Adolescent Health Care: A Practical Guide

Chapter 37

Chest Pain

John Kulig

Lawrence S. Neinstein

Chest pain is reported by as many as 5% of patients attending adolescent clinics and accounts for approximately 650,000 physician visits annually from patients aged 10 to 21 years.

In contrast to adults, acute chest pain of cardiac origin is uncommon among adolescents. Yet 44% of adolescents with complaints of chest pain fear heart attack, 12% fear heart disease, and 12% fear cancer.

Differential Diagnosis

The underlying cause of chest pain in adolescents includes several diverse etiologies. The following sections provide a broad classification, in order of frequency, based on several studies.

Musculoskeletal (31%)

In general, musculoskeletal pain is a well-localized, sharp, nagging pain. The onset is often insidious. Movement and breathing may increase the intensity of the pain.

  1. Precordial catch/“stitch”: A common cause of chest pain, with sudden onset of a sharp needle-like or stabbing pain, lasting 30 seconds to 3 minutes, usually localized at the left sternal border or cardiac ape The pain most often occurs at rest, is increased with deep breathing, and may be relieved by stretching. The cause is attributed to irritation of the parietal pleura or intercostal nerves.
  2. Muscle strain/overuse: Strain of the chest wall, upper back, or shoulder muscles after exercise or lifting can result in chest pain. Localized tenderness is frequently present. Movement of the arms and chest often increases the pain. Prolonged coughing can also lead to muscle strain.
  3. Costochondritis (8%): Costochondral pain is well-localized with focal tenderness, usually anywhere from the second through the sixth ribs, on the anterior chest wall. The pain is more often unilateral and in multiple locations. The pain may radiate to the back or abdomen. Deep breathing may increase the pain. The clue to the diagnosis is tenderness over the involved articulations at the costochondral junction. Actual swelling is not characteristic. Costochondritis may be preceded by an upper respiratory tract infection or by exercise.
  4. Tietze syndrome: This rare cause of costochondral pain is associated with a tender solitary swelling or nodule, usually located at the second or third costal cartilage. The swelling is typically unilateral, with either a sudden or gradual onset. The pain is often increased with breathing and movement, and may persist for days to months or longer.
  5. Slipping rib syndrome: An unusual cause of lower chest pain. This syndrome is caused by slipping of the eighth, ninth, or 10th rib on the immediately superior rib. These three ribs do not attach to the sternum. A tear in the connecting fibrous tissue between these ribs can cause this slippage. The pain is sharp, stabbing, and located in the upper quadrant of the abdomen or at the inferior costal margin. It is usually insidious in onset, unilateral, and worsens with exercise. Occasionally, a click is heard with movement.
  6. Fibromyalgia syndrome: Chronic, persistent pain associated with aching, fatigue, and morning stiffness. Symmetric, bilateral, localized tender points present at the top of the shoulders and adjacent to the upper sternum.
  7. Thoracic outlet obstruction: Brachial plexus compression may be due to a cervical rib.
  8. Malignant disease of bone: Primary or metastatic. A rare cause of chest pain in adolescents.

Idiopathic/Psychogenic (25%)

  1. Stress or anxiety: Adolescents under stress may describe a tightness or heaviness in the chest, with or without hyperventilation. Anxiety may also induce intermittent sharp, knife-like pains, or persistent precordial aching unrelated to exertion.
  2. Hyperventilation: Hyperventilation syndrome may cause chest pain associated with lightheadedness, shortness of breath, paresthesias, and syncope. Is more common in female adolescents.
  3. Depression: Chest pain may occur among multiple somatic complaints.
  4. Bulimia nervosa: Esophagitis or Mallory-Weiss tear from frequent self-induced emesis.

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Pulmonary (21%)

Most pulmonary causes of chest pain in adolescents are associated with other symptoms such as cough, fever, pain on inspiration, and dyspnea. The pain associated with pleural and pulmonary causes is usually more diffuse and difficult for the adolescent to describe.

  1. Cough (10%): Persistent cough is a frequent cause of chest pain.
  2. Asthma (4%): Asthma is another relatively common cause of chest pain.
  3. Pneumonia/bronchitis (7%): Pulmonary infection, particularly when the infection involves the pleura.
  4. Pleural effusion: Seen in 10% of Mycoplasmainfections in the lower respiratory tract; may be a presenting sign of pulmonary tuberculosis.
  5. Pleurodynia: Infection with type B coxsackie virus often leads to paroxysmal pain in the intercostal muscles. The onset follows a typical viral prodrome.
  6. Spontaneous pneumothorax/pneumomediastinum: Symptoms include an acute onset of pleuritic chest pain and dyspnea. Individuals with cystic fibrosis, asthma, or Marfan syndrome are at increased risk of this complication.
  7. Acute chest syndrome in sickle cell disease: May be difficult to distinguish from pulmonary infection, infarction, or embolization.
  8. Pulmonary embolism/infarction: A pulmonary embolism can give rise to the acute onset of dyspnea, hemoptysis, and chest pain. This is an uncommon problem in teenagers, unless predisposing factors exist, such as obesity, immobilization, coagulopathy, pregnancy, or use of combined hormonal contraception, particularly with disorders of coagulation.
  9. Lemierre syndrome: Pharyngeal abscess complicated by thrombophlebitis of the internal jugular vein and embolic pulmonary abscesses. Presents with throat, neck, and chest pain.

