory to medical therapy when revascularization is not suitable 3, 4

• Post-cardiac surgery pain: TENS can help manage sternal pain after open heart surgery, improving deep breathing capacity and reducing analgesic requirements 5

Mechanism of Action

TENS works through multiple mechanisms:

• Inhibition of pain transmission
• Release of endogenous opioids
• Reduced muscle ischemia
• Decreased sympathetic nervous stimulation of the heart 3, 6

Implementation Protocol

For patients with cardiac-related electrical chest pain:

1. First-line therapy: Begin with standard medical therapy (nitrates, beta-blockers, calcium channel blockers) 1

2. When to consider TENS:

   • After failure of standard medical therapy
   • For patients unsuitable for revascularization
   • For persistent pain despite optimal medical management

3. Application technique:

   • Place electrodes on the chest wall over the area of pain
   • Initial settings: Low-frequency (1-70 Hz) or high-frequency based on patient response 7
   • Treatment duration: 1-3 hours daily, divided into multiple sessions 3

4. Monitoring:

   • Assess pain relief response
   • Monitor for adverse effects
   • Evaluate functional improvement

Important Caveats

• Rule out acute coronary syndrome before initiating TENS therapy 1
• Not a substitute for emergency care in acute chest pain scenarios
• Contraindicated in undiagnosed chest pain until cardiac causes are ruled out
• Limited evidence for long-term outcomes in non-anginal electrical chest pain

Conclusion

TENS represents a viable non-pharmacological option for managing electrical chest pain, particularly in patients with syndrome X or refractory angina who have failed standard medical therapy. The evidence supports its use as an adjunctive therapy rather than a first-line treatment for cardiac-related chest pain.

For non-cardiac electrical chest pain, TENS may still provide symptomatic relief, but the underlying cause should be identified and treated appropriately.