Pediatric Chest Pain

Andrew J. Maxwell, M.D. FAAP, FACC

 Facts about Pediatric
Chest Pain
• Out of every 1000 pediatric
outpatient visits to pediatricians and
ERs, 2 to 3 (0.25%) are for chest
pain.
• Chest pain accounts for 650,000
physician visits per year in U.S.
patients 10 to 21 years of age.
 Facts about Pediatric
Chest Pain
• Out of every 100 new patient
consults at my office, 10 (10%) are
for chest pain.
• Chest pain accounts for 110 visits per
year in my patients 4 to 21 years of
age.
 Relative Frequencies of CP in Pediatric
Outpatient/ER Setting
– Selbst Pantell Driscol
• Idiopathic 13 46 45
• Costochondritis 9 16 23
• Musculoskeletal 16 13 5
• Hyperventilation 0 23 0
• Trauma 7 3 5
• Bronchitis 0 0 13
• Reactive Airways Dz 12 0 0
• Psychogenic 9 0 0
• GI Disease 3 3 0
• Sickle-cell disease 3 0 0
• Miscellaneous 6 2 10
• Cardiac 4 1 0

• DJ Driscol, Pediatrics 57, 648-51 1976

• R Pantell, Pediatrics 71, 881-87 1983
• Selbst, S. Clinical Pediatrics, 29, 374-377, 1990
 Relative Frequencies of CP
Outpatient/ER vs. My Office
– OP/ER My Office
• Idiopathic 35% 41%
• Costochondritis 16% 12%
• Musculoskeletal 11% 6%
• Trauma 5% 1%
• Reactive Airways Disease 4% 31%
• Psychogenic 3% 5%
• GI disease 2% 4%
• Cardiac/Pericardial 2% 4%
• Miscellaneous 6% 9%

• DJ Driscol, Pediatrics 57, 648-51 1976

• R Pantell, Pediatrics 71, 881-87 1983
• Selbst, S. Clinical Pediatrics, 29, 374-377, 1990
 Relative Frequencies of CP in Pediatric
Cardiologist’s Office
– # and % of 164 patients with CP
• Idiopathic 68 41%
– Precordial Catch Syndrome/suspected growing pains 20
– Suspected Arrhythmia 12
• Occult Reactive Airways Disease 51 31%
• Chest Wall Pain 30 18%
– Costochondritis 20, muscle strain 5, pleurodynia 3,
– trauma 1, pectus 1
• GI Cause 7 4%
– Reflux 5, esophagitis 1, gastritis 1
• Psychogenic 5 3%
– Anxiety 2, somatization 1, depression 1, aversion 1
• Cardiac 4 2%
– Arrythmia 3, HCM 1, anomalous CoA, Cor Art disease 0
• Pericarditis 2 1%
• Radiculopathy 1
• Vocal cord dysfunction 1
 Cardiac Causes of CP in Pediatrics
• Arrhythmias
• Pericarditis
• Aortic Stenosis
• Mitral Valve Prolapse
• Hypertrophic Cardiomyopathy
• Coronary insufficiency
• Aortic Dissection

• Allen, Moss and Adams 2001

 Cardiac Causes of CP in Pediatrics
Causes of Coronary insufficiency
• Kawasaki Disease
• Williams syndrome
• Anomalous coronary arteries
• Coronary AV and Coronary-Cameral Fistula

Chest pain is uncommon within these populations!!

• Allen, Moss and Adams 2001
 Cardiac Causes of CP in Pediatrics
Anomalous coronary arteries (1% of population)
• Anomalous right coronary artery (0.3%)
• Coronary-Cameral Fistula (0.2%)
• Single coronary artery (0.024%)
• Anomalous left coronary artery (0.02%)

Chest pain is uncommon within these populations!!