Gastrointestinal (7%)

Numerous gastrointestinal (GI) disorders can cause chest pain. However, these conditions are relatively uncommon among adolescents. Included in this group are the following:

  1. Reflux esophagitis
  2. Esophageal foreign body, including pill-induced esophagitis/ulceration
  3. Esophageal spasm
  4. Caustic ingestion
  5. Gastritis, including alcoholic gastritis
  6. Peptic ulcer disease
  7. Nonulcer dyspepsia
  8. Cholecystitis
  9. Pancreatitis

Trauma (5%)

  1. Rib contusion or fracture
  2. Sternal contusion or separation
  3. Clavicular contusion or fracture
  4. Hepatic or splenic trauma

Breast (5%)

  1. Pubertal gynecomastia: May be associated with tender and painful breast tissue. Male adolescents may believe that this physiological breast tissue represents cancer or a serious anomaly in their pubertal development.
  2. Premenstrual or pregnancy-associated breast tenderness.
  3. Fibrocystic breast changes.
  4. Breast mass, especially fibroadenoma.
  5. Mastitis.

Cardiac (4%)

Pain related to cardiac disease is among the least common causes of chest pain in adolescents. The pain may be associated with exertion. Other symptoms may include syncope, palpitations, and dizziness.

  1. Mitral valve prolapse: A controversial cause of either exertional or nonexertional chest pain.
  2. Dysrhythmias: Supraventricular tachycardia, prolonged QT interval, atrioventricular block, sick sinus syndrome, and ventricular ectopy can cause palpitations and chest pain.
  3. Pericarditis: Pericardial pain is usually sharp and aggravated by respiratory motion, yawning, or swallowing. Sitting up and leaning forward often lessens the pain. Distant heart sounds, a friction rub, tachycardia, and a recent viral infection suggest pericarditis.
  4. Myocarditis or cardiomyopathy: May progress to congestive heart failure.
  5. Left ventricular outflow obstruction: Severe aortic stenosis or hypertrophic obstructive cardiomyopathy can cause chest pain. Both conditions have been associated with syncope and sudden death in athletes.
  6. Ischemic heart disease: Ischemic heart pain is almost nonexistent in the adolescent age-group. Ischemic heart disease in unlikely, unless there are predisposing factors such as a strong family history, severe hyperlipidemia, prolonged hypertension, or local arteritis.
  7. Coronary arteritis in Kawasaki disease.
  8. Dissecting aortic aneurysm: Dissecting aortic aneurysm is an extremely rare problem during adolescence, except with a predisposing connective tissue disorder such as Marfan syndrome or Ehlers-Danlos syndrome.
  9. Anomalous origin of the coronary arteries.

Miscellaneous (2%)

  1. Mediastinitis
  2. Mediastinal mass
  3. Herpes zoster (shingles)
  4. Cigarette smoking
  5. Carbon monoxide poisoning
  6. Illicit drug use: Cocaine, Ecstasy (MDMA), amphetamine, anabolic steroids

Massin et al. (2004) evaluated 168 older Belgian children and young adolescents and also found that chest wall pain was the most common (64%) followed by pulmonary causes (13%), psychological (9%), cardiac (5%), traumatic (5%), and GI problems (4%). Of interest was that the organic causes were all identified by history and physical

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examination and in no cases were organic diseases diagnosed by ancillary studies.

Diagnosis

History

A careful history is the most effective means of determining the cause of chest pain in adolescents. The history should include questions regarding the following:

