From the Guidelines
Yes, it is common to experience chest wall pain even a year after coronary artery bypass grafting (CABG) surgery, with the incidence of post-sternotomy pain syndrome ranging from 7% to 66%. This persistent pain, often called post-sternotomy pain syndrome or post-CABG pain syndrome, affects patients due to various reasons such as musculoskeletal pain from sternotomy, myocardial ischemia, pericarditis, or sternal wound infection 1. The pain typically manifests as discomfort around the sternum, incision sites, or where chest tubes were placed.
Management Options
Management options include:
- Acetaminophen (500-1000mg every 6 hours as needed) or NSAIDs like ibuprofen (400-600mg every 6-8 hours with food) for mild to moderate pain.
- For more severe cases, gabapentin (starting at 300mg daily and gradually increasing) or pregabalin (75-150mg twice daily) may help with neuropathic components, although their use as adjunct medications has been less successful in promoting an opioid-sparing technique, with adverse effects that include visual disturbances, dizziness, respiratory depression, and postoperative delirium in patients ≥65 years of age 1.
- Physical therapy focusing on gentle stretching and strengthening exercises can improve chest wall mobility. The pain occurs because the sternotomy during surgery disrupts chest wall integrity, potentially damaging intercostal nerves, causing inflammation, or creating scar tissue that pulls on surrounding structures. While this pain typically improves over time, some patients may require ongoing management strategies for several years after surgery.
Key Considerations
Key considerations in managing chest wall pain after CABG include:
- Identifying the underlying cause of the pain, whether it be musculoskeletal, cardiac, or other.
- Using a multimodal approach to pain management, including pharmacologic and non-pharmacologic interventions.
- Monitoring patients for potential adverse effects of pain management strategies, particularly in older adults.
From the Research
Chest Wall Pain after CABG
- Chest wall pain is a common condition that can occur after coronary artery bypass graft (CABG) surgery, although the provided studies do not specifically address the incidence of chest wall pain after CABG 2, 3, 4.
- A study on chest wall syndrome among primary care patients found that the syndrome is common and benign, but can lead to anxiety and recur frequently 3.
- Another study on chest wall syndrome in primary care patients with chest pain found that 46.6% of patients had pain originating from the chest wall, and 28.0% of these patients showed persistent pain 2.
- There is no direct evidence in the provided studies to suggest that chest wall pain is a common complication after CABG surgery, but it is known that chest wall pain can be a cause of unexplained cardiac pain 4.
- A study on non-cardiac chest pain patients in the emergency department found that musculoskeletal chest pain was a common underlying disease, but it did not specifically address the incidence of chest wall pain after CABG 5.
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is common in perioperative pain management of patients undergoing CABG surgery, but there is no evidence to suggest that NSAIDs are used to treat chest wall pain after CABG 6.
Diagnosis and Treatment
- The diagnosis of chest wall syndrome is often made based on the atypical nature of the pain and confirmed by chest wall tenderness simulating the spontaneously occurring pain 4.
- A simple score containing four determinants (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) can help in the diagnostic workup of chest pain patients 2.
- Treatment for chest wall pain may include analgesics, and a diagnostic test with proton pump inhibitor (PPI) may be prescribed in some cases 5.