Ruling out other causes than chest wall syndrome for patients with chest pain

Abstract

Up to 15% of the population is concerned by musculoskeletal-like chest pain making it a frequent reason to request manipulative care. 1 A recent clinical trial suggests that such care could be beneficial to diminish chest pain even for patients who have had an acute myocardial infarction (AMI). 2 For general practitioners, osteopaths and other manipulative practitioners, it is nevertheless important to rule out any serious non-musculoskeletal conditions before initiating a treatment for CWS. In a recent publication the Swiss group of Ronga et al. (including the current reviewer) therefore provided a simple clinical prediction rule to detect CWS in primary care settings. This study combined data from two cohorts including patients attending their GP and complaining of chest pain; the Lausanne cohort included 644 patients from 59 GPs in western Switzerland, and the Marburgh cohort included 1249 patients from 74 GPs in Hesse, Germany. Signs and symptoms related to chest pain were collected at inclusion. Diagnosis of origin of chest pain were then confirmed by following all patients over six months. Chest wall syndrome was defined as “a benign cause of chest pain localized to the anterior chest wall and caused by a musculoskeletal disorder.” The Lausanne cohort served to derivate a predictive score whereas the Marburg cohort served to validate the score. The CWS-score derived relies on six questions (Table), each condition worth one point apart for “reproduction of pain during palpation” which is worth two. In the validation cohort, the receiver operator curve for this score was of 0.76 (95%CI: 0.73-0.79) revealing an acceptable discrimination tradeoff between specificity and sensitivity across different score values. The cut-off point for considering CWS as the single cause of chest pain was set for scores of six points or more. This provided a specificity of 93.4% (proportion of patients without CWS correctly identified as such) and a sensitivity of 22% (proportion of patients with CWS correctly identified as such). CWS score correctly ruled out all seven cases of parietal metastasis, all ten cases of unstable angina and myocardial infarction and 105/108 cases of all cardiovascular diseases, 53/55 cases of pulmonary infection disease, and 46/47 digestive peptic affections. However, even with scores 6, other affections cannot be totally ruled out. From the 75 cases of stable angina, three presented a score that would have led to a false rejection of such a cause.