pediatric chest pain

Evaluation of Chest Pain Evaluation of Chest Pain in the Pediatric Patientin the Pediatric Patient

Jennifer ThullJennifer Thull--Freedman, MD, MSCI, FAAP(PEM)Freedman, MD, MSCI, FAAP(PEM)Assistant Professor of PaediatricsAssistant Professor of Paediatrics

University of TorontoUniversity of TorontoCoCo--director, PEM Clinical Fellowshipdirector, PEM Clinical Fellowship

The Hospital for Sick ChildrenThe Hospital for Sick Children

From my residencyFrom my residency……

A 12A 12--yearyear--old previously healthy boy presented old previously healthy boy presented to the ED after first seeking care at the to the ED after first seeking care at the neighborhood fire department for chest painneighborhood fire department for chest pain

Told to take a warm bath for muscle achesTold to take a warm bath for muscle aches

Arrived several hours later alert but in painArrived several hours later alert but in painHR=130, BP not doneHR=130, BP not doneCXR obtainedCXR obtainedChild waited in room for CXR to be reviewedChild waited in room for CXR to be reviewed

From my residencyFrom my residency……

Child suddenly became unresponsive and Child suddenly became unresponsive and pulselesspulselessUnable to be resuscitatedUnable to be resuscitatedCXR reviewed during resuscitation showed CXR reviewed during resuscitation showed widened mediastinumwidened mediastinumAutopsy revealed dissection of the aortaAutopsy revealed dissection of the aorta

HoweverHowever……

Most cases of chest pain in children are not Most cases of chest pain in children are not related to serious pathologyrelated to serious pathologyHistory and physical exam often sufficient History and physical exam often sufficient evaluationevaluation

The challengeThe challenge

ObjectivesObjectives

Review relevant literatureReview relevant literatureReview common causes of chest pain in childrenReview common causes of chest pain in childrenDiscuss uncommon but serious causes Discuss uncommon but serious causes Present an approach to the child with chest painPresent an approach to the child with chest painSummarize takeSummarize take--home pointshome points

Etiology of chest pain in kidsEtiology of chest pain in kids

Very few studiesVery few studiesMost retrospectiveMost retrospectiveVariable inclusion/exclusion criteriaVariable inclusion/exclusion criteriaLimited detail providedLimited detail provided

SelbstSelbst et al.et al.

Objectives:Objectives:Identify causes of chest pain in childrenIdentify causes of chest pain in childrenAssess value of echocardiogramAssess value of echocardiogram

Prospective Prospective Enrolled all patients with chest painEnrolled all patients with chest painECG and echo offered to those with illECG and echo offered to those with ill--defined defined or suspected cardiac etiologyor suspected cardiac etiology

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al.et al.

PopulationPopulation407 patients407 patientsPhiladelphia, PennsylvaniaPhiladelphia, PennsylvaniaMedian age 12.5 yearsMedian age 12.5 years55% female, 90% African55% female, 90% African--AmericanAmerican43% acute pain <48 hours 43% acute pain <48 hours Did not exclude known diseaseDid not exclude known disease

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al.et al.

ECGECG’’ss in 191/235 childrenin 191/235 children31 abnormal (16%)31 abnormal (16%)

27 minor or previously known findings27 minor or previously known findings3 dysrhythmias detected on physical exam3 dysrhythmias detected on physical exam1 with known SLE had findings of pericarditis1 with known SLE had findings of pericarditis

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al.et al.

Echocardiograms in 139/235Echocardiograms in 139/23517 abnormal (12%)17 abnormal (12%)

12 mitral valve prolapse (8.6%)12 mitral valve prolapse (8.6%)Similar prevalence to general populationSimilar prevalence to general population

2 pericardial effusion2 pericardial effusion2 mitral valve regurgitation2 mitral valve regurgitation1 poor LV function1 poor LV function

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al.et al.

