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Muscular Tenderness in the Anterior Chest Wall in Patients With Stable Angina Pectoris is Associated With Normal Myocardial Perfusion
MUSCULAR TENDERNESS IN THE ANTERIOR CHEST WALL IN PATIENTS WITH STABLE ANGINA PECTORIS IS ASSOCIATED WITH NORMAL MYOCARDIAL PERFUSION Preman Kumarathurai, MD, a Mohammed Kashaf Farooq, MD, b Henrik Wulff Christensen, MD, DC, PhD, c Werner Vach, PhD, d and Poul F. Ho/ ilund-Carlsen, MD, DMSc e
ABSTRACT Objective: This study examines the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion imaging in patients with known or suspected stable angina pectoris. Methods: Two hundred seventy-five patients were recruited. Myocardial perfusion imaging was performed on 273 of the subjects. Chest pain was classified according to type by criteria given by the Danish Society of Cardiology and severity by the Canadian Cardiovascular Society. Pectoralis major and pectoralis minor were palpated for tenderness using a standardized procedure. Results: The association between tenderness and myocardial perfusion imaging (normal vs abnormal) produced an odds ratio (OR) of 2.24 (confidence interval, 1.26-3.99; P = .009). The OR was the same magnitude and significance when stratified by sex, age, type of pain, or class. When adjusting simultaneously for sex, age, type of pain, and class, the association between tenderness and myocardial perfusion imaging (normal vs abnormal) was still present (OR = 2.57; confidence interval, 1.342-4.902; P = .004). Conclusion: Presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal myocardial perfusion imaging in patients with known or suspected angina pectoris, and this association cannot be explained by a common association to age, sex, or pain. (J Manipulative Physiol Ther 2008;31:344-347) Key Indexing Terms: Chest Pain; Angina Pectoris; Muscles; Pain; Palpation
alpation is widely used in clinical settings to differentiate and classify patients with chest pain. In a literature review by Chun and McGee,1 they found reproducibility of chest pain by palpation to reduce the likelihood of acute myocardial infarction, and similar with the clinical review by Swap and Nagurney,2 they state that
P a
Registrar, University of Southern Denmark, Denmark. Registrar, University of Southern Denmark, Denmark. c Senior Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics, DK-5230 Odense M, Denmark. d Professor, Department of Statistics, University of Southern Denmark, Denmark. e Professor, Department of Nuclear Medicine, Odense University Hospital, Denmark. Submit requests for reprints to: Henrik Wulff Christensen, MD, DC, PhD, Senior Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics, Forskerparken 10, DK-5230 Odense M, Denmark (e-mail: [email protected]; URL: www.nikkb.dk). Paper submitted December 6, 2007; in revised form February 28, 2008; accepted March 6, 2008. 0161-4754/$34.00 Copyright © 2008 by National University of Health Sciences. doi:10.1016/j.jmpt.2008.04.009 b
344
chest wall tenderness suggest a noncardiac etiology. On the contrary, a study examined whether there was a relation between reproduction of chest pain by palpation and prevalence of pulmonary emboli.3 That study showed that reproduction of chest pain was not associated with a lower prevalence of pulmonary emboli. In the present study, which is the first of its kind, we examined the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion scintigraphy (MPS) imaging in patients with known or suspected stable angina pectoris.
METHODS Design This study was a single center, prospective observational study.
Patients This study was conducted as a substudy of the Myocardial Ischemic Logistic Evaluation Study project, which included
Journal of Manipulative and Physiological Therapeutics Volume 31, Number 5
Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
Table 1. Exclusion criteria in 241 patients Exclusion criteria Lack of compliance (did not show up for examination) No written consent Previous surgery to the thorax No self-reported chest pain, neck pain, or thoracic spinal pain Inflammatory joint disease Malignant disease Stroke Others
Table 3. The CCS functional classification of angina pectoris No. of patients 89 49 32 26 18 18 14 13
Note that some patients fulfilled several criteria.
