Park's Pediatric Cardiology for Practitioners, 6th Ed.

Child with Chest Pain

A complaint of chest pain is frequently encountered in children in the office and emergency department (ED). Although chest pain does not indicate serious disease of the heart or other systems in most pediatric patients, in a society with a high prevalence of atherosclerotic cardiovascular disease, it can be alarming to the child and parents. Physicians should be aware of the differential diagnosis of chest pain in children and should make every effort to find a specific cause before making a referral to a specialist or reassuring the child and the parents of the benign nature of the complaint. Making a routine referral to a cardiologist is not always a good idea; it may increase the family’s concern and may result in a prolonged and costly cardiac evaluation.

Cause and Prevalence

Chest pain occurs in children of all ages and equally in male and female patients, with an average age of presentation at 13 years. Most of the data on the frequency of causes of chest pain in children come from studies performed in pediatric ED and cardiology clinics. Chest pain accounts for approximately 0.3% to 0.6% of pediatric ED visits. Table 30-1 lists the frequency of the causes of chest pain in children according to the organ systems based on data from 6 published reports from pediatric emergency departments or pediatric clinics and data from 4 pediatric cardiology clinics (Thull-Freedman, 2011). According to the table, trauma or muscle strain of the chest wall, costochondritis, and respiratory illness are the three most frequent causes of the pain. Gastrointestinal and psychogenic causes are identified in fewer than 10% of cases, and a cardiac cause is found infrequently (5% or less). In another report, chest wall pathology, including costochondritis, was the cause of the pain in 64% of patients seen in an ED and in 88% of the patients seen in cardiology clinic (Massin et al, 2004). Whereas children younger than 12 years of age were two times more likely to have an organic cause, adolescents were 2.5 times more likely to have a psychogenic cause. Box 30-1 is a partial list of possible causes of noncardiac and cardiac chest pain in children.

Clinical Manifestations

Idiopathic Chest Pain

No cause can be found in 12% to 85% of patients even after a moderately extensive investigation. In many children with chronic chest pain, an organic cause is less likely to be found. In some of these children, chest pain is resolved spontaneously, and some of them are eventually referred for specialty evaluation.

Noncardiac Causes of Chest Pain

Most cases of pediatric chest pain originate in the organ systems other than the cardiovascular system. Identifiable noncardiac causes of chest pain are found in 56% to 86% of reported cases. Causes of chest pain are found most often on the thorax and respiratory system.

Costochondritis. Costochondritis causes chest pain in 9% to 22% of children with such pain. A single study reported rates as high as 79%. It is more common in girls than boys. Pain is generally sharp, anterior chest pain and usually unilateral but occasionally bilateral. Pain is usually exaggerated by physical activity or breathing. A specific position may also cause the pain. The pain may radiate to the remainder of the chest, back, and abdomen. The pain may be preceded by exercise, an upper respiratory infection, or physical activity. Physical examination is diagnostic; the clinician finds a reproducible tenderness on palpation over the chondrosternal or costochondral junctions. It is a benign condition, but the pain may persist for several months.

TABLE 30-1

FREQUENCY OF CAUSES OF CHEST PAIN IN CHILDREN

Causes

Pediatric Emergency Department or Pediatric Clinic (Data from Six Reports) (%)

Cardiology Clinic (Data from Four Reports) (%)

Idiopathic or cause unknown

12–61

37–54

Musculoskeletal or costochondritis

7–69

1–89

Respiratory or asthma

13–24

1–12

Gastrointestinal or gastroesophageal reflux disease

3–7

3–12

Psychogenic

5–9

4–19

Cardiac

2–5

3–7

From Thull-Freedman J: Evaluation of chest pain in the pediatric patients. Med Clin North Am 94:327-347, 2010.

BOX 30-1 Selected Causes of Chest Pain

Noncardiac Causes

Musculoskeletal

Costochondritis

Trauma to chest wall (from sports, fights, or accident)

Muscle strains (pectoral, shoulder, or back muscles)

Overused chest wall muscle (from coughing)

Abnormalities of the rib cage or thoracic spine

Tetze’s syndrome

Slipping rib syndrome

Precordial catch (Texidor’s twinge or stitch in the side)

Respiratory

Reactive airway disease (exercise-induced asthma)

Pneumonia (viral, bacterial, mycobacterium, fungal, or parasitic)

Pleural irritation (pleural effusion)

Pneumothorax or pneumomediastinum

Pleurodynia (devil’s grip)

