title: Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study.
abstract: OBJECTIVE
  Acute chest pain (ACP) is a leading cause of hospital emergency unit consultation. As there are various underlying conditions, ranging from musculoskeletal disorders to acute coronary syndrome (ACS), thorough clinical diagnostics are warranted. The aim of this prospective study was to assess whether reproducible chest wall tenderness (CWT) on palpation in patients with ACP can help to rule out ACS.
  
  
  METHODS
  In this prospective, double-blinded diagnostic study, all consecutive patients assessed in the emergency unit at the University Hospital Zurich because of ACP between July 2012 and December 2013 were included when a member of the study team was present. Reproducible CWT on palpation was the initial step and was recorded before further examinations were initiated. The final diagnosis was adjudicated by a study-independent physician.
  
  
  RESULTS
  121 patients (60.3% male, median age 47 years, IQR 34-66.5 years) were included. The prevalence of ACS was 11.6%. Non-reproducible CWT had a high sensitivity of 92.9% (95% CI 66.1% to 98.8%) for ACS and the presence of reproducible CWT ruled out ACS (p=0.003) with a high negative predictive value (98.1%, 95% CI 89.9% to 99.7%). Conversely non-reproducible CWT ruled in ACS with low specificity (48.6%, 95% CI 38.8% to 58.5%) and low positive predictive value (19.1%, 95% CI 10.6% to 30.5%).
  
  
  CONCLUSIONS
  This prospective diagnostic study supports the concept that reproducible CWT helps to rule out ACS in patients with ACP in an early stage of the evaluation process. However, ACS and other diagnoses should be considered in patients with a negative CWT test.
  
  
  BACKGROUND
  ClinicalTrial.gov: NCT01724996.
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.
authors: Christoph
authors: C
authors: Gräni
authors: Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland.
authors: Oliver
authors: O
authors: Senn
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.
authors: Manuel
authors: M
authors: Bischof
authors: Division of Nephrology, University Hospital Zurich, Zurich, Switzerland.
authors: Pietro E
authors: PE
authors: Cippà
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.
authors: Till
authors: T
authors: Hauffe
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland Center of Competence Multimorbidity and University Research Priority Program Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland.
authors: Lukas
authors: L
authors: Zimmerli
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland Center of Competence Multimorbidity and University Research Priority Program Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland.
authors: Edouard
authors: E
authors: Battegay
authors: Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland Pulmonary Division, University Hospital Zurich, Zurich, Switzerland.
authors: Daniel
authors: D
authors: Franzen
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000453:epidemiology; D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010173:Palpation; D015995:Prevalence; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013557:Switzerland / Q000453:epidemiology; D035441:Thoracic Wall / Q000473:pathology*
keywords: acute chest pain; chest wall tenderness; emergency admission; thoracic pain
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