Table 2. Typical angina pectoris: a + b + c Danish Society of Cardiology and Danish Society of Thoracic Surgery criteria for angina pectoris 2 (a)
(b) (c)
Class
Definition
Class I
Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. Class II Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and in normal condition. Class III Marked limitations of ordinary physical activity. Angina occurs on walking 1 to 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace. Class IV Inability to carry on any physical activity without discomfort —angina symptoms may be present at rest.
Pain/discomfort in the chest wall, eventually radiating to the neck, jaw, upper extremity or the back, lasting a few minutes up to 10-15 min. The pain/discomfort is provoked by cold, physical, or psychological stress. The pain/discomfort is normally relieved by rest or nitroglycerin.
Atypical angina pectoris: a + b or b + c or a + c. Noncardiac chest pain: a or b or c.
516 patients who were referred for coronary angiography from their general practitioner to a local hospital or Odense University Hospital and with known or suspected stable angina pectoris.4 Those patients who did not fulfill exclusion criteria like previous surgery of the thorax, no self-reported chest pain, inflammatory joint disease, malignant disease, and stroke (Table 1) were offered participation in this study, and finally, 275 appeared for the palpation. They all gave written consent to participate in the study, which was approved by Den Videnskabsetiske Komite for Vejle and Fyns Amter, the ethics review committee for counties Fynen and Vejle. Myocardial perfusion scintigraphy was not performed in 1 patient, and data regarding tenderness were not available in another patient, leaving a total study population of 273 patients (170 men and 103 women with an average age of 56.0 and 56.7 years, respectively).
Myocardial Perfusion Scintigraphy Gated single photon emission computed tomographic imaging was performed using a sequential same-day rest thallium-201/stress technetium-99m sestamibi dual-isotope protocol as originally described by Berman et al.5 Standard procedures for image interpretation included review of all scans by 2 experienced observers who were blinded to clinical history and data regarding physical examination, and final and overall image interpretation was achieved by consensus.6 Abnormal myocardial perfusion meant the presence of 1 of 3 types of perfusion abnormality: reversible (stressinduced), nonreversible (presence of hypoperfusion during rest and stress), or partly reversible (combination of the
Fig 1. Illustration of the 14 points on the anterior chest wall, which were evaluated for muscular tenderness. 2 above-mentioned) as opposed to normal perfusion (no hypoperfusion during rest or stress).
Palpation and Interview Chest pain was classified according to type by criteria given by the Danish Society of Cardiology (Table 2) and severity by the Canadian Cardiovascular Society (CCS) (Table 3) grading.7,8 Manual palpation was performed on
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Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
Journal of Manipulative and Physiological Therapeutics June 2008
Table 4. MPS results and the presence of tenderness MPS
Total (N = 273)
Tenderness (n = 211) Nontenderness (n = 62)
Normal, n (%)
Reversible, n (%)
Partly reversible, n (%)
Nonreversible, n (%)
P
127 (60) 25 (40)
48 (23) 16 (26)
24 (11) 9 (5)
12 (6) 12 (19)
.003
Table 5. Odds ratio and common OR in subgroups % tenderness in patients with
Men (n = 170) Women (n = 103) Young (n = 133) Old (n = 140) Typical angina (n = 156) Nontypical angina (n = 117) CCS low (n = 130) CCS high (n = 143)
Normal MPS
Abnormal MPS
OR
Common OR
67/79 (85%) 60/73 (82%) 75/88 (85%) 52/64 (81%) 68/76 (89%) 59/76 (78%) 71/89 (80%) 56/63 (89%)
62/91 (68%) 22/30 (73%) 34/45 (76%) 50/76 (66%) 59/80 (74%) 25/41 (61%) 27/41 (66%) 57/80 (71%)
2.61 1.68 1.87 2.25 3.03 2.22 2.05 3.23
2.23 (CI, 1.23-4.04) 2.08 (CI, 1.15-3.74) 2.57 (CI, 1.41-4.68) 2.52 (CI, 1.38-4.61)
Young indicates age ≤56 years; Old, age ≥57 years; Nontypical angina, atypical angina pectoris + noncardiac chest pain; CCS low, CCS class I; CCS high, CCS class II-IV.