Chest radiographs in 137/407Chest radiographs in 137/40737 abnormal (27%)37 abnormal (27%)

Most frequent: infiltrates, atelectasis, hyperinflationMost frequent: infiltrates, atelectasis, hyperinflation1 pneumothorax in a child with Marfan1 pneumothorax in a child with Marfan’’s syndromes syndrome1 clavicle fracture suspected clinically1 clavicle fracture suspected clinically1 child with SLE had pleural effusion, large heart1 child with SLE had pleural effusion, large heart

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al.et al.

Diagnostic categoriesDiagnostic categories

0

5

10

15

20

25

Idiopathic Resp. Chest Wall Psych. Trauma Cardiac GI Other

SelbstSelbst et al.et al.

Organic disease related toOrganic disease related toAge <12 yearsAge <12 yearsPain awakening child from sleepPain awakening child from sleepAcute onsetAcute onsetAbnormal physical examAbnormal physical examNotNot related to description or location of painrelated to description or location of pain

PediatricsPediatrics 1988; 82: 3191988; 82: 319--323323

SelbstSelbst et al. #2et al. #2

66--month followmonth follow--up of 149/407 patientsup of 149/407 patients43% had intermittent or persistent pain43% had intermittent or persistent painNo significant disease identifiedNo significant disease identified

1 mitral valve prolapse1 mitral valve prolapse1 gastrointestinal disease1 gastrointestinal disease3 asthma3 asthma

Conclusion: Conclusion: H&P sufficient for identifying majority of significant H&P sufficient for identifying majority of significant etiologies etiologies

Clinical Clinical PedsPeds 1990; 29: 3741990; 29: 374--77

Rowe et al.Rowe et al.

325 CHEO PED patients325 CHEO PED patientsPrimary or secondary complaint of chest painPrimary or secondary complaint of chest pain

CMAJCMAJ 1990; 143:3881990; 143:388--9494

0

5

10

15

20

25

30

Chest Wall Resp. Psych. Trauma GI Cardiac Other

Rowe et al.Rowe et al.

Chest XChest X--rays done in 50%rays done in 50%18/161 with positive result18/161 with positive result

15 infiltrates15 infiltrates2 pneumomediastinum2 pneumomediastinum1 pneumothorax1 pneumothorax

ECG done in 18%ECG done in 18%2/60 with significant new findings2/60 with significant new findings

Tachycardia and ST changes suggested myocarditisTachycardia and ST changes suggested myocarditisWPWWPW

CMAJCMAJ 1990; 143:3881990; 143:388--9494

MassinMassin et al.et al.

168 patients in Belgian PED with chest pain168 patients in Belgian PED with chest pain69 patients in cardiology clinic with chest pain69 patients in cardiology clinic with chest pain

0

10

20

30

40

50

60

70

80

90

Chest Wall Resp. Psych. Cardiac Trauma GI Other

PEDCard Clinic

ClinClin PediatrPediatr 2004;43:2312004;43:231--88

MassinMassin et al.et al.

9 cases cardiac etiology in 168 PED patients9 cases cardiac etiology in 168 PED patients3 SVT3 SVT2 MVP2 MVP4 sick sinus4 sick sinus1 myocarditis1 myocarditis1 pericarditis1 pericarditis1 cardiac hemochromatosis with 1 cardiac hemochromatosis with ββ--thalassemiathalassemia

5 cases cardiac etiology in 69 card. clinic patients5 cases cardiac etiology in 69 card. clinic patients5 SVT5 SVT ClinClin PediatrPediatr 2004;43:2312004;43:231--88

MassinMassin et al.et al.