• Allen, Moss and Adams 2001
 Cardiac Causes of CP in Pediatrics
Anomalous coronary arteries (1% of population)
• Anomalous left coronary artery (0.02%)
 Cardiac Causes of CP in Pediatrics
Anomalous coronary arteries (1% of population)
• Anomalous right coronary artery (0.02%)
 Evaluation of Chest Pain
• History
– Duration of problem?
– Frequency of events?
– Duration or each event?
– Intensity (scale of 1 to 10)?
– Location (can you point to exactly where
it hurts?)
 Evaluation of Chest Pain
• History
– Type of Pain ?
• Sharp pain/stabbing pain?
• Pressure pain/sitting on you?
• Twisting pain?
• Squeezing pain?
• Poky pain (with finger or finger nail)?
• Needles?
• Numbness?
• Beeping pain?
 Evaluation of Chest Pain
• History
– Does it change with breathing?
• Does it catch your breath?
• Do you feel as if the slightest breath will
cause much worse pain?
• Does it only hurt more on deep inspiration?
• Do you find that if you ‘bite the bullet’ and
take a deep, painful breath, the pain stops?
 Evaluation of Chest Pain
• History
– Do you have other accompanying
symptoms?
• Palpitations?
• Tachycardia?
• Dizziness?
• Near-fainting or fainting?
• Shortness of breath?
 Evaluation of Chest Pain
• History
– What are you doing at the time of the pain?
• With rest or exertion?
• With anxiety?
• Before or after meals?
• Every time during exertion?
• Only when extreme exertion?
• Does it go away with recovery?
• Is it with all sports equally?
 Evaluation of Chest Pain
• History
– Have there been any recent illnesses?
• Pneumonia, chest cold?
• Trauma or sports injury?
• Kawasaki Disease?
• Chest procedures/surgeries?
• Aspirations?
 Evaluation of Chest Pain
• History
– Other Pertinent Questions:
• Do you consume caffeinated beverages?
• Has there been a recent growth spurt?
 Evaluation of Chest Pain
• Family History
– Any early heart disease?
– Any sudden unexplained deaths?
– Any congenital heart disease?
 Evaluation of Chest Pain
• Physical Exam
– Marfan Features?
– Costochondral Tenderness?
– Signs of Trauma?
– Murmurs? Clicks?
– Wheezing is rarely heard
 Evaluation of Chest Pain
• Electrocardiogram
– Hypertrophy?
– Global ST segment elevation?
– ST/T wave changes rarely sensitive
– Underlying arrhythmia rarely present
 Evaluation of Chest Pain
• Echocardiogram
– Hypertrophic cardiomyopathy?
– Origin and course of coronary arteries?
– Caliber of aorta?
– Coronary aneurisms following Kawasaki?
Evaluation of Chest Pain
• Event Recorder
– Suspected arrhythmia
– Sporadic non-exertional chest pain of
unclear etiology
Evaluation of Chest Pain
• Stress Test with Pulmonary
Function Testing
– Suspected reactive airways
disease
– Especially exercise-induced RAD
– Suspected cardiac ischemia
– Most exertional chest pain in
children over 7 years
Evaluation of Chest Pain

• Pulmonary Function Testing

– Before and after Exercise
– Before and after Albuterol
and other inhalers
 Chest Pain in Pediatrics
Exercise-Induced Asthma
 Chest Pain in Pediatrics
Exercise-Induced Asthma
Pre and Post-exercise Post-Albuterol
 Chest Pain in Pediatrics
AH is a 9-year-old male who is being evaluated for intermittent chest pain .

HPI: AH is otherwise healthy. He began to have chest pain about 1 year ago.
This is intermittent and not associated with activity. Indeed, it has been
happening more often lately but never when playing sports. Most commonly
its while watching TV. It feels like a stabbing pain anywhere on the front
of his chest. It lasts just a couple of seconds. He denies palpitations,
syncope, or dizziness with the episodes. He rates the pain a 10 out of 10 in
intensity and he can’t move or even breath until the pain goes away. He’s
active in sports and does not tire easily. His mother states that he has
been going through a growth spurt recently.

Physical exam, ECG and echocardiogram are normal.

 Chest Pain in Pediatrics
JK is a 16-year-old male who is being evaluated for exertional chest pain.

HPI: JK is otherwise completely healthy. For the past few weeks, since he
started football practice, he has been having exertional chest pain. Last
Monday during training he suddenly felt a chest tightness and he couldn't
breath. He fell over and nearly passed out. He was taken to St. Rose in an
ambulance. He was discharged from the ER with the request for a full
cardiology work-up. This pain was the typical pain for him; a pressure pain
that he rates an 8 out of 10 in intensity. He has associated SOB with the
pain but no sweating. JK's exercise tolerance is not so good because he
took the summer off from training. He has no history of asthma.

Physical exam is unremarkable.

ECG and echocardiogram are normal. His stress test showed no ST changes.
 Chest Pain in Pediatrics
Exercise-Induced Asthma
Pre and Post-exercise Pre and Post-exercise
Before trial of Albuterol After trial of albuterol x 2 weeks
 Chest Pain in Pediatrics
DL is a 16-year-old male who is being evaluated for intermittent chest pain .

HPI: DL has been complaining of chest pain for nearly 2 months. He describes
it as substernal pressure and severe. He was evaluated for the pain about
1 month ago by his pediatrician. He was sent to Children's Hospital for an
ECG which was read as abnormal. Despite continued pain at the time, he
failed to go for follow-up as he believed he had gas. Last night, DJ
presented to the ED in distress from chest discomfort. An ECG was
performed which showed changes consistent with an acute MI. Cardiac
CPK and troponin were drawn. The CPK was normal but the initial troponin
was elevated. A second troponin was drawn according to protocol and this
was normal. His chest pain continued but improved somewhat on morphine
and antacid. Because the second troponin was normal, it was presumed that
he had no enzymatic evidence of cardiac ischemia. He was therefore
discharged to my clinic for a stress test.
Chest Pain in Pediatrics
 Chest Pain in Pediatrics
AA is a 15-year-old male who is being evaluated for left arm numbness with
exercise.