  1. Characterization of the pain
  2. Quality: A localized sharp or aching pain suggests a chest wall etiology, whereas a deep, gnawing pain suggests a visceral cause.
  3. Onset: Patients with sudden, acute onset of chest pain are more likely to have organic disease.
  4. Severity: Does the pain restrict the patient's usual activities?
  5. Location: Pain in the T1 to T4 dermatome distribution is often referred from the myocardium, pericardium, aorta, or esophagus. Pain in the T5 to T8 distribution may arise from the diaphragm, gallbladder, liver, pancreas, duodenum, or stomach. This pain may also be referred to the back and right scapula. Is the pain positional?
  6. Timing and duration: Brief pain may have a musculoskeletal or chest wall origin. Deep, long-lasting pain suggests a visceral origin. Is the pain related to meals?
  7. Precipitating and alleviating factors: Substernal pain increasing when lying down suggests reflux esophagitis. Pain decreasing with antacids suggests gastritis. Pain increasing with breathing, cough, or movement suggests pleural or chest wall pain. Pain increasing with stress suggests anxiety with or without hyperventilation. Pain that increases at night or awakens the adolescent suggests an organic cause.
  8. Recent activity: This includes activity that could cause chest wall strain, such as lifting weights, exercising, athletic competition, or performing household chores.
  9. Recent trauma: Has the adolescent sustained an injury?
  10. Recent infections or systemic illness: Are there any systemic illnesses such as asthma or sickle cell disease that could contribute to the chest pain? Has there been persistent coughing or vomiting?
  11. Medications or drugs. Are there any prescribed medications that could account for the chest pain? Any tobacco or alcohol use? Any illicit drug use?
  12. Associated symptoms: Is there lightheadedness, paresthesias, or tingling in the extremities, suggesting hyperventilation syndrome?
  13. Previous treatment: What treatment has been tried in the past? What has worked?
  14. Family history: Known cardiovascular disease? Hypertension? Lipid disorder? Coagulopathy? Sudden deaths?
  15. Recent stress: A thorough psychosocial evaluation is important, including questions about functioning at home, at school, and with peers. Recent deaths in the family? Any history of abuse?
  16. 10. Fears and concerns: Interview patients alone to determine if they are worried about conditions such as heart disease or cancer.

Physical Examination

A detailed examination, with particular attention to the chest wall, is essential for diagnosis and reassuring for the patient.

  1. General state: Evidence of anxiety or hyperventilation? Normal respiratory pattern? Cyanosis? Pallor?
  2. Vital signs: Tachypnea, tachycardia, or fever? Hypertension?
  3. Chest wall palpation: Examine the adolescent for localized tenderness or swelling along the ribs and intercostal spaces. Check for evidence of trauma, such as swelling or ecchymoses. Individual sternocostal and costochondral junctions should be palpated. Is there asymmetry, kyphosis, or scoliosis? Check for supraclavicular crepitus, a sign of subcutaneous air. Perform the hooking maneuver to check for “slipping” rib. Pain or subluxation can be reproduced by hooking the examiner's fingers under the affected ribs and pulling anteriorly. In males, examine the areolae for palpable breast tissue.
  4. Cardiopulmonary examination for the following:
  5. Heaves or thrills/peripheral pulses
  6. Asymmetrical breath sounds: Pneumothorax, pleural effusion, and empyema
  7. Rales: Pneumonia and pulmonary embolism
  8. Pleural friction rub: Pleurisy and pulmonary embolism
  9. Cardiac friction rubs/distant heart sounds: Pericarditis and effusion
  10. Mid-systolic click, late-systolic murmur: Mitral valve prolapse
  11. Other cardiac murmurs: Aortic stenosis, for example
  12. Cardiac dysrhythmia
  13. Breast examination: Symmetry, masses, tenderness, discharge.
  14. Abdominal examination: Epigastric tenderness may suggest a GI etiology.

Laboratory Testing

Most adolescents require no evaluation other than a detailed history and physical examination. Unless these findings are suggestive of a specific organic cause, testing is usually not helpful in diagnosing chest pain. An electrocardiogram and chest radiograph almost always show no abnormalities in this situation. Indications for further evaluation include acute chest pain that is precipitated by exercise, interferes with sleep, or is associated with dyspnea, palpitations, dizziness, or syncope. Adolescents with a history of cardiac disease, asthma, sickle cell disease, or Marfan syndrome may also require diagnostic studies, as will those patients with specific abnormal physical findings. Studies to consider include the following:

  • Chest radiograph
  • Electrocardiogram
  • Echocardiography
  • 24-hour Holter monitoring
  • Exercise stress testing
  • Cardiac enzymes (troponin 1, CPK-MB)

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  • Lipid profile
  • Urine drug screening
  • Pulse oximetry
  • D-dimer
  • Abdominal ultrasonography
  • Upper GI tract endoscopy

Therapy

Chest pain is rarely life threatening in adolescents and rarely necessitates emergent intervention. Because the diagnosis is usually based on the history and physical examination findings, adolescents rarely need referral to a subspecialist. In most instances, the adolescent needs reassurance that he or she does not have a significant cardiac problem and, in addition, that spontaneous resolution of the chest pain is likely. Consider advising the patient to keep a pain diary for further evaluation if the chest pain is chronic or recurrent.

Therapy depends on the specific diagnosis.

