The sternal brace: a novel osteopathic diagnostic screening tool to rule out cardiac chest pain in the emergency department

Abstract

Abstract Context Chest pain is one of the most common emergency medicine complaints in the United States, yet no reliable physical examination finding exists to help differentiate cardiac chest pain (CCP) from noncardiac chest pain (non-CCP). Objectives This is a diagnostic accuracy study of the sternal brace, a novel physical examination maneuver to rule out cardiac-related chest pain from non-CCP. Methods We performed this double-blind prospective diagnostic accuracy pilot study on 34 adults in the Newark Beth Israel emergency department with a chief complaint of chest pain. We utilized the Numerical Rating Scale 0–10 (NRS) to quantify chest pain severity before and after the maneuver. Eligible for inclusion were adults over 18 years old who were able to provide written informed consent. We performed the sternal brace on all consenting adults meeting these criteria, and the researchers were blinded between test results and final diagnosis. Cardiac ischemia in the US with a disease prevalence of 0.029 was utilized. Results A total of 34 patients were included, of whom 11 had a final diagnosis of cardiac-related chest pain. The cutoff value was a decrease in pain severity of 2 or greater between pretest and posttest. Sensitivity was 81.8 % (95 % confidence interval [CI], 48.2–97.7 %); specificity 34.8 % (95 % CI, 16.4–57.3 %), the positive predictive value was 3.6 % (95 % CI, 0.1–20.3 %), and the negative predictive value was 98.4 % (95 % CI, 66.8–100.0 %). Conclusions The sternal brace is a good screening test because if a person with chest pain has an NRS that decreases by 2 or more with the maneuver, then there is a 98.5 % chance that the chest pain is noncardiac, given the prevalence of cardia ischemia. In addition, if the disease is present, then it is 81.8 % likely that their NRS will not decrease by more than 2.