HPI: AA is otherwise healthy. For the past year he has been having a problem
where he notices that when he runs, his left arm becomes numb.
Occasionally he feels that his legs become numb too but not to the extent
that of his arm. He also feels numbness in his jaw at the same time that
his arm becomes numb. He notices that this problem most usually occurs
when he exercises without warming up first. If he stretches and prepares
for exercise, he can run at high intensity without a problem. The problem
is occurring more and more frequently. He notes that the numbness only
lasts a few seconds then goes away despite continuing to run even at high
intensity. While it is numb, he has some limited use of his hand and arm.

Physical Exam and ECG, echocardiogram and PFTs before and after exercise
are normal.
Chest Pain in Pediatrics
 Chest Pain in Pediatrics
TV is a 13-year-old male who is being evaluated for chest pain.

For the past 6 or 7 years TV has been having episodes where he feels chest
pain. The episodes now occur about twice per month. Initially it would hurt
for about 1 to 10 minutes. Now the episodes occur for less time because he
can break them by breathing deeply. He has a racing heart along with the
pain. His father has confirmed this by feeling his pulse. He often develops
a headache and weakness shortly after. Indeed, it was thought that the
constellation was due to migraines. He has also felt dizzy at least once
during an episode.

Physical Exam, ECG and echocardiogram are unremarkable.

 Chest Pain in Pediatrics

SVT

Event Recorder Recording

 Chest Pain in Pediatrics
HF is a 17-year-old male who is being evaluated for exertional chest
discomfort.

HPI: HF is a 17 year old who came in for evaluation of a murmur and for chest
pain that he has been having on exertion for the past 9 months. He states
that he had a flu-like illness in October. This lasted for about 5 weeks.
When the flu symptoms resolved, he continued to feel fatigued until
present. He also felt pains when exerting himself. He says the pain is a
pressure type pain under his left clavicle. Sometimes he feels needles
there also. He also has a muscular type pain in his left back at the same
time. It limits his exercise capacity. He has no other symptoms except
fatigue and dizziness with exertion. He admits to long-time use of cocaine.

Physical exam is shows increased apical impulse and a soft murmur.

Chest Pain in Pediatrics
 Chest Pain in Pediatrics

Hypertrophic Cardiomyopathy
Apical 4 chamber View Parasternal Long Axis View
 Chest Pain in Pediatrics
DG is a 16-year-old female who is being evaluated for intermittent chest pain.

HPI: Last night DG experienced sudden onset of chest pain. It progressed to where it woke her
up at midnight. She went to the ER at SRRMC. She describes the pain as initially a pressure
pain. It was not associated with exertion although she was exercising intensely earlier in the
daytime. At the time that she reached the ER she rated her pain an 8 out of 10. This
improved over the course of the ER stay. She was given Mylanta without relief and liquid
ibuprofen which may or may not have contributed to the pain relief. Her ECG and cardiac
enzymes were reported as normal. A CXR was reported as cardiomegaly. The pain continued
into the morning but has resolved spontaneously at this point. She felt no dizziness at the
time nor palpitations nor racing heart.

• DG admits to a decline in her exercise tolerance. She clearly has had a decline in her times
during practices and races and this is attributed to early exhaustion. She feels that she does
well until she reaches a certain exercise intensity where she suddenly becomes short of
breath. She feels she suddenly cannot get air in. This past May, she had a championship race
and at the end of the event she passed out and was incontinent to urine and bowels. In July,
she went to high altitude training and again nearly lost consciousness and was noted to have
grey and clammy skin following an intense workout.

• PE, ECG, echocardiogram were normal. Stress test was that of a well-
trained athlete.
 Chest Pain in Pediatrics
Vocal Cord Dysfunction Syndrome
 Chest Pain in Pediatrics
Vocal Cord Dysfunction Syndrome
 Relative Frequencies of CP
Outpatient/ER vs. My Office
– OP/ER My Office
• Idiopathic 35% 41%
• Costochondritis 16% 12%
• Musculoskeletal 11% 6%
• Trauma 5% 1%
• Reactive Airways Disease 4% 31%
• Psychogenic 3% 5%
• GI disease 2% 4%
• Cardiac/Pericardial 2% 4%
• Miscellaneous 6% 9%

• DJ Driscol, Pediatrics 57, 648-51 1976

• R Pantell, Pediatrics 71, 881-87 1983
• Selbst, S. Clinical Pediatrics, 29, 374-377, 1990