Definition (Pediatr Clin North Am 2004;51:1553; Pediatr Rev 2010;31:e1)
• Chest pain (CP) in the pediatric population is overwhelmingly benign, but can have significant impact on patients; ½ miss school, 69% self-limit activity
• Source can be 2/2 musculoskeletal, respiratory, cardiac, GI, or nervous system
• Incidence of chest pain 2/2 cardiac etiology 2–5%
Epidemiology (Pediatr Rev 1986;8:56; Pediatr Rev 2010;31:e1)
• Primary complaint in 0.3–0.6% of pediatric patients in ED or outpt care
• May be chronic lasting up to 6 mo in 15–36% of patients, 1 yr in 8%
• Mean age of presentation is 12–14 yr
Clinical Manifestations
• Detailed Hx: Describe pain (location and duration) quality, radiation, severity, temporal assoc (w/ breathing, eating, activity), exacerb or alleviating factors
• In younger patients, assess history of occult toxic ingestion
• Chest pain assoc w/ exertion, syncope, light-headedness, or palpitations is concerning
• FHx of sudden death, HOCM, MVP, Marfan’s or personal Hx of Kawasaki concerning
Etiologies (Pediatr Rev 2010;31:e1; Pediatr Clin North Am 2004;51:1553)
• Cardiac: Rare; responsible for <5–6% of pediatric chest pain
• Mitral valve prolapse: 18% pts w/ MVP have chest pain, though pain not 2/2 valve prolapse, unclear if neuroendocrine or autonomic dysfunction
• Check flat, sitting, and standing for midsystolic click and late systolic murmur
• Association with anxiety exists; echo diagnosis
• Pericarditis: Sharp and stabbing, often pleuritic and positional; improved w/ leaning forward; may have recent URI sx, fever. Viral cause most common
• Can be infectious, inflammatory (w/ CTDs), neoplastic, or 2/2 XRT
• Exam w/ pericardial rub; EKG w/ PR depressions and diffuse ST elevations across all leads. PR elevation in aVR is the most specific finding
• Myocarditis can also p/w chest pain but usually 2/2 assoc pericarditis
• Coronary vasospasm: P/w crushing, diffuse chest pain w/ assoc SOB, diaphoresis, radiation to L arm, neck, or jaw; light-headedness/syncope
• Exam may have gallop (S3 and S4), +/− signs of poor cardiac function
• Consider cocaine induced, check tox screen, and if suspected use combined α-
and β-antagonist (pure β-antagonist → unopposed α activity and periph
vasospasm)
• Can also see vaso-occlusive dz w/ some types of systemic dz; e.g., sickle cell
• Anomalous coronary artery: Rare; coronary arteries arise from opposite sinus of Valsalva, increases risk for ischemia and sudden death
• Usually p/w sudden death but 5/27 in 1 study w/ CP in prior 2 yr
• Chest pain associated w/ exertion; often nml physical exam
• EKG and stress test have not shown to be helpful in identifying at-risk pts
• Aortic dissection: Pts w/ Marfan, Turner, type IV Ehlers–Danlos, or homocystinuria; p/w severe tearing chest pain radiating to back
• Kawasaki dz: If c/b coronaryartery aneurysm, can see stenosis or aneurismal thrombus; if Hx prior Kawasaki w/ aneurysm & p/w CP, ischemia until proven not
• LV outflow obstruction: Hypertrophic obstructive cardiomyopathy (HOCM) most common though rarely p/w chest pain; exam w/ systolic murmur at aortic region that amplifies w/ standing or Valsalva
• Pulm HTN: Unclear mech; may be 2/2 pulm art stretch or RV ischemia (Am Fam Physician 2001;63:1789)
• Tachyarrhythmias: Abrupt onset and cessation, w/ or w/o activity, often w/ N/V
• Idiopathic: 21% cases, no cause identified in prospective study (Pediatrics 1988;82:319)
• Avg pt w/ wks to mos intermittent CP, sharp, w/ or w/o exertion, short duration, no assoc sx, recurrence common, PE nml, and pain not reproducible
• Musculoskeletal: 15–31% cases in prospective study (Pediatrics 1988;82:319)
• Strain or costochondritis from overuse or trauma. Reproducible on exam
• Hx of exertion/activity, pain usually sharp and radiating, can be pleuritic
• Costochondritis w/ tenderness on palpation of site of rib attachment to sternum
• Tietze syndrome—localized nonsuppurative inflammation of costochondral,
costosternal, or sternoclavicular joints in adolescents; usually only a single joint
• Precordial catch syndrome—sharp, well-localized twinge of pain, acute onset at rest, and lasts sec to min; not reproducible on palpation
• Slipping rib syndrome: 8th, 9th, 10th ribs slip over one another (Pediatrics 1985;76:810)
• Pop or click → dull chest wall/abd pain, reproduced by lifting rib anteriorly
• Psychosomatic/anxiety: 9–20% cases; often chronic and usually adol females
• 1/3 w/ Hx of sign sleep disturbance, ½ w/ +FHx of chest pain
• Respiratory—2–11% cases
• Specific etiologies include asthma (most common) and exercise-induced asthma (check for wheeze, +FHx; trial of albuterol), PNA (fever, cough), PE
• Pneumothorax p/w sharp chest pain; steady, pleuritic, tachycardic and w/ dec breath sounds (not always appreciable). Inc risk w/ CF, asthma, and Marfan
• GI: 8% cases; GERD (burning pain, assoc w/ meals, worse when supine; trial of PPI), also consider peptic ulcer disease, esophageal spasm or inflammation, & cholecystitis
• Foreign body ingestion or caustic substance ingestion can p/w chest pain
• Other: Important to assess for breast masses in both M and F; usually in puberty
• Pleurodynia (devil’s grip) paroxysms of sharp pain 2/2 coxsackie virus infection
Evaluation
• Examine chest for evidence of trauma, symmetry, and palpation for reproducibility
• Focused cardiovascular exam to assess pulses, BP, JVP, PMI, murmurs, and extra heart sounds, peripheral perfusion. Hx will guide further focused evaluation
• EKG rarely useful outside of suspected congenital or structural heart disease or
dysrhythmia, f/u with echo and consult cardiology if these are suspected
• In prospective study EKG in 47% cases; only 4/191 EKGs w/ abn related to final dx. Echo in 34% cases; only 17/139 abn (12/17 w/ MVP) (Pediatrics 1988;82:319)