ResultsResultsPalpitations or abnormal auscultation predicted all Palpitations or abnormal auscultation predicted all cases of cardiac diseasecases of cardiac disease

ConclusionsConclusionsChest pain in children usually benignChest pain in children usually benignHistory and physical usually sufficientHistory and physical usually sufficientLaboratory testing guided by H&PLaboratory testing guided by H&P

ClinClin PediatrPediatr 2004;43:2312004;43:231--88

Limitations of current literatureLimitations of current literature

Small numbers for characterizing rare eventsSmall numbers for characterizing rare eventsLimited detailLimited detailChildren with known disease not excludedChildren with known disease not excludedLack of followLack of follow--upupNo evidenceNo evidence--based guidelinesbased guidelines

Differential DiagnosisDifferential Diagnosis

Chest wallChest wallTraumaTraumaCostochondritisCostochondritisPrecordial catchPrecordial catchSlipping ribSlipping ribInfectionInfectionMastalgiaMastalgiaZosterZoster

GastroesophagealGastroesophagealReflux Reflux Foreign body

PulmonaryPulmonaryAsthmaAsthmaPneumonia/effusionPneumonia/effusionPneumothoraxPneumothoraxPleurisyPleurisyPulmonary embolusPulmonary embolusMalignancyMalignancy

HematologicHematologicSickle cell diseaseSickle cell disease

PsychogenicPsychogenicForeign body

Differential DiagnosisDifferential Diagnosis

CardiacCardiacAnginaAngina

Coronary abnormalitiesCoronary abnormalitiesHypercoagulable stateHypercoagulable stateCocaineCocaine

Obstructive heart diseaseObstructive heart diseaseIHSS, aortic stenosisIHSS, aortic stenosis

Pericardial effusion/pericarditisPericardial effusion/pericarditisArrhythmiasArrhythmiasMyocarditisMyocarditisAortic aneurysmAortic aneurysm

CasesCases

CaseCase

A 12A 12--yearyear--old girl presents to the emergency old girl presents to the emergency department with chest pain for 2 daysdepartment with chest pain for 2 days

Started graduallyStarted graduallyWorse with deep breathWorse with deep breathHad URTI last weekHad URTI last weekAfebrileAfebrileTender on both sides of sternumTender on both sides of sternumRemainder of physical exam normalRemainder of physical exam normal

CostochondritisCostochondritis

Inflammation of costochondral cartilageInflammation of costochondral cartilageCauseCause

OveruseOverusePreceding URTI with coughPreceding URTI with coughIdiopathicIdiopathic

Sharp pain, worse with movement Sharp pain, worse with movement All agesAll agesTenderness over costochondral jointsTenderness over costochondral joints

Guess the eponymGuess the eponym

Costochondritis Costochondritis

+ visible costochondral swelling+ visible costochondral swelling

==

CaseCase

A 10A 10--yearyear--old boy presents to the ED with old boy presents to the ED with recurrent episodes of left chest pain. recurrent episodes of left chest pain.

Feels like a sudden stabFeels like a sudden stabCanCan’’t take a deep breatht take a deep breathLasts 2Lasts 2--3 minutes3 minutesOccurs at restOccurs at restNot reproducibleNot reproducibleNormal physical examNormal physical exam

Guess the eponym Guess the eponym

+ +

Precordial Catch SyndromePrecordial Catch Syndrome

““TexidorTexidor’’ss twingetwinge””Sudden, briefSudden, briefOccurs at restOccurs at restLocalizedLocalizedSharpSharpExacerbated by deep breathExacerbated by deep breathNo associated symptomsNo associated symptomsNo physical findingsNo physical findings

CaseCase

A 6A 6--yearyear--old girl comes to the emergency old girl comes to the emergency department after having chest pain at home.department after having chest pain at home.

Stopped playing, became clingy, said chest hurtStopped playing, became clingy, said chest hurtMom thought she looked paleMom thought she looked paleNow looks and feels betterNow looks and feels betterHR=110, normal physical examHR=110, normal physical exam

SVTSVT

In children >1 yearIn children >1 year82% present with palpitations82% present with palpitations14% with pain14% with pain14% perspiration14% perspiration14% dizzy14% dizzy4% pallor4% pallor

11--3% of chest pain complaints in ED3% of chest pain complaints in ED6% of chest pain referred to cardiologist6% of chest pain referred to cardiologistMedian time from symptoms to diagnosis 138dMedian time from symptoms to diagnosis 138d

CaseCase

A 13A 13--yearyear--old boy presents to the emergency old boy presents to the emergency department with sudden severe chest paindepartment with sudden severe chest pain

