What is coronary stent pain?

Coronary Stent Pain: Characteristics and Management

Coronary stent pain is a common non-ischemic chest discomfort that occurs in approximately 41% of patients following stent implantation, primarily due to arterial wall stretching caused by the stent, and is typically brief, intermittent, and self-limiting. 1

Definition and Incidence

• Coronary stent pain is a non-ischemic chest discomfort that occurs after successful coronary stent placement, affecting approximately 41% of patients compared to only 12% of patients who undergo balloon angioplasty alone 1
• This pain is distinct from ischemic chest pain and occurs despite patent coronary arteries without evidence of stent restenosis or thrombosis 2
• Post-stent chest symptoms are frequently recurrent, with about 33% of patients experiencing symptoms at both 4 and 10 weeks post-procedure 3

Pathophysiology

• The primary mechanism is believed to be continuous stretching of the arterial wall by the stent, as the elastic recoil that occurs after angioplasty alone is minimized by stent placement 2
• The minimal lumen diameter after intervention is significantly larger in stented vessels compared to those treated with angioplasty alone (3.14±0.75 versus 1.95±0.67 mm), supporting the "stretch pain" hypothesis 1
• Enhanced coronary vasoreactivity may also play a role, as patients with persistent chest pain after stenting show more intense vasoconstriction with ergonovine and more vasodilation with nitroglycerin compared to asymptomatic patients 4

Clinical Characteristics

• Most patients (90.3%) report that this pain differs from their previous angina symptoms 1
• Patients typically describe the pain as discomforting with qualities such as dull, tight, sharp, pressing, or flickering 3
• The pain tends to be brief and/or intermittent (65% of cases), lasting from a few seconds to a few minutes (63% of cases) 3
• The pain may occur immediately after the procedure and/or in the following months, even in the absence of in-stent restenosis 4

Differential Diagnosis

• True ischemic pain due to acute stent thrombosis, restenosis, or incomplete revascularization must be ruled out 5
• Coronary artery spasm can occur at the stent site or in non-stented segments 4
• Non-cardiac causes of chest pain should be considered if symptoms persist despite a negative cardiac evaluation 5
• Gastrointestinal causes may include esophageal reflux or spasm, particularly after eating in a near-supine position during recovery 5

Evaluation

• ST-segment monitoring in the immediate post-intervention period can help distinguish between ischemic and non-ischemic chest pain 5
• The absence of ST-segment deviation during symptoms provides reassurance that the pain is not likely ischemic 5
• For persistent symptoms beyond the immediate post-procedure period, further evaluation may be needed to exclude in-stent restenosis 4
• Exercise thallium-201 perfusion scintigraphy followed by coronary angiography may be appropriate for persistent symptoms to rule out restenosis 4

Management

• Patient education about the benign nature of this pain is crucial, as most patients (75%) believe their symptoms are related to their stent and are unsure what to do 3
• Reassurance that this is a common phenomenon that typically resolves over time is important 2
• Short-term analgesics may be helpful for symptom management 5
• Cardiac rehabilitation staff are ideally positioned to support and inform stent recipients about appropriate responses to these symptoms 3

When to Seek Medical Attention

• Patients should seek immediate medical attention if the pain is prolonged (>20 minutes), severe, associated with dyspnea, diaphoresis, or hemodynamic instability, or unrelieved by rest or nitroglycerin 5
• Only about 5% of patients interpret their post-stent chest pain as ischemic, and 4% present to the hospital for evaluation 3
• Younger patients appear to experience post-stent chest pain more frequently than older patients 3

Prevention

• There is no established preventive strategy for coronary stent pain, as it appears to be an inherent consequence of the mechanical effect of the stent on the vessel wall 1
• Appropriate stent sizing and avoiding excessive post-dilation may theoretically reduce the incidence, but this must be balanced against the need for optimal stent expansion to prevent restenosis 2