14 points of the anterior chest wall (Fig 1). The pectoralis major points were located at the anterior axillary line 3 cm caudal to the clavicles (Fig 1, points 1 and 8). The pectoralis minor points were located at the medioclavicular lines just caudal to the clavicles (Fig 1, points 2 and 9). Points 3 through 7 and points 10 through 14 were located lateral to the sternum at the intercostal space between II/III and VI/VII, on each side of the anterior chest wall. All examinations were carried out according to a standard written procedure and have been previously described.9,10 The subjects were seated on a chair with their arms down by their sides. A flat digital index contact with a standardized pressure was used for manual palpation. The same examiner, who was blinded for the MPS results, interviewed all the patients using standardized questions.
Statistical Analysis The χ2 test was used to test for an association in a 2 × 4 table, and logistic regression with normal/abnormal MPS as outcome was used to compute crude and adjusted odds ratios (ORs). Age and CCS were entered as continuous covariates. Sex and type of chest pain were used as categorical covariates. Precision of estimates were described by 95% confidence intervals (CIs). P values less than .05 were regarded as significant. The calculations were performed using SPSS version 13.0 (SPSS Inc, Chicago, Ill).
RESULTS Table 4 gives an overview of the MPS results in relation to presence of tenderness in the total study population. The association between tenderness and MPS (normal vs
abnormal) was an OR of 2.24 (CI, 1.26-3.99; P = .009). If the analysis was stratified by sex, age, type of pain, or CCS class, the OR remains in the same magnitude and significance (Table 5). When adjusting simultaneously for sex, age, type of pain, and CCS class, the association between tenderness and MPS (normal vs abnormal) was still present (OR = 2.57; CI, 1.342-4.902; P = .004).
DISCUSSION In patients with known or suspected stable angina pectoris, palpation evoked tenderness is associated with a higher prevalence of normal MPS. This study has some methodological limitations. Tenderness is a subjective element that is difficult to evaluate by objective methods. Application of a standardized pressure can be difficult, and localization of the palpation points may vary within patients due to different body structures. We cannot exclude that the use of a dolorimeter or a pressure algometer would have reduced the variation of the pressure applied; however, because we find this method less clinically practicable, we did not use it.11 Moreover, the interview and the manual palpation of the anterior chest wall were carried out by the same examiner who, therefore, was not completely blinded. Ho et al12 and Levine et al13 examined the presence of tenderness evoked by palpation in patients with chest pain, and Ho et al used a spring loaded dolorimeter for palpation, which strengthens their study. However, in contrast to our results, they both suggested that tenderness in the anterior chest wall was not associated with absence of heart problems. This can be due to a relatively low number of participants in their studies (71 and 62 patients, respectively), as well as the use of coronary angiography as a
Journal of Manipulative and Physiological Therapeutics Volume 31, Number 5
reference standard. Thus, ischemia is considered the substrate for angina, but angiography shows anatomical stenoses rather than ischemia because collaterals can compensate for the lack of blood flow to the subtended areas, and therefore, the result of coronary angiography may not always correlate with MPS.6
CONCLUSION Palpation of the anterior chest wall for the presence of tenderness is often used as part of the clinical examination when assessing patients with known or suspected stable angina pectoris. Our study shows that presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal MPS in patients with known or suspected angina pectoris and that this association cannot be explained by a common association to age, sex, or pain.
Practical Applications • Chest pain can be of cardiac or noncardiac origin • Manual palpation of the anterior chest wall is being used as part of the clinical examination • Presence of chest wall tenderness is often considered as an indication of the patient having chest pain of musculoskeletal origin • Presence of tenderness in patients with known or suspected stable angina pectoris was associated with normal myocardial scintigraphy
REFERENCES 1. Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004;117:334-43.
Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
2. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:2623-9. 3. Le Gal G, Testuz A, Righini M, Bounameaux H, Perrier A. Reproduction of chest pain by palpation: diagnostic accuracy in suspected pulmonary embolism. BMJ 2005;330:452-3. 4. Høilund-Carlsen PF, Johansen A, Christensen HW, Vach W, Møldrup M, Bartram P, et al. Potential impact of myocardial perfusion scintigraphy as gatekeeper for invasive examination and treatment in patients with stable angina pectoris: observational study without post-test referral bias. Eur Heart J 2006;27: 29-34. Electronic publication 2005 Sep 23. 5. Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455-64. 6. Johansen A, Hoilund-Carlsen PF, Christensen HW, Vach W, Jorgensen HB, Veje A, Haghfelt T. Diagnostic accuracy of myocardial perfusion imaging in a study population without post-test referral bias. J Nucl Cardiol 2005;12:530-7. 7. Haghfelt T, Alstrup P, Grande P, Madsen JK, Rasmussen K, Thiis J. Guidelines for diagnosis and treatment of patients with stable angina pectoris. Copenhagen: Danish Society of Cardiology and Danish Society of Thoracic Surgery; 1996. 8. Campeau L. Letter: grading of angina pectoris. Circulation 1976;54:522-3. 9. Christensen HW, Vach W, Manniche C, Haghfelt T, Hartvigsen L, Hoilund-Carlsen PF. Palpation of the upper thoracic spine: an observer reliability study. J Manipulative Physiol Ther 2002; 25:285-92. 10. Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Hoilund-Carlsen PF. Palpation of the anterior chest wall— an observer reliability study. J Manipulative Physiol Ther 2003; 26:469-75. 11. Bendtsen L, Jensen R, Jensen NK, Olesen J. Pressurecontrolled palpation: a new technique which increases the reliability of manual palpation. Cephalalgia 1995;15:205-10. 12. Ho M, Walker S, McGarry F, Pringle S, Pullar T. Chest wall tenderness is unhelpful in the diagnosis of recurrent chest pain. QJM 2001;94:267-70. 13. Levine PR, Mascette AM. Musculoskeletal chest pain in patients with “angina”: a prospective study. South Med J 1989;82:580-5.
347
ABSTRACT Objective: This study examines the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion imaging in patients with known or suspected stable angina pectoris. Methods: Two hundred seventy-five patients were recruited. Myocardial perfusion imaging was performed on 273 of the subjects. Chest pain was classified according to type by criteria given by the Danish Society of Cardiology and severity by the Canadian Cardiovascular Society. Pectoralis major and pectoralis minor were palpated for tenderness using a standardized procedure. Results: The association between tenderness and myocardial perfusion imaging (normal vs abnormal) produced an odds ratio (OR) of 2.24 (confidence interval, 1.26-3.99; P = .009). The OR was the same magnitude and significance when stratified by sex, age, type of pain, or class. When adjusting simultaneously for sex, age, type of pain, and class, the association between tenderness and myocardial perfusion imaging (normal vs abnormal) was still present (OR = 2.57; confidence interval, 1.342-4.902; P = .004). Conclusion: Presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal myocardial perfusion imaging in patients with known or suspected angina pectoris, and this association cannot be explained by a common association to age, sex, or pain. (J Manipulative Physiol Ther 2008;31:344-347) Key Indexing Terms: Chest Pain; Angina Pectoris; Muscles; Pain; Palpation
alpation is widely used in clinical settings to differentiate and classify patients with chest pain. In a literature review by Chun and McGee,1 they found reproducibility of chest pain by palpation to reduce the likelihood of acute myocardial infarction, and similar with the clinical review by Swap and Nagurney,2 they state that
P a
Registrar, University of Southern Denmark, Denmark. Registrar, University of Southern Denmark, Denmark. c Senior Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics, DK-5230 Odense M, Denmark. d Professor, Department of Statistics, University of Southern Denmark, Denmark. e Professor, Department of Nuclear Medicine, Odense University Hospital, Denmark. Submit requests for reprints to: Henrik Wulff Christensen, MD, DC, PhD, Senior Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics, Forskerparken 10, DK-5230 Odense M, Denmark (e-mail: [email protected]; URL: www.nikkb.dk). Paper submitted December 6, 2007; in revised form February 28, 2008; accepted March 6, 2008. 0161-4754/$34.00 Copyright © 2008 by National University of Health Sciences. doi:10.1016/j.jmpt.2008.04.009 b
344
chest wall tenderness suggest a noncardiac etiology. On the contrary, a study examined whether there was a relation between reproduction of chest pain by palpation and prevalence of pulmonary emboli.3 That study showed that reproduction of chest pain was not associated with a lower prevalence of pulmonary emboli. In the present study, which is the first of its kind, we examined the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion scintigraphy (MPS) imaging in patients with known or suspected stable angina pectoris.