Sharp pain in anterior chestSharp pain in anterior chestAppears anxiousAppears anxiousBP 80/40 in right armBP 80/40 in right armDiastolic murmurDiastolic murmur

Marfan syndromeMarfan syndrome

Caused by fibrillin gene mutationCaused by fibrillin gene mutationManifestationsManifestations

Musculoskeletal: Tall, long limbs and fingers, pectusMusculoskeletal: Tall, long limbs and fingers, pectusOcular: Lens dislocationOcular: Lens dislocationCardiovascular: Aortic root dilation, MVP Cardiovascular: Aortic root dilation, MVP Pulmonary: Spontaneous pneumothorax Pulmonary: Spontaneous pneumothorax

50% have aortic root dilation by age 10 years50% have aortic root dilation by age 10 years90% have aortic root dilation by age 20 years90% have aortic root dilation by age 20 years

Aortic dissectionAortic dissection

Children at riskChildren at riskMarfan syndromeMarfan syndromeEhlersEhlers--DanlosDanlosCoarctationCoarctationAortic stenosis Aortic stenosis Turner syndrome Turner syndrome EndocarditisEndocarditisCocaine useCocaine use

CaseCase

A 17A 17--yearyear--old female presents to the ED with old female presents to the ED with chest pain that has lasted for 1 hourchest pain that has lasted for 1 hour

Pain began during soccer practicePain began during soccer practiceHas happened previously with exerciseHas happened previously with exerciseMidsternal, squeezing, radiates to left armMidsternal, squeezing, radiates to left armPMH: Admitted to hospital for FUO at age 2 yearsPMH: Admitted to hospital for FUO at age 2 years

What was the FUO?What was the FUO?

Kawasaki DiseaseKawasaki Disease

Acute febrile vasculitis of childhoodAcute febrile vasculitis of childhoodFeaturesFeatures

Fever (>39 degrees for 5 days)Fever (>39 degrees for 5 days)NonNon--exudative conjunctivitisexudative conjunctivitisErythema of oral mucosa and tongueErythema of oral mucosa and tongueErythema and swelling of hands and feetErythema and swelling of hands and feetCervical adenitis >1.5 cmCervical adenitis >1.5 cmRashRash

Leading cause of acquired heart disease in kidsLeading cause of acquired heart disease in kids

Cardiac sequelae of KDCardiac sequelae of KD

Acute and subacuteAcute and subacuteMyocarditis (50% of patients)Myocarditis (50% of patients)PericarditisPericarditisMitral, aortic insufficiencyMitral, aortic insufficiencyArrhythmias Arrhythmias Coronary aneurysmsCoronary aneurysms

2020--25% if untreated25% if untreated5% if treated with IVIG5% if treated with IVIGAppear 7 days to 4 weeks after onset of feverAppear 7 days to 4 weeks after onset of fever

Cardiac sequelae of KDCardiac sequelae of KD

LongLong--term followterm follow--up (> 10 years) of 594 up (> 10 years) of 594 untreated patientsuntreated patients

IVIG treatment standard since late 1980IVIG treatment standard since late 1980’’ss24.6% had coronary aneurysms24.6% had coronary aneurysms

49% had regression49% had regression19% developed stenosis (4% of total)19% developed stenosis (4% of total)8% developed myocardial infarction (2% of total)8% developed myocardial infarction (2% of total)

Circulation 1996;94:1379-85

Myocardial ischemia in kidsMyocardial ischemia in kids

Anomalous coronary arteriesAnomalous coronary arteriesPrevalence 2:1000Prevalence 2:1000Anomalous origin of L coronary from Anomalous origin of L coronary from pulmpulm. artery. artery

Presents in first months of lifePresents in first months of lifeIrritability, heart failure, cardiac enlargementIrritability, heart failure, cardiac enlargement

Anomalous origin from incorrect sinus of ValsalvaAnomalous origin from incorrect sinus of ValsalvaPresents later in childhoodPresents later in childhoodCompression between aorta and Compression between aorta and pulmpulm. artery. artery

