Thursday, February 9, 2012

Chest Pain in Children - majority not cardiac

From Medscape Pediatrics > Viewpoints

Chest Pain in Children: Is It Cardiac?

William T. Basco, Jr., MD
Posted: 01/30/2012
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Effectiveness of Screening for Life-Threatening Chest Pain in Children

Saleeb SF, Li WY, Warren SZ, Lock JE
Pediatrics. 2011;128:e1062-e1068

Chest Pain in Children

Studies have consistently shown that most chest pain experienced in childhood and adolescence is not cardiac in nature. Therefore, chest pain in children does not have the same concerning connotation that it does in adults. This study was done to determine whether unexpected cardiac events occurred in children who were evaluated in a cardiology clinic and determined to have a noncardiac origin for their pain.

Study Summary

All children were evaluated at a single medical center in Boston over a 10-year period, 2000-2009. Children were older than 6 years and had no known cardiac defects or cardiovascular disease. Children who were seen for chest pain were identified from medical records. Additional data included demographic features, clinical characteristics, cardiac testing, discharge diagnoses, other medical diagnoses, and follow-up.
Children were divided into those who had chest pain on exertion and those who had chest pain at rest. In general, children who experienced chest pain on exertion as one of the presenting symptoms had more extensive testing. ECGs were performed on all children, but additional testing varied during the study period at the discretion of the cardiologist evaluating the patient. Two sources were used to identify deaths after the visit: the National Death Index from the Centers for Disease Control and Prevention and the Social Security Death Index.
The final cohort included 3700 children. The median age at the time of the cardiac evaluation was 13.4 years, and the children had a median of 4.4 years of follow-up. Chest pain at rest was the most common scenario (56%), followed by exertional chest pain (33%). Palpitations accompanied the chest pain in 22% of patients, shortness of breath in 16%, dizziness in 11%, and syncope in 1.3%. Almost 1 of 5 children had made at least 1 emergency department visit for chest pain before the cardiac evaluation. Fifteen percent of the children had a history of asthma, and almost 2% had a history of gastroesophageal reflux. Approximately 1% had a minor congenital heart problem, and an additional 1% had an inflammatory disorder. The physical examination findings were mostly normal.
Results of cardiac evaluations. Identified cardiac abnormalities included clicks (1.4%), structural abnormalities of the sternum (1.1%), and pathologic murmurs (0.8%). The ECG evaluations were largely normal, with left ventricular hypertrophy demonstrated in only 2.5% of children and abnormal ST segments, abnormal T waves, right ventricular hypertrophy, or conduction abnormalities demonstrated in less than 1%. Echocardiography was done in 38% of patients; these evaluations were normal in 88%, and an additional 11% had incidental findings that the investigators felt were unrelated to chest pain. In 0.8% of patients, the echocardiograms identified abnormalities that might be related to the chest pain; these incidental findings included mild dilations of the aorta, mild mitral regurgitation, mitral valve prolapse, and miscellaneous problems.
Causes of chest pain. The discharge diagnoses from the cardiology clinic evaluation for chest pain were apportioned as follows:
  • Unknown origin, 52%;
  • Musculoskeletal origin, 36%;
  • Pulmonary origin, 7%;
  • Gastrointestinal origin, 3%;
  • Anxiety, 1%; and
  • Cardiac origin, 1%.
Deaths during follow-up. Among the 3700 patients, 3 deaths (0.1%) occurred during follow-up. Two of these deaths were suicides, and the third was the result of retroperitoneal hemorrhage. The researchers concluded that chest pain is a common pediatric symptom that rarely has a cardiac cause and that, in almost 18,000 patient-years of follow-up, no patient discharged from the clinic died of a cardiac condition.


This is an excellent study that may or may not reassure primary care practitioners. Although the incidence of cardiac diagnoses was exceedingly low at 1%, some of the conditions that were identified are potentially serious cardiac abnormalities. Allaying residual concerns about missing even the small percentage of true cardiac diagnoses is exactly why these investigators conducted the main analyses that looked at deaths after discharge from their clinic. Children discharged with a diagnosis of chest pain are probably a selected group, so the investigators repeated the analysis to include the 41 children who had chest pain as a presenting symptom but ended up with a more severe cardiac diagnosis. This increased the overall incidence of cardiac disease in children with chest pain to 2%. Even among the 41 children with a more serious cardiac diagnosis, no deaths occurred.
It is worth noting that this is a subspecialty referral population, meaning that primary care practitioners probably filtered out many other cases of chest pain before they arrived at the pediatric cardiology clinic. Therefore, the incidence of cardiac disease is probably even lower among all children in a primary care who are experiencing chest pain. Nevertheless, Saleeb and colleagues are evaluating an outpatient application of a decision approach to referral and testing for chest pain in primary care practitioner offices, and I know that having such a validated guideline would be very welcome to most pediatric practitioners when seeing a patient with chest pain.

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