METHODS Design This study was a single center, prospective observational study.
Patients This study was conducted as a substudy of the Myocardial Ischemic Logistic Evaluation Study project, which included
Journal of Manipulative and Physiological Therapeutics Volume 31, Number 5
Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
Table 1. Exclusion criteria in 241 patients Exclusion criteria Lack of compliance (did not show up for examination) No written consent Previous surgery to the thorax No self-reported chest pain, neck pain, or thoracic spinal pain Inflammatory joint disease Malignant disease Stroke Others
Table 3. The CCS functional classification of angina pectoris No. of patients 89 49 32 26 18 18 14 13
Note that some patients fulfilled several criteria.
Table 2. Typical angina pectoris: a + b + c Danish Society of Cardiology and Danish Society of Thoracic Surgery criteria for angina pectoris 2 (a)
(b) (c)
Class
Definition
Class I
Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. Class II Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and in normal condition. Class III Marked limitations of ordinary physical activity. Angina occurs on walking 1 to 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace. Class IV Inability to carry on any physical activity without discomfort —angina symptoms may be present at rest.
Pain/discomfort in the chest wall, eventually radiating to the neck, jaw, upper extremity or the back, lasting a few minutes up to 10-15 min. The pain/discomfort is provoked by cold, physical, or psychological stress. The pain/discomfort is normally relieved by rest or nitroglycerin.
Atypical angina pectoris: a + b or b + c or a + c. Noncardiac chest pain: a or b or c.
516 patients who were referred for coronary angiography from their general practitioner to a local hospital or Odense University Hospital and with known or suspected stable angina pectoris.4 Those patients who did not fulfill exclusion criteria like previous surgery of the thorax, no self-reported chest pain, inflammatory joint disease, malignant disease, and stroke (Table 1) were offered participation in this study, and finally, 275 appeared for the palpation. They all gave written consent to participate in the study, which was approved by Den Videnskabsetiske Komite for Vejle and Fyns Amter, the ethics review committee for counties Fynen and Vejle. Myocardial perfusion scintigraphy was not performed in 1 patient, and data regarding tenderness were not available in another patient, leaving a total study population of 273 patients (170 men and 103 women with an average age of 56.0 and 56.7 years, respectively).
Myocardial Perfusion Scintigraphy Gated single photon emission computed tomographic imaging was performed using a sequential same-day rest thallium-201/stress technetium-99m sestamibi dual-isotope protocol as originally described by Berman et al.5 Standard procedures for image interpretation included review of all scans by 2 experienced observers who were blinded to clinical history and data regarding physical examination, and final and overall image interpretation was achieved by consensus.6 Abnormal myocardial perfusion meant the presence of 1 of 3 types of perfusion abnormality: reversible (stressinduced), nonreversible (presence of hypoperfusion during rest and stress), or partly reversible (combination of the
Fig 1. Illustration of the 14 points on the anterior chest wall, which were evaluated for muscular tenderness. 2 above-mentioned) as opposed to normal perfusion (no hypoperfusion during rest or stress).
