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Chest pain after coronary interventional procedures. Incidence and pathophysiology
A Jeremias1, S Kutscher, M Haude
1Department of Cardiology, University Hospital Essen, Germany.
Insights
Chest pain after coronary interventions is common. While sometimes serious, it
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Chest pain post-percutaneous coronary intervention (PCI) is frequent, causing patient and staff distress.
- Potential causes include acute coronary artery closure, spasm, myocardial infarction, or local trauma.
- Distinguishing benign from hazardous causes is critical for appropriate patient management.
Purpose of the Study:
- To differentiate the causes of chest pain following coronary interventional procedures.
- To highlight the significance of non-ischemic chest pain, particularly after stent implantation.
Main Methods:
- Review of clinical presentations and outcomes of patients experiencing chest pain after PCI.
- Analysis of data from registries like the National Heart, Lung, and Blood Institute PTCA Registry.
- Comparison of chest pain incidence and causes between percutaneous transluminal coronary angioplasty (PTCA) and newer interventions like stenting.
Main Results:
- A minority of post-procedural chest pain cases are due to ischemic events.
- Coronary artery spasm, occlusion, or myocardial infarction occur in a small percentage of patients.
- Non-ischemic chest pain, potentially 'stretch pain' from stent implantation, is more common (41% vs. 12% after PTCA).
Conclusions:
- Chest pain after coronary interventions requires careful evaluation to rule out ischemia.
- Non-ischemic 'stretch pain' is a significant consideration, especially after coronary stent placement.
- Recognizing diverse origins of cardiac chest pain is essential for effective clinical management.
Abstract:
Chest pain following successful percutaneous coronary interventions is a common problem. Although the development of chest pain after coronary interventions may be of benign character, it is disturbing to patients, relatives and hospital staff. Such pain may be indicative of acute coronary artery closure, coronary artery spasm or myocardial infarction, but may also simply reflect local coronary artery trauma. The distinction between these causes of chest pain is crucial in selecting optimal care. Management of these patients may involve repeat coronary angiography and additional intervention. Commonly, repeat coronary angiography following percutaneous transluminal coronary angioplasty (PTCA) in patients with chest pain demonstrates widely patent lesion sites suggesting that the pain was due to coronary artery spasm, coronary arterial wall stretching or was of non-cardiac origin. As reported by the National Heart, Lung and Blood Institute PTCA Registry, 4.6% of patients after angioplasty have coronary occlusions, 4.8% suffer a myocardial infarction, and 4.2% have coronary spasm. The frequency of chest pain after new device coronary interventions (atherectomy and stenting) seems to be even higher. However, only the minority of patients with post-procedural chest pain have indeed an ischemic event. Therefore, the vast majority of patients have recurrent chest pain without any signs of ischemia. There is some evidence that non-ischemic chest pain after coronary interventions is more common after stent implantation as compared to PTCA (41% vs. 12%). This may be due to the continuous stretching of the arterial wall by the stent as the elastic recoil occurring after PTCA is minimized. In conclusion, chest pain after coronary interventional procedures may potentially be hazardous when due to myocardial ischemia. However, especially after coronary stent placement, cardiologists must consider "stretch pain" due to the overdilation and stretching of the artery caused by the stent in the differential diagnosis. Clinically, it is, therefore, important to recognize that in addition to ischemia-related chest pain other types of chest pain do exist with cardiac origin.