Is chest pain and painful breathing 2 days after Coronary Artery Bypass Grafting (CABG) normal?

Chest Pain and Painful Breathing 2 Days After CABG: Normal Findings and Management

Chest pain and painful breathing 2 days after coronary artery bypass grafting (CABG) is normal and most commonly due to musculoskeletal pain from sternotomy. 1, 2

Common Causes of Post-CABG Chest Pain (Days 1-7)

• Musculoskeletal pain from sternotomy is the most common cause of chest pain in the early post-operative period 1, 2
• Post-sternotomy pain syndrome affects between 7% and 66% of patients, with higher prevalence in women (51.4%) compared to men (31.3%) within the first 3 months 1, 2
• Pleural effusions are common after CABG and can cause chest pain with breathing, with most patients having small left-sided effusions 3
• Pericarditis can develop post-operatively and cause pleuritic chest pain 1
• Early graft failure due to technical issues at anastomotic sites or thrombosis can cause ischemic chest pain, though less common 1, 2

Evaluation of Early Post-CABG Chest Pain

When to Suspect Normal Post-Surgical Pain:

• Pain localized to sternotomy site that worsens with movement, coughing, or deep breathing 1
• Absence of concerning ECG changes or hemodynamic instability 1
• Pain that responds to standard analgesics 4

When to Suspect Complications:

• New-onset ECG changes suggesting ischemia 1
• Hemodynamic instability 1
• Fever, which may suggest infection or post-cardiac injury syndrome 3
• Severe dyspnea disproportionate to expected post-surgical state 3

Management Approach

For Typical Post-Sternotomy Pain:

• Appropriate analgesic therapy with scheduled acetaminophen and as-needed opioids 4
• Proper splinting techniques when coughing or moving 4
• Early but careful mobilization as tolerated 4

For Concerning Symptoms:

• If ischemia is suspected (based on ECG changes or atypical pain), stress imaging is effective to evaluate for myocardial ischemia 1
• Coronary CT angiography (CCTA) has 99% sensitivity and specificity for detecting graft occlusions if needed 1
• Invasive coronary angiography (ICA) is useful for patients with indeterminate/nondiagnostic stress tests or high-risk features 1

Monitoring Recommendations

• Continuous electrocardiographic monitoring for at least 48 hours after CABG is recommended to detect arrhythmias, which commonly occur 2-4 days post-operatively 1, 4
• ST-segment monitoring in the early postoperative period can help detect myocardial ischemia 4
• Monitor for signs of infection, particularly in patients with diabetes, as hyperglycemia increases risk of sternal wound infections 4

Common Pitfalls to Avoid

• Dismissing all chest pain as "normal" without appropriate evaluation of ECG changes 1
• Failing to distinguish between musculoskeletal pain and ischemic pain 1
• Overlooking pleural effusions as a cause of painful breathing in the early post-operative period 3
• Inadequate pain control leading to poor respiratory effort and potential pulmonary complications 4

Long-Term Outlook

• While immediate post-operative pain is expected, persistent pain beyond 2 months without apparent cause defines post-sternotomy pain syndrome 1
• Most patients (56%) report no chest pain 5 years after CABG, though this decreases slightly to 54% at 10 years 5
• Dyspnea improves in many patients after CABG but tends to increase over time, with only 31% reporting no dyspnea after 10 years 5, 6