Management of Pain in Patients with History of NSTEMI

Introduction to Alternative Therapies

The American College of Cardiology recommends that for patients with a history of NSTEMI and shoulder pain due to supraspinatus tendinosis, bursitis, and arthritis, non-dihydropyridine calcium channel blockers represent the safest alternative to narcotics when acetaminophen is ineffective and NSAIDs are contraindicated 1
The American Heart Association suggests that acetaminophen is generally the first choice for patients with cardiovascular history, but has already been tried without success in this case 2, 3

The American College of Cardiology states that NSAIDs are contraindicated in patients with a history of NSTEMI due to an increased risk of major cardiovascular events 1, 3
The American Heart Association recommends that selective COX-2 inhibitors present an even higher cardiovascular risk and are formally contraindicated 4

Non-dihydropyridine calcium channel blockers are recommended for recurrent ischemia with contraindications to beta-blockers 1
Salicylates (such as salsalate) are recommended in a stepwise approach for the management of chronic musculoskeletal pain in patients with a history of NSTEMI 3, 4
Targeted physical therapy for the shoulder, application of heat or cold, and muscle relaxation techniques are also recommended 2, 6

The American Heart Association notes that NSAIDs increase the risk of cardiovascular events, particularly in patients with established cardiovascular disease 3
A Danish study showed a significant increase in mortality risk with different NSAIDs in post-infarction patients: HR 1.50 for ibuprofen, 2.40 for diclofenac 3
The American College of Cardiology recommends that NSAIDs should not be administered to patients with NSTEMI/unstable angina 1, 4

Start with acetaminophen (already tried without success) 3
Try non-acetylated salicylates 3
Consider non-dihydropyridine calcium channel blockers 1
Use small doses of narcotics if necessary, while awaiting consultation with the orthopedic surgeon 3, 4

If opioids are necessary, use the effective dose for the shortest possible period 7
Morphine may be administered intravenously and titrated to relieve pain in patients with STEMI, but should be used with caution 7