Podcast #160 - Five Key Reminders When Evaluating Chest Pain after CABG

In emergency medicine, we are generally very good about evaluating chest pain.  We also are familiar with procedures including coronary artery bypass grafts (CABG).  However, in patients with recent CABG, there are some key reminders we need with this patient population.

These pearls come from a recent paper by Gimpel et al. published by The BMJ titled "Primary care management of chest pain after coronary artery bypass surgery" which was released earlier this year.  As the title suggests, this was originally designed for those in primary care but this paper has pearls we all can benefit from when taking care of these patients.

• In sudden or severe chest pain, consider ischemia or aortic dissection.
  • Early graft failure is the major reason for resistant/recurrent chest pain after surgical revascularization.
  • Ongoing smoking is linked to recurrent angina.
• Suspect infection with localized pain to the surgical scar especially with redness or discharge from the site, fever, or malaise.
• If any of the following two are present, consider postcardiac injury syndrome.
  • Fever without other cause
  • Pericarditis or pleuritic chest pain
  • Pericardial or pleural rub
  • Pericardial effusion
  • Pleural effusion on imaging with elevated CRP
• Persistent pain after surgery with a normal evaluation may be attributed to musculoskeletal or chronic post-op pain.
• Offer analgesics, education, lifestyle changes, and behavioral treatment for those patients with chronic post-op pain.

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