Chest pain interventions

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]

Indications

Common indications of coronary angiography in high risk ACS patients include:

• New ischemic changes on the ECG
• Troponin-confirmed acute myocardial injury
• New-onset left ventricular systolic dysfunction (ejection fraction <40%)
• Newly diagnosed moderate-severe ischemia on stress imaging

• For high-risk patients presented with documented AMI and normal epicardial coronary arteries on CCTA or invasive coronary angiography, or nonobstructive CAD, CMR and echocardiography are useful for evaluation of nonischemic cardiomyopathy or myocarditis.

• Among high risk patients, invasive coronary angiography provides a comprehensive assessment of the extent and severity of obstructive CAD.
• The determination of the severity of anatomic CAD is critical to guide the use of coronary revascularization. *Approximately 6% to 15% of troponin-positive ACS occurs in the absence of obstructive CAD.
• Additional testing may be helpful to determin the strategy of treatment.
• Evidence supports that CMR can identify wall motion abnormalities and myocardial edema and distinguish infarct-related scar from non-CAD causes such as myocarditis and nonischemic cardiomyopathy.
• Performing CMR within 2 weeks of ACS, can be useful to identify MI with nonobstructive CAD (MINOCA) from other causes.

Common causes of acute chest pain in the months after CABG include:

• Musculoskeletal pain from sternotomy: the most common cause
• Myocardial ischemia from acute graft stenosis or occlusion
• Pericarditis
• Pulmonary embolism
• Sternal wound infection
• Nonunion
• Post-sternotomy pain syndrome is defined as discomfort after thoracic surgery, persisting for at least 2 months, and without apparent cause.
• The incidence of post-sternotomy pain syndrome is varied 7%-66% with a higher prevalence in women compared with men within the first 3 months of thoracic surgery but, after 3 months, postoperative sex difference in prevalence was not seen.
• Causesa of Graft failure within the first year post-CABG using saphenous venous grafts are:

*Technical  issues

• Intimal hyperplasia
• Thrombosis
• Internal mammary artery graft failure within the first-year post-CABG is most commonly attributable to issues with the anastomotic site of the graft.
• Causes of acute chest pain several years after CABG including:

  Graft stenosis

  Occlusion or progression of disease in a non-bypassed vessel

• One year after CABG, about 10%-20% of saphenous vein grafts fail.
• By 10 years, about half of saphenous vein grafts are patent.
• The internal mammary artery has patency rates of 90% to 95% 10 to 15 years after CABG.
• The use of radial artery grafts for CABG has a higher patency rate at 5 years of follow-up, compared with the use of saphenous vein grafts.