Pulmonary embolism

Foreign bodies in the airway

Gastrointestinal

Gastroesophageal reflux

Peptic ulcer disease

Esophagitis

Gastritis

Esophageal diverticulum

Hiatal hernia

Foreign bodies (e.g., coins)

Cholecystitis

Pancreatitis

Psychogenic

Life stressor (death in family, family discord, divorce, failure in school, nonacceptance from peers, sexual molestation)

Hyperventilation

Conversion symptoms

Somatization disorder

Depression

Bulimia nervosa (esophagitis, esophageal tear)

Miscellaneous

Sickle cell disease (vaso-occlusive crisis)

Mastalgia

Herpes zoster

Cardiac Causes

Ischemic Ventricular Dysfunction

Structural abnormalities of the heart (severe aortic or pulmonary stenosis, hypertrophic obstructive cardiomyopathy, Eisenmenger syndrome

Mitral valve prolapse

Coronary artery abnormalities (previous Kawasaki disease, congenital anomaly, coronary heart disease, hypertension, sickle cell disease)

Cocaine abuse

Aortic dissection and aortic aneurysm (Turner’s, Marfan’s, and Noonan’s syndromes)

Inflammatory Conditions

Pericarditis (viral, bacterial, or rheumatic)

Postpericardiotomy syndrome

Myocarditis (acute or chronic)

Kawasaki disease

Arrhythmias (and Palpitations)

Supraventricular tachycardia

Frequent premature ventricular tachycardia or ventricular tachycardia (possible)

Tietze’s syndrome is a rare form of costochondritis characterized by a large, tender, fusiform (spindle-shaped), nonsuppurative swelling at the chondrosternal junction. It usually affects the upper ribs, particularly the second and third costochondral junctions.

Musculoskeletal. Musculoskeletal chest pain is also common in children. The pain is caused by strains of the pectoral, shoulder, or back muscles after exercise; overused chest wall muscle for coughing; or because of trauma to the chest wall from sports, fights, or accidents. A history of vigorous exercise, weightlifting, or direct trauma to the chest and the presence of tenderness of the chest wall or muscles clearly indicate muscle strain or trauma. Abnormalities of the rib cage or thoracic spine can cause mild, chronic chest pain in children.

Respiratory. Respiratory problems are responsible for about 10% to 20% of cases of pediatric chest pain, which may result from lung pathology, pleural irritation, or pneumothorax. A history of severe cough, with tenderness of intercostal or abdominal muscles, is usually present. The presence of crackles, wheezing, tachypnea, retraction, or fever on examination suggests a respiratory cause of chest pain. Pleural effusion may cause pain that is worsened by deep inspiration. Radiographic examination may confirm the diagnosis of pleural effusion, pneumonia, or pneumothorax.

Exercise-induced asthma. The prevalence of exercise-induced asthma is probably underestimated. Exercise triggers bronchospasm in up to 80% of individuals with asthma. The response of the patient with asthma to exercise is quite characteristic. Running for 1 to 2 minutes often causes bronchodilatation in patients with asthma, but strenuous exercise for 3 to 8 minute’s duration causes bronchoconstriction in virtually all subjects with asthma, especially when the heart rate rises to 180 beats/min. Symptoms range from mild to severe and may include coughing; wheezing; dyspnea; and chest congestion, constriction, or pain. They also complain of limited endurance during exercise. Environmental factors such as cold temperature, pollens, and air pollution, as well as viral respiratory infection, can worsen exercise-induced asthma. Exercise-induced bronchospasm provocation test is diagnostic, which is described under Stress Tests in Chapter 6.

Gastrointestinal. Some gastrointestinal disorders, including gastroesophageal reflux disease (GERD), may present as chest pain in children. In addition to chest pain, children with GERD may complain of abdominal pain, frequent sore throat, gagging or choking, extreme pickiness about foods, frequent respiratory problems (e.g., bronchitis, wheezing, asthma), and poor weight gain. The onset and relief of pain in relation to eating and diet may help clarify the diagnosis. The incidence of GERD is higher in patients with Down syndrome, cerebral palsy, and other causes of developmental delay. Esophagitis resulting from gastroesophageal reflux should be suspected in a child who complains of burning substernal pain that worsens with a reclining posture or abdominal pressure or that worsens after certain foods are eaten. Cholecystitis presents with postprandial pain referred to the right upper quadrant of the abdomen and part of the chest.

Young children sometimes ingest foreign bodies, such as coins, which lodge in the upper esophagus, or they may ingest caustic substances that burn the entire esophagus. In such cases, the history makes the diagnosis obvious.