Hypoplastic coronary arteriesHypoplastic coronary arteries

Myocardial ischemia in kidsMyocardial ischemia in kids

Sickle cell diseaseSickle cell diseaseMyocardial infarction uncommon but describedMyocardial infarction uncommon but describedPerfusion defects in 5% children studied in a Paris Perfusion defects in 5% children studied in a Paris sickle cell clinic (sickle cell clinic (Arch Arch DisDis ChildChild 2004;89:3592004;89:359--62)62)Microvascular occlusion of small vesselsMicrovascular occlusion of small vesselsExchange transfusion may be helpful for acute Exchange transfusion may be helpful for acute ischemia (ischemia (PediatricsPediatrics 2003;111:e1832003;111:e183--7)7)

Myocardial ischemia in kidsMyocardial ischemia in kids

Nephrotic syndromeNephrotic syndromeThrombotic occlusion of coronary arteriesThrombotic occlusion of coronary arteries

LongLong--standing diabetes mellitusstanding diabetes mellitusFamilial hypercholesterolemiaFamilial hypercholesterolemiaSLE, Antiphospholipid antibody syndromesSLE, Antiphospholipid antibody syndromesCardiac transplantCardiac transplantCocaine abuseCocaine abuse

CaseCase

A 16A 16--yearyear--old boy presents to the emergency old boy presents to the emergency department after fainting at a track meetdepartment after fainting at a track meet

Remembers having chest pain during his raceRemembers having chest pain during his raceFather died suddenly in his 30Father died suddenly in his 30’’ssSystolic murmur on exam Systolic murmur on exam

Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

Autosomal dominantAutosomal dominantSymptoms in 2Symptoms in 2ndnd decadedecadeMay present with anginaMay present with angina--like pain or syncopelike pain or syncope

Impaired diastolic relaxation, increased OImpaired diastolic relaxation, increased O22 demanddemand

Risk of sudden death 6% in childrenRisk of sudden death 6% in children

Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

DiagnosisDiagnosisSystolic ejection murmur Systolic ejection murmur

Increases with decreased LV volume Increases with decreased LV volume (Valsalva, squatting, standing)(Valsalva, squatting, standing)

Normal or increased heart size on CXRNormal or increased heart size on CXRECG with LVH, LAD, conduction abnormalitiesECG with LVH, LAD, conduction abnormalitiesEchocardiography diagnosticEchocardiography diagnostic

CaseCase

A 6A 6--yearyear--old girl presents to the ED with cough old girl presents to the ED with cough for 3 weeks and chest pain for 1 weekfor 3 weeks and chest pain for 1 week

Feels very tiredFeels very tiredIllness began with URTI 3 weeks agoIllness began with URTI 3 weeks agoAfebrileAfebrileHeart rate = 160Heart rate = 160Liver palpable 3 cm below RCMLiver palpable 3 cm below RCM

MyocarditisMyocarditis

Usually viral etiologyUsually viral etiologyEnterovirus (coxsackie), adenovirusEnterovirus (coxsackie), adenovirus

PresentationPresentationHeart failureHeart failureChest painChest pain

More likely in older kids and adultsMore likely in older kids and adultsIschemia or concurrent pericarditisIschemia or concurrent pericarditis

MyocarditisMyocarditis

Physical findingsPhysical findingsTachycardia, tachypneaTachycardia, tachypneaPoor perfusionPoor perfusionMuffled heart sounds, S3, murmur Muffled heart sounds, S3, murmur HepatomegalyHepatomegaly

CXRCXRCardiomegalyCardiomegalyPulmonary edemaPulmonary edema

MyocarditisMyocarditis

ECGECGSinus tachycardiaSinus tachycardiaDecreased voltages (<5 mm) limb leadsDecreased voltages (<5 mm) limb leadsLVHLVHProlonged PR interval, prolonged QT intervalProlonged PR interval, prolonged QT interval

EchocardiogramEchocardiogramHypokinesis, impaired functionHypokinesis, impaired function

CaseCase

You are working in the ED when a nurse You are working in the ED when a nurse asks you to assess a 15asks you to assess a 15--yearyear--old girl with old girl with chest pain who seems unwell. You recall chest pain who seems unwell. You recall treating her for pneumonia last week.treating her for pneumonia last week.