  1. Musculoskeletal pain
  2. Education and reassurance
  3. Analgesics: Nonsteroidal anti-inflammatory drugs (NSAIDs)
  4. Application of heat to affected area
  5. Psychogenic
  6. Education and reassurance
  7. Stress-reduction techniques
  8. Referral for counseling
  9. Consider prescribing sertraline if symptoms are chronic
  10. Pulmonary
  11. Pleurodynia: Analgesics
  12. Pneumothorax
  • Small pneumothorax in healthy adolescents: May be well tolerated and managed with observation. Consider treatment with 100% oxygen.
  • Large pneumothorax: Immediate insertion of a chest tube to allow reexpansion of the lung; alternatively, a small opening in the chest wall can be created with a large-bore needle as an emergency, temporary measure.
  • Evaluate for Marfan syndrome or other connective tissue disorder.
  1. Community-acquired pneumonia: Macrolide antibiotic or doxycycline
  2. Pulmonary embolism: Hospitalization and anticoagulation
  3. GI
  4. Esophagitis and gastritis: Antacids, histamine (H2) antagonists, gastric acid pump inhibitors
  5. Dietary modification
  6. Trauma
  7. Analgesics: NSAIDs
  8. Binder or sling as needed
  9. Breast: Education and reassurance
  10. Cardiac
  11. Mitral valve prolapse
  • Education and reassurance
  • Endocarditis prophylaxis in the presence of significant mitral insufficiency
  • Severe chest pain or chest pain associated with dysrhythmias: May benefit from a β-blocker
  1. Pericarditis: Analgesics

Web Sites

For Teenagers and Parents

http://www.cincinnatichildrens.org/health/heart-encyclopedia/signs/chest.htm. Causes of chest pain and advice for parents.

http://familydoctor.org/523.xml

http://familydoctor.org/x2586.xml

http://familydoctor.org/x2587.xml. Self-help flowcharts (3) for chest pain.

For Health Professionals

http://www.obgyn.net/femalepatient/?mcfee tfp Clinical approach to chest pain in female adolescents.

http://www.emedicine.com/ped/topic487.htm. Review of costochondritis as a cause of chest pain.

References and Additional Readings

Anzai AK, Merkin TE. Adolescent chest pain. Am Fam Physician 1996;53:1682.

Basso C, Maron BJ, Corrado D, et al. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in competitive athletes. J Am Coll Cardiol 2000;35:1493.

Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004;51:1553.

Daley WR, Smith A, Paz-Argandona E, et al. An outbreak of carbon monoxide poisoning after a major ice storm in Maine. J Emerg Med 2000;18:87.

Gumbiner CH. Precordial catch syndrome. South Med J 2003;96:38.

Hotopf M, Mayou R, Wadsworth M, et al. Psychosocial and developmental antecedents of chest pain in young adults. Psychosom Med 1999;61:861.

James LP, Farrar HC, Komoroski EM, et al. Sympathomimetic drug use in adolescents presenting to a pediatric emergency department with chest pain. J Toxicol Clin Toxicol1998;36:321.

Lawrence PR, Delaney AE. Chest pain in children and adolescents: most causes are benign. Adv Nurse Pract 2004;12:61.

Massin MM, Bourguignont A, Coremans C, et al. Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr (Phila) 2004;43:863.

Owens TR. Chest pain in the adolescent. Adolesc Med: State Art Rev 2001;12:95.

Palmer KM, Selbst SM, Shaffer S, et al. Pediatric chest pain induced by tetracycline ingestion. Pediatr Emerg Care 1999;15:200.

Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol 2000;21:363.

Sabri MR, Ghavanini AA, Haghighat M, et al. Chest pain in children and adolescents: epigastric tenderness as a guide to reduce unnecessary work-up. Pediatr Cardiol 2003;24:3.

Selbst SM. Consultation with the specialist: chest pain in children. Pediatr Rev 1997;18:169.

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Taubman B, Vetter VL. Slipping rib syndrome as a cause of chest pain in children. Clin Pediatr (Phila) 1996;35:403.

Tunaoglu FS, Olgunturk R, Akcabay S, et al. Chest pain in children referred to a cardiology clinic. Pediatr Cardiol 1995;16:69.

Varia I, Logue E, O'Connor C, et al. Randomized trial of sertraline in patients with unexplained chest pain of noncardiac origin. Am Heart J 2000;140:367.

Vichinsky EP, Neumayr LD, Earles AN, et al. National Acute Chest Syndrome Study Group. Causes and outcomes of the acute chest syndrome in sickle cell disease. N Engl J Med2000;342:1855.

Zartner P, Raith W, Beitzke A. Acute chest pain in a young adult. Cardiol Young 2004;14:85.

Zirkin WM, Nadel ES, Brown DFM. Recurrent pleuritic chest pain. J Emerg Med 1999;17:329.