**Author details**

*Differential Diagnosis of Chest Pain*

inferior QRS axis.

bundle pacing [74, 76–78].

**3. Conclusion**

Delayed cardiac perforation

angina

**Table 1.**

Pacemaker-mediated

Post cardiac injury syndrome

Painful left bundle branch block syndrome

right ventricle. On electrocardiography, this can be differentiated from an acute LBBB using the six criteria outlined by Shvilkin et al. [70]: abrupt onset of chest pain coinciding with the development of LBBB; simultaneous resolution of symptoms with resolution of LBBB; normal 12-lead ECGs before and after LBBB; absence of myocardial ischemia during functional stress testing; normal left ventricular function and the absence of other abnormalities to explain symptoms; and low precordial S/T wave ratio consistent with new-onset LBBB (<1.8 in this series) and

Most of the patients tolerate right ventricular pacing without any significant clinical features. However, a small population of patients may develop significant chest pain, independent of coronary artery disease [71, 72]. Although the underlying mechanism is unclear, several mechanisms have been postulated: (1) dyssynchronous ventricular contraction occur due to paradoxical septal movement during ventricular pacing, (2) there is abnormal activation of the neurons responsible for interception ventricular pacing, and (3) there is microvascular ischemia during ventricular pacing as noted by elevated concentration of lactic acid in the coronary sinus [73–75]. A careful history and observation of chest pain only during right ventricular pacing is the clue to the correct diagnosis. Treatment of these patients is very challenging but patients may respond very well to either CRT therapy or His

Almost all the patients that undergo CIED implantation will have some sort of chest pain dependent on the time of occurrence (**Table 1**). Most of the time this is secondary to surgical site pain. However, this could also be secondary to multiple reasons including life-threatening complications. Hence, early diagnosis and

prompt treatment is warranted to minimize morbidity and mortality.

**(postoperative period, 1–2 days)**

Pleuritic/pericardial involvement Pneumothorax

Stress cardiomyopathy Mediastinal bleed

Diaphragmatic pacing Pericardial effusion/tamponade

Surgical site pain Surgical site pain Musculoskeletal

**Immediate chest pain (perioperative period)**

**Delayed chest pain Post procedural chest pain** 

**54**

**Conflict of interest**

The authors declare no conflict of interest.

*Chest pain occurrence after cardiac implantable electronic device.*

Umashankar Lakshmanadoss1 \*, Imran Sulemankhil<sup>2</sup> and Karnika Senthilkumar3

1 Mercy Heart Institute, Cincinnati, OH, USA

2 Department of Medicine, Jewish Hospital of Cincinnati, Cincinnati, OH, USA

3 Cambridge International School, Dubai, UAE

\*Address all correspondence to: drlumashankar@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