Worsening dyspnea and chest pain for 3 daysWorsening dyspnea and chest pain for 3 daysLeaning forward holding her chestLeaning forward holding her chest

PericarditisPericarditis

Infectious etiology common in childrenInfectious etiology common in childrenPainPain

More common in older children and adolescentsMore common in older children and adolescentsWorse when supine, relieved by leaning forwardWorse when supine, relieved by leaning forward

Physical findingsPhysical findingsFriction rub if effusion smallFriction rub if effusion smallMuffled heart sounds, pulsus paradoxus if largeMuffled heart sounds, pulsus paradoxus if large

PericarditisPericarditis

ECGECGLow voltagesLow voltagesST elevationST elevation

Usually leads I, II, V5, V6Usually leads I, II, V5, V6Electric alternansElectric alternans

Produced by swinging motion of heart within Produced by swinging motion of heart within effusioneffusion

CaseCase

A 9A 9--yearyear--old obese boy is brought to the ED at old obese boy is brought to the ED at 11pm complaining of chest pain since dinner 11pm complaining of chest pain since dinner preventing him from sleepingpreventing him from sleeping

Has been having episodes for few weeksHas been having episodes for few weeksDescribed as burningDescribed as burningWorse after big meals and when lying down Worse after big meals and when lying down Normal physical exam Normal physical exam

Gastroesophageal RefluxGastroesophageal Reflux

BerezinBerezin et al.et al.27 children 827 children 8--20 years with idiopathic chest pain20 years with idiopathic chest painAll received EGD, manometry, pH monitoringAll received EGD, manometry, pH monitoringNot blinded, no control groupNot blinded, no control groupResults: 78% had gastroesophageal causeResults: 78% had gastroesophageal cause

16 of 27 (59%) had esophagitis16 of 27 (59%) had esophagitis4 of 27 (15%) had gastritis4 of 27 (15%) had gastritis1 of 27 (4%) with abnormal manometry1 of 27 (4%) with abnormal manometry

Archives Dis Child 1988;63:1457-60

Gastroesophageal RefluxGastroesophageal Reflux

Accounts for 5Accounts for 5--10% of PED chest pain visits10% of PED chest pain visitsClassic pain is temporally associated with mealsClassic pain is temporally associated with mealsBurning, retrosternalBurning, retrosternalTrial of antacid, H2RA, PPI is appropriateTrial of antacid, H2RA, PPI is appropriateConsider pH probe if diagnostic testing needed Consider pH probe if diagnostic testing needed

CaseCase

A 3A 3--yearyear--old boy is evaluated in the emergency old boy is evaluated in the emergency department with chest pain for several hoursdepartment with chest pain for several hours

Points to sternal notchPoints to sternal notchDroolingDroolingRefusing juiceRefusing juiceAfebrile, wellAfebrile, well--appearingappearingBreath sounds equalBreath sounds equal

Esophageal foreign bodyEsophageal foreign body

CaseCase

An 8An 8--yearyear--old boy is brought to the ED directly old boy is brought to the ED directly from a hockey practice during which he said his from a hockey practice during which he said his chest hurt and he couldnchest hurt and he couldn’’t breathet breathe

Several similar episodesSeveral similar episodesFeeling better since arrival to EDFeeling better since arrival to EDTight coughTight coughNormal breath sounds, no murmurNormal breath sounds, no murmurNormal CXR and EKGNormal CXR and EKG

AsthmaAsthma

May account for 10May account for 10--20% chest pain in kids20% chest pain in kidsPersonal or family history atopic conditionsPersonal or family history atopic conditionsAssociated with coughAssociated with coughMay be worse at night or with exerciseMay be worse at night or with exerciseWheezing not always detectableWheezing not always detectableTrial of bronchodilator Trial of bronchodilator Consider PFT for pain with exerciseConsider PFT for pain with exercise

