Die diagnostische Aussagekraft der Schmerzlokalisation bei Brustschmerzpatienten in der Primärversorgung

Background Chest pain in primary care is a common symptom and a frequent reason for consul-tation. The evaluation of these patients can be a diagnostic challenge for General Practitioners (GPs). There exists a wide range of underlying diseases, under which the life threatening cardiovascular etiologies are rare. In the differential diagnosis of chest pain, the pain localization has been assigned a certain discriminative value. The purpose of this study was to synthesize digital pain drawings from a large sample of chest pain patients in primary care and by this means answer especially the following research question: Is chest pain localization in primary care useful in discriminating between patients with coronary heart disease (CHD) and other diseases? Method This project is a subanalysis of a cross-sectional study in primary care, in which 1212 chest pain patients from 74 GP offices in the state of Hesse (Germany) were consecutively recruited. GPs were to draw the pain localization and pain radiation of each patient into a figure of the human thorax on a standardized case report form. Altogether pain drawings of 1211 patients could be gathered. An independent reference panel decided after a six month period of Follow-Up about the etiology of chest pain at the time of patient recruitment. For the present analysis a special computer program was designed, making it possible to digitalize each pain drawing manually, using the mouse pointer. By aggregating the digitalized images, pain distribution for different chest pain etiologies could be illustrated. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff-Distance and the C-Index. Results Pain localization for almost all chest pain etiologies was mainly situated on the left anterior chest, concentrating on the precordial region. It was not helpful to distinguish between CHD and other diseases, such as chest wall syndrome (CWS), gas-troesophageal reflux disease (GERD) or psychogenic chest pain. For patients with CWS who assumed a cardiac origin of their pain the distribution of pain differed significantly from the patients with CWS that did not assume a cardiac origin. Conclusion Chest pain localization is neither helpful in differentiating between CHD and other chest pain etiologies in primary care, nor is it useful in identifying individual dis¬eases. In the differential diagnosis of chest pain the pain localization as a symptom by itself is therefore not of particular help to a GP and should only be evaluated in combination with other clinical information. One can assume that because of a close association between left anterior chest pain and dangerous cardiac diseases in the general population, especially the left thoracic pain localization has become a trigger for the consultation of health care providers. Therefore the diagnostic value of chest pain localization in primary care is limited.