This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.
Dwain M. Daniel, D.C.
How this evidence was rated:
Strength of Recommendation Taxonomy (SORT)
January 18, 2011
The diagnosis of costochondritis (CC), when it is present, is relatively easy to establish when confronted in a patient experiencing anterior chest pain. However the dire consequence of missing a concurrent cardiovascular event, pulmonary embolism (PE) or pneumonia when making this diagnosis places an extra burden upon the diagnosing physician. A review of the literature reveals several sobering facts. Miller et al found in their study of 17737 patients who were diagnosed with non-cardiac chest pain and released from the hospital emergency rooms, 4.3% had definite evidence of adverse cardiac events or unstable angina (1). A second study of 108 patients that were diagnosed with non-cardiac chest pain found 2.7% had died within 1 year of heart disease or emphysema. This study also reported 6% of patients with presumed CC were also experiencing myocardial infarction (MI) (2).
Other study findings which are of interest when dealing with a patient with chest pain follow:
An aid to identifying high risk patients for MI, PE and pneumonia with anterior chest pain are prediction rules that are well accepted in the literature. The American Family Physician recently published an article detailing the these prediction rules which are available in more detail at http://www.aafp.org/afp/2005/1115/p2012.html (5). A brief synopsis of these rules follows:
- Musculoskeletal presentation of chest pain is far more common in general practice than in emergency rooms, 36% compared to 6% (3).
- The percent of chest pain that remains undiagnosed after 1 year is approximately 11% (2;4)
- Causes of chest pain in the emergency room (4):
- Cardiac diseases: 51.7%
- Pulmonary disease: 14.2%
- Gastro-esophageal diseases: 2.4%
- Musculoskeletal pathology: 7.1%
- Somatization disorders: 9.2%
- Other: 4.3%
- Unknown: 11.1%
Rouan Decision Rule for MI
Cayley indicates chest pain radiating to both arms, hypotension, S3 gallop, dyspnea and hyperlipidemia are associated with increased risk of MI (5).
- Age greater than 60 years
- History of MI or angina
- Pain described as pressure
- Radiating pain
Wells Model for PE
Diehr Rule for Pneumonia
- Clinical signs of deep vein thrombosis (DVT)
- PE most likely diagnosis
- Patient experienced 3 or more consecutive days of bedrest in last 4 weeks
- Previous diagnosis of DVT
- Cancer treatment that is ongoing or during past 6 months
Chest wall syndrome is a term to describe pain arising from the chest wall that is musculoskeletal in origin. It is a term which includes CC as well as several other sources of musculoskeletal pain. Verdon et al provided 6 characteristics of chest wall syndrome (CWS) that help to distinguish CWS from other more serious conditions (6). These include:
- Night sweats
- Sputum production all day
- Respiratory rate more than 25
- Temperature over 100 degrees
- Presence of rhinorrhea and/or sore throat decrease probability
- Not squeezing or oppressive: Odds Ratio (OR) 2.52 (1.21-5.28)
- Localized on the left or median left part of the chest wall: OR 2.26 (1.58-3.28)
- Well localized on the chest wall: OR 2.10 (1.37-3.22)
- Non-exercise induced pain: OR 1.58 (1.00-2.49)
- Influenced by movement or posture: OR 1.54 (1.06-2.24
- Reproducible by palpation: 5.72 (1.20-5.28)
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Miller CD, Lindsell CJ, Khandelwal S, Chandra A, Pollack CV, Tiffany BR, et al. Is the initial diagnostic impression of "noncardiac chest pain" adequate to exclude cardiac disease? Ann Emerg Med 2004 Dec;44(6):565-74.
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