Psychogenic. Psychogenic disturbances account for 5% to 17% of cases and are seen in both boys and girls at equal rates. Often a recent major stressful event parallels the onset of the chest pain such as a death, divorce or separation in the family, a serious illness, a disability, a recent move, failure in school, or sexual molestation. However, a psychological cause of chest pain should not be lightly assigned without a thorough history taking and a follow-up evaluation. Psychological or psychiatric consultation may reveal conversion symptoms, a somatization disorder, or even depression.

Miscellaneous

• The precordial catch (Texidor’s twinge or stitch in the side), a one-sided chest pain, lasts a few seconds or minutes and is associated with bending or slouching. The cause is unclear, but the pain is relieved by straightening and taking a few shallow breaths or one deep breath. The pain may recur frequently or remain absent for months.

• Slipping rib syndrome results from excess mobility of the 8th to 10th ribs, which do not directly insert into the sternum. In many cases, the ligaments that hold these ribs to the upper ribs are weak, resulting in slippage of the ribs, causing pain.

• Some male and female adolescents complain of chest pain caused by breast masses (mastalgia). These tender masses may be cysts (in postpubertal girls) or may be part of normal breast development in pubertal boys and girls.

• Pleurodynia (devil’s grip), an unusual cause of chest pain caused by coxsackievirus infection, is characterized by sudden episodes of sharp pain in the chest or abdomen.

• Herpes zoster is another unusual cause of chest pain.

• Spontaneous pneumothorax and pneumomediastinum are serious but rare respiratory causes of acute chest pain in children; children with asthma, cystic fibrosis, or Marfan’s syndrome are at risk. Inhalation of cocaine can provoke pneumomediastinum and pneumothorax with subcutaneous emphysema.

• Pulmonary embolism, although extremely rare in children, has been reported in female adolescents who use oral contraceptives or have had elective abortions. It has also been reported in male adolescents with recent trauma of the lower extremities and in children with shunted hydrocephalus. It may occur in children with hypercoagulation syndromes. Affected patients usually have dyspnea, pleuritic pain, fever, cough, and hemoptysis.

• Hyperventilation can produce chest discomfort and is often associated with paresthesia and lightheadedness.

Cardiovascular Causes of Chest Pain

Cardiovascular disease is identified as the cause of pediatric chest pain in 0% to 5% of cases. Cardiac chest pain may be caused by ischemic ventricular dysfunction, pericardial or myocardial inflammatory processes, or arrhythmias. A typical anginal pain in adults is located in the precordial or substernal area and radiates to the neck, jaw, either or both arms, the back, or the abdomen. The patient describes the pain as a deep, heavy pressure; the feeling of choking; or a squeezing sensation. Older adolescents are expected to describe the pain this way, but young children may not. Exercise, cold stress, emotional upset, or a large meal typically precipitates anginal pain. Table 30-2 summarizes clinical findings of cardiac causes of chest pain in children for practitioners.

If a noncardiac cause of chest pain is not found and the nature of the pain is consistent with that of cardiac origin, cardiology consultation should be considered. Children with exertional chest pain, especially if it is associated with dizziness or palpitation, should be considered for a possible cardiac cause of chest pain. The electrocardiographic (ECG) and echocardiographic study should demonstrate or rule out most of the chest pain of cardiac origin, except for those associated with cardiac arrhythmias or substance abuse.

Ischemic Myocardial Dysfunction. Congenital heart defects. Severe obstructive lesions, such as aortic stenosis (AS), subaortic stenosis, severe pulmonary stenosis (PS), and pulmonary vascular obstructive disease (Eisenmenger’s syndrome), may cause chest pain. Mild stenotic lesions do not cause ischemic chest pain. Chest pain from severe obstructive lesions results from increased myocardial oxygen demands from tachycardia and increased pressure work by the ventricle. Therefore, the pain is usually associated with exercise and is a typical anginal pain. Cardiac examination often reveals a loud heart murmur best audible at the upper right or left sternal border, usually with a thrill, except in patients with Eisenmenger’s syndrome. The ECG usually shows ventricular hypertrophy with or without “strain” pattern. Chest radiographs may be abnormal in patients with AS or PS with a prominent ascending aorta or main pulmonary artery trunk, respectively. Chest films are definitely abnormal in patients with Eisenmenger’s syndrome, with a marked prominence of the main pulmonary artery segment. Echocardiography and Doppler studies permit accurate diagnosis of the type and severity of the obstructive lesion.

