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Practice Practice Pointer

Primary care management of chest pain after coronary artery bypass surgery

BMJ 2019; 365 doi: (Published 12 April 2019) Cite this as: BMJ 2019;365:l1303
  1. Damian Gimpel, unaccredited cardiothoracic registrar1 2,
  2. Raewyn Fisher, cardiologist3,
  3. Zahoor Khan, general practitioner4,
  4. David J McCormack, consultant cardiothoracic surgeon1 2
  1. 1Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand
  2. 2Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
  3. 3Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
  4. 4General Practice, Roodlane Medical, London, UK
  1. Correspondence to: D J McCormack david.mccormack{at}

What you need to know

  • Investigate any chest pain after coronary artery bypass grafting by requesting an electrocardiogram, chest x ray, and tests such as troponin assay and complete blood count

  • Chest pain of sudden onset or of increasing severity may be due to ischaemic heart disease or aortic dissection. Urgently refer the patient to specialist cardiology or emergency services

  • Suspect sternal wound infection if the pain is localised to the surgical scar and is accompanied by erythema or discharge at the site, fever, or malaise

  • Persistent pain after surgery with normal findings on assessment and investigations may be attributed to musculoskeletal cause or chronic postoperative pain

  • There is no evidence based treatment for chronic postoperative pain, but a combination of analgesics for pain relief, patient education and counselling to address lifestyle risk factors, behavioural therapy, and follow-up may be offered

Coronary artery bypass grafting (CABG) is increasingly common and accounts for over half of all adult cardiac surgeries globally.1 Over 16 000 operations were performed in the UK in 2015.2 Recurrent or chronic chest pain after CABG can be extremely worrying for the patient and affect their quality of life.3 In a prospective cohort study (183 patients), a third of patients reported chronic chest pain on movement and 17% reported chest pain at rest at one year after CABG.4 This presents a diagnostic challenge in primary care and requires prompt investigation.5

This article presents a practical approach for non-specialists to evaluate chest pain in patients after a CABG with a median sternotomy (see box 1). We focus on chest pain in the medium to long term after surgery, when the patient has been discharged from postoperative services and is under the care of their general practitioner in the community. The approach can be relevant in patients with post-sternotomy chest pain after …

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