What can I give to a patient with costochondritis after ruling out Acute Coronary Syndrome (ACS)?

Management of Costochondritis After Ruling Out ACS

For patients with costochondritis after ruling out Acute Coronary Syndrome (ACS), acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment, along with activity modification and reassurance. 1

First-Line Treatment Options

• Acetaminophen (Tylenol) is recommended as a safe first-line option for pain relief in costochondritis, especially in patients with cardiovascular risk factors 1
• NSAIDs such as ibuprofen can be effective for inflammation and pain relief, but should be used with caution due to cardiovascular risks 2
• Short-acting nitrates (nitroglycerin) may be used for immediate relief of chest pain if symptoms persist and are similar to angina 3, 4
• Activity modification to avoid movements that exacerbate chest wall pain is recommended 1

Important Considerations for NSAID Use

• NSAIDs should be used at the lowest effective dose for the shortest duration possible to minimize cardiovascular risks 2
• NSAIDs can increase risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke 2
• Avoid NSAIDs in patients with:
  • Recent myocardial infarction 2
  • History of coronary artery bypass graft surgery 2
  • Severe heart failure 2
  • Hypertension that is not well controlled 2

Nitrate Therapy Considerations

• If using nitroglycerin for pain relief, administer 0.3-0.4 mg sublingually, which may be repeated every 5 minutes up to 3 doses if needed 3, 4
• Monitor blood pressure closely as nitrates can cause hypotension 3
• Contraindicated with recent phosphodiesterase-5 inhibitor use (avoid within 24 hours of sildenafil/vardenafil, 48 hours of tadalafil) 3

Pain Management Algorithm

1. First step: Start with acetaminophen 650-1000 mg every 6 hours (not to exceed 4000 mg/day) 1
2. If inadequate relief: Add or switch to an NSAID (e.g., ibuprofen 400-600 mg every 6-8 hours) if no contraindications exist 1
3. For severe or persistent pain: Consider short-acting nitrates for immediate relief 3, 4
4. For pain resistant to above measures: Consider referral for evaluation of other interventions 1

Patient Education and Follow-up

• Reassure patients about the benign, self-limited nature of costochondritis in most cases 1, 5
• Advise patients to avoid activities that produce chest muscle overuse 1
• Inform patients that symptoms may persist for weeks to months but typically resolve spontaneously 5
• Follow up if symptoms worsen or do not improve with conservative management 1

Common Pitfalls and Caveats

• Never use NSAIDs to mask symptoms of potential ACS; ensure ACS has been definitively ruled out before treating as costochondritis 2, 6
• Be aware that coronary artery disease can coexist with costochondritis in 3-6% of adult patients with chest wall tenderness 1
• In patients older than 35 years or with cardiac risk factors, ensure appropriate cardiac workup has been completed before attributing chest pain solely to costochondritis 1
• Morphine should be reserved for pain that is resistant to other maximally tolerated anti-ischemic medications and is not typically indicated for uncomplicated costochondritis 3