Mitral valve prolapse. Chest pain associated with mitral valve prolapse (MVP) has been reported in about 20% of patients with the condition. The pain is usually a vague, nonexertional pain of short duration located at the apex without a constant relationship to effort or emotion. The pain is presumed to result from abnormal tension on papillary muscles, but the causal relationship between chest pain and MVP remains unclear in children. Occasionally, supraventricular or ventricular arrhythmias may result in cardiac symptoms, including chest discomfort. Thoracoskeletal deformities commonly occur in these children and may cause chest pain. Nearly all patients with Marfan’s syndrome have MVP.

TABLE 30-2

IMPORTANT CLINICAL FINDINGS OF CARDIAC CAUSES OF CHEST PAIN

image

+, Positive; ±, may be present; AP, anteroposterior; AS, aortic stenosis; CHD, congenital heart disease; FH, family history; HOCM, hypertrophic obstructive cardiomyopathy; LPLs, left precordial leads; LVH, left ventricular hypertrophy; MI, myocardial infarction; MVP, mitral valve prolapse; PA, pulmonary artery; PS, pulmonary stenosis; RV, right ventricle; RVH, right ventricular hypertrophy; SEM, systolic ejection murmur; ULSB, upper left sternal border; URI, upper respiratory infection; URSB, upper right sternal border; WPW, Wolff-Parkinson-White.

Cardiac examination reveals a midsystrolic click with or without a late systolic murmur. The midsystolic click becomes more prominent on standing. The ECG may show T-wave inversion in the inferior leads. Two-dimensional echocardiographic findings of MVP in adults are well established, but diagnostic echocardiographic findings of MVP have not been established in children (see Chapter 21).

Cardiomyopathy. Hypertrophic and dilated cardiomyopathies can cause chest pain from ischemia, with or without exercise, or from rhythm disturbances. Cardiac examination reveals no diagnostic findings, but the ECG or chest radiographs are abnormal, leading to further studies. Echocardiographic studies are diagnostic of the conditions (see Chapter 18).

Coronary artery disease. Coronary artery anomalies rarely cause chest pain. They include rare cases of anomalous origin of the left coronary artery from the pulmonary artery (usually symptomatic during early infancy), single coronary artery, coronary artery fistula, aneurysm or stenosis of the coronary arteries as a result of Kawasaki’s disease, or coronary insufficiency secondary to previous cardiac surgery involving the coronary arteries or the vicinity of these arteries.

The pain caused by coronary artery abnormalities is expected to be typical of anginal pain. Cardiac examination may be normal or may reveal a heart murmur (systolic murmur of mitral regurgitation or continuous murmur of coronary artery fistula). The ECG may show myocardial ischemia (ST-segment elevation) or old myocardial infarction. Chest radiographs may reveal abnormalities suggestive of these conditions. Although echo can be helpful, computed tomography or coronary angiography is usually indicated for the definitive diagnosis.

Cocaine abuse. Even children with normal hearts are at risk of ischemia and myocardial infarction if cocaine is used. Cocaine blocks the reuptake of norepinephrine in the central nervous system and peripheral sympathetic nerves. An increase in the sympathetic output and circulating level of catecholamines causes coronary vasoconstriction. Cocaine also induces the activation of platelets in some patients and causes increased production of endothelin and decreased production of nitric oxide. The resulting increase in heart rate and blood pressure, increase in myocardial oxygen consumption, possible increase in platelet activation, and myocardial electrical abnormalities may collectively produce anginal pain, infarction, arrhythmias, or sudden death. History and drug screening help physicians in the diagnosis of cocaine-induced chest pain.

Aortic dissection or aortic aneurysm. Aortic dissection or aortic aneurysm rarely causes chest pain. Children with Turner’s, Marfan’s, and Noonan’s syndrome are at risk.

Pericardial or Myocardial Disease. Pericarditis. Irritation of the pericardium may result from inflammatory pericardial disease; pericarditis may have a viral, bacterial, or rheumatic origin. In a child who had recent open-heart surgery, the cause of the pain may be postpericardiotomy syndrome. Older children with pericarditis may complain of a sharp, stabbing precordial pain that worsens when lying down and improves after sitting and leaning forward. Examination may reveal distant heart sounds, neck vein distention, friction rub, and paradoxical pulse. The ECG may reveal low QRS voltages and ST-T changes, and chest radiographs may show varying degrees of cardiac enlargement and changes in the cardiac silhouette. Diagnosis of pericardial effusion with or without tamponade can be accurately made by echo examination.

Myocarditis. Acute myocarditis often involves the pericardium to a certain extent and can cause chest pain. Examination may reveal fever, respiratory distress, distant heart sounds, neck vein distention, and friction rub. Chest radiographs and the ECG may suggest the correct diagnosis, which can be confirmed by