Palpation and Interview Chest pain was classified according to type by criteria given by the Danish Society of Cardiology (Table 2) and severity by the Canadian Cardiovascular Society (CCS) (Table 3) grading.7,8 Manual palpation was performed on
345
346
Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
Journal of Manipulative and Physiological Therapeutics June 2008
Table 4. MPS results and the presence of tenderness MPS
Total (N = 273)
Tenderness (n = 211) Nontenderness (n = 62)
Normal, n (%)
Reversible, n (%)
Partly reversible, n (%)
Nonreversible, n (%)
P
127 (60) 25 (40)
48 (23) 16 (26)
24 (11) 9 (5)
12 (6) 12 (19)
.003
Table 5. Odds ratio and common OR in subgroups % tenderness in patients with
Men (n = 170) Women (n = 103) Young (n = 133) Old (n = 140) Typical angina (n = 156) Nontypical angina (n = 117) CCS low (n = 130) CCS high (n = 143)
Normal MPS
Abnormal MPS
OR
Common OR
67/79 (85%) 60/73 (82%) 75/88 (85%) 52/64 (81%) 68/76 (89%) 59/76 (78%) 71/89 (80%) 56/63 (89%)
62/91 (68%) 22/30 (73%) 34/45 (76%) 50/76 (66%) 59/80 (74%) 25/41 (61%) 27/41 (66%) 57/80 (71%)
2.61 1.68 1.87 2.25 3.03 2.22 2.05 3.23
2.23 (CI, 1.23-4.04) 2.08 (CI, 1.15-3.74) 2.57 (CI, 1.41-4.68) 2.52 (CI, 1.38-4.61)
Young indicates age ≤56 years; Old, age ≥57 years; Nontypical angina, atypical angina pectoris + noncardiac chest pain; CCS low, CCS class I; CCS high, CCS class II-IV.
14 points of the anterior chest wall (Fig 1). The pectoralis major points were located at the anterior axillary line 3 cm caudal to the clavicles (Fig 1, points 1 and 8). The pectoralis minor points were located at the medioclavicular lines just caudal to the clavicles (Fig 1, points 2 and 9). Points 3 through 7 and points 10 through 14 were located lateral to the sternum at the intercostal space between II/III and VI/VII, on each side of the anterior chest wall. All examinations were carried out according to a standard written procedure and have been previously described.9,10 The subjects were seated on a chair with their arms down by their sides. A flat digital index contact with a standardized pressure was used for manual palpation. The same examiner, who was blinded for the MPS results, interviewed all the patients using standardized questions.
Statistical Analysis The χ2 test was used to test for an association in a 2 × 4 table, and logistic regression with normal/abnormal MPS as outcome was used to compute crude and adjusted odds ratios (ORs). Age and CCS were entered as continuous covariates. Sex and type of chest pain were used as categorical covariates. Precision of estimates were described by 95% confidence intervals (CIs). P values less than .05 were regarded as significant. The calculations were performed using SPSS version 13.0 (SPSS Inc, Chicago, Ill).
RESULTS Table 4 gives an overview of the MPS results in relation to presence of tenderness in the total study population. The association between tenderness and MPS (normal vs
abnormal) was an OR of 2.24 (CI, 1.26-3.99; P = .009). If the analysis was stratified by sex, age, type of pain, or CCS class, the OR remains in the same magnitude and significance (Table 5). When adjusting simultaneously for sex, age, type of pain, and CCS class, the association between tenderness and MPS (normal vs abnormal) was still present (OR = 2.57; CI, 1.342-4.902; P = .004).