CaseCase

A 17A 17--yearyear--old boy presents to the emergency old boy presents to the emergency department with right chest paindepartment with right chest pain

Just returned hours ago from vacation in Just returned hours ago from vacation in CozumelCozumelPain began one day agoPain began one day agoProgressive dyspnea during flight homeProgressive dyspnea during flight home

Pneumothorax/pneumomediastinumPneumothorax/pneumomediastinum

Children at riskChildren at riskAsthma, bronchiolitisAsthma, bronchiolitisBarotraumaBarotraumaCough, choking, vomitingCough, choking, vomitingCrack, cannabisCrack, cannabisCystic fibrosisCystic fibrosisMarfan syndromeMarfan syndromeTall male teenagersTall male teenagers

CaseCase

A 15A 15--yearyear--old girl presents to the ED with chest old girl presents to the ED with chest painpain

Present for several daysPresent for several daysReports feeling dizzy and short of breathReports feeling dizzy and short of breathNot associated with exerciseNot associated with exercisePhysical exam unremarkablePhysical exam unremarkableGrandmother died last week of heart attackGrandmother died last week of heart attack

PsychogenicPsychogenic

55--20% of chest pain in children20% of chest pain in childrenMore common in adolescentsMore common in adolescentsRecent or current stressful situationRecent or current stressful situationFamily illness, especially cardiovascularFamily illness, especially cardiovascularFamily history of chest painFamily history of chest painOther somatic and sleep complaintsOther somatic and sleep complaintsDepressionDepression

The approach: HistoryThe approach: History

Description of painDescription of painNot as reliable in children as in adultsNot as reliable in children as in adults

Precipitating factorsPrecipitating factorsExertionExertionEatingEatingDeep breathingDeep breathingMuscle useMuscle useTraumaTraumaEmotional stressEmotional stress

The approach: HistoryThe approach: History

Frequency and chronicityFrequency and chronicityAssociated symptomsAssociated symptoms

FeverFeverCoughCoughShortness of breathShortness of breathSyncopeSyncopeDizzinessDizzinessPalpitationsPalpitations

The approach: HistoryThe approach: History

Past medical historyPast medical historyKnown heart diseaseKnown heart diseaseAsthma or atopic conditionsAsthma or atopic conditionsProthrombotic conditionsProthrombotic conditions

CancerCancerSLESLENephrotic syndromeNephrotic syndrome

Medications and drugsMedications and drugsFamily historyFamily history

The approach: Physical examThe approach: Physical exam

General appearanceGeneral appearanceBody habitusBody habitusVital signsVital signsChest wall palpationChest wall palpationAuscultationAuscultationAbdomenAbdomenPeripheral perfusionPeripheral perfusion

Red flagsRed flags

Pain associated with exercise, palpitations, or syncopePain associated with exercise, palpitations, or syncopeShortness of breathShortness of breathPain limits daily activities or disturbs sleepPain limits daily activities or disturbs sleepSubstance abuseSubstance abusePresence of prothrombotic conditionsPresence of prothrombotic conditionsPMH consistent with Kawasaki diseasePMH consistent with Kawasaki diseaseFamily history of sudden death or Family history of sudden death or

early cardiac deathearly cardiac deathAbnormal vital signs or physical findingsAbnormal vital signs or physical findings

The approachThe approach

Further evaluationFurther evaluationCXRCXRECGECGHolter monitorHolter monitorEchocardiogramEchocardiogramCardiology consultationCardiology consultationTherapeutic trialsTherapeutic trials

SummarySummary

Chest pain in pediatrics usually due to benign, Chest pain in pediatrics usually due to benign, identifiable etiologyidentifiable etiologyCardiac and other lifeCardiac and other life--threatening causes of threatening causes of chest pain rare but do existchest pain rare but do exist

Often can be ruled out by history and physical examOften can be ruled out by history and physical examDiagnostic tests appropriate in presence of red flagsDiagnostic tests appropriate in presence of red flags

The EndThe End