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March 28, 2013

White Whale

There he is.
I've been trying to find this paper for a while, finally was able to. I saw Judd Hollander quote it in a grand rounds as PGY2:

Costochondritis. A prospective analysis in an emergency department setting.

This might be the coolest chest pain study ever done.

Rheumatologists evaluated 122 consecutive ED patients with chest pain at the Cabrini ED in 1991-2, and used the American College of Rheumatology criteria for diagnosing costochondritis.
Costochondritis was identified by digital palpation, applying enough pressure to induce partial blanching of the examining finger (=4 kg/cm2), over the costochondral and costostemaljoints (CCSJ), as previously reported. Patients were asked if such a maneuver: (1) caused no pain, (2) caused a pain different from original chest pain, or (3) caused a pain similar to the original one. Patients were considered to have CC if the answer was (2) or (3). The rest was used as a control group. Not included in this study were patients whose chest pain was associated with recent trauma, surgery, infection, fever, or malignancy.
6% of patients with costochondritis diagnosed by Rheumatologists in the ED = acute MI.

That's right. One out of every 17 patients who was diagnosed by a Rheumatologist, using the ACR costochondritis diagnostic criteria were having a heart attack.

Not ACS. Not positive stress. Biomarker-positive my-o-cardial in-farct.*

Judd Hollander's conclusion was: don't ever use the word costochondritis. If a resident uses it, send them home for the day because they did a bad job.

One big question remains:
How hard were these Rheumatologists pushing?**
For features from the HPI that make ACS more likely, see Salim Rezaie's great summary in Academic Life in EM.

A great question came up:

(Perhaps that's why Cabrini closed? Also, I recently called a Rheum fellow for what I thought was a clear "can I send this patient to you on Monday?" and shortly thereafter, fellow + attending were in the ED injecting patient's ankle, at 9pm on a Saturday!)

On a historical note, I find it interesting that the authors included this line in their discussion:
One of the most interesting observations in  this study was the low frequency of AMI in the CC group,  which was four times lower than in the control group, in spite of having similar risk factors for CAD,  based on age, history of smoking, and hypertension.
That thinking on working up chest pain is (in hindsight) now outdated. See this great discussion on ERCAST.

Basically, the "risk factors for CAD" are just that: risk factors for developing CAD, which is a very different question than: does this patient with chest pain have ACS?

The way I think about it: traditional risk factors don't differentiate between which patients in the ED with chest pain have ACS; rather, the Framingham risks tell us which patients will end up in the ED with ACS at some point in the future. 

*plasma CK-MB. It was the early 1990s, after all.

**Actually we know: about kg/cm2, "enough pressure to induce partial blanching of the examining finger"


  1. Twitter inadequate to discuss this paper but in short: why was #2 included?, why was there a 28% incidence of AMI in the non-CC grp, and why do we all bash this study for telling us what we already knew: that reproducibility if pain slightly lowers ACS risk.
    1. If the pain you get when you push on them isn't what they're here for then.it's an incidental finding.
    2. Really sick populace? Or Rheum evaluated pts. that clinicians had higher suspicion?
    3. The CC folks had a lot lower rule in rate than the rest. Was it still too high? Absolutely. So, like every other lower rusk variable (sharp, pleuritic, positional) it can't stand alone. But in combination w other low risk features of HPI, can be useful.

    Bottom line: I agree that pt. saying "ow" when you poke them is a poor "r/o" test and CC is a dx akin to constipation in terms of dx certainty.
    But it's not totally useless if the same pain they're here for is reproducible, as long as there are other low risk indicators.

    Reproducible = 6%, Sharp = 6%, pleuritic = 6%.
    .06 * .06 * .06 = real low.

    1. All excellent points.
      They said "consecutive patients" so it shouldn't have just been higher suspicion.
      Not sure what to make of the high rule-in rate (by today's standards) -- were these "the good old days" when chest pain = MI and men were men? Is this what people mean when they say that our current definition of "low risk" chest pain is really "no risk" chest pain?

      The problem with the 0.06x0.06x0.06 is that it's only for MI, not ACS...