DISCUSSION In patients with known or suspected stable angina pectoris, palpation evoked tenderness is associated with a higher prevalence of normal MPS. This study has some methodological limitations. Tenderness is a subjective element that is difficult to evaluate by objective methods. Application of a standardized pressure can be difficult, and localization of the palpation points may vary within patients due to different body structures. We cannot exclude that the use of a dolorimeter or a pressure algometer would have reduced the variation of the pressure applied; however, because we find this method less clinically practicable, we did not use it.11 Moreover, the interview and the manual palpation of the anterior chest wall were carried out by the same examiner who, therefore, was not completely blinded. Ho et al12 and Levine et al13 examined the presence of tenderness evoked by palpation in patients with chest pain, and Ho et al used a spring loaded dolorimeter for palpation, which strengthens their study. However, in contrast to our results, they both suggested that tenderness in the anterior chest wall was not associated with absence of heart problems. This can be due to a relatively low number of participants in their studies (71 and 62 patients, respectively), as well as the use of coronary angiography as a
Journal of Manipulative and Physiological Therapeutics Volume 31, Number 5
reference standard. Thus, ischemia is considered the substrate for angina, but angiography shows anatomical stenoses rather than ischemia because collaterals can compensate for the lack of blood flow to the subtended areas, and therefore, the result of coronary angiography may not always correlate with MPS.6
CONCLUSION Palpation of the anterior chest wall for the presence of tenderness is often used as part of the clinical examination when assessing patients with known or suspected stable angina pectoris. Our study shows that presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal MPS in patients with known or suspected angina pectoris and that this association cannot be explained by a common association to age, sex, or pain.
Practical Applications • Chest pain can be of cardiac or noncardiac origin • Manual palpation of the anterior chest wall is being used as part of the clinical examination • Presence of chest wall tenderness is often considered as an indication of the patient having chest pain of musculoskeletal origin • Presence of tenderness in patients with known or suspected stable angina pectoris was associated with normal myocardial scintigraphy
REFERENCES 1. Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004;117:334-43.
Kumarathurai et al Muscular Tenderness and Stable Angina Pectoris
2. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:2623-9. 3. Le Gal G, Testuz A, Righini M, Bounameaux H, Perrier A. Reproduction of chest pain by palpation: diagnostic accuracy in suspected pulmonary embolism. BMJ 2005;330:452-3. 4. Høilund-Carlsen PF, Johansen A, Christensen HW, Vach W, Møldrup M, Bartram P, et al. Potential impact of myocardial perfusion scintigraphy as gatekeeper for invasive examination and treatment in patients with stable angina pectoris: observational study without post-test referral bias. Eur Heart J 2006;27: 29-34. Electronic publication 2005 Sep 23. 5. Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455-64. 6. Johansen A, Hoilund-Carlsen PF, Christensen HW, Vach W, Jorgensen HB, Veje A, Haghfelt T. Diagnostic accuracy of myocardial perfusion imaging in a study population without post-test referral bias. J Nucl Cardiol 2005;12:530-7. 7. Haghfelt T, Alstrup P, Grande P, Madsen JK, Rasmussen K, Thiis J. Guidelines for diagnosis and treatment of patients with stable angina pectoris. Copenhagen: Danish Society of Cardiology and Danish Society of Thoracic Surgery; 1996. 8. Campeau L. Letter: grading of angina pectoris. Circulation 1976;54:522-3. 9. Christensen HW, Vach W, Manniche C, Haghfelt T, Hartvigsen L, Hoilund-Carlsen PF. Palpation of the upper thoracic spine: an observer reliability study. J Manipulative Physiol Ther 2002; 25:285-92. 10. Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Hoilund-Carlsen PF. Palpation of the anterior chest wall— an observer reliability study. J Manipulative Physiol Ther 2003; 26:469-75. 11. Bendtsen L, Jensen R, Jensen NK, Olesen J. Pressurecontrolled palpation: a new technique which increases the reliability of manual palpation. Cephalalgia 1995;15:205-10. 12. Ho M, Walker S, McGarry F, Pringle S, Pullar T. Chest wall tenderness is unhelpful in the diagnosis of recurrent chest pain. QJM 2001;94:267-70. 13. Levine PR, Mascette AM. Musculoskeletal chest pain in patients with “angina”: a prospective study. South Med J 1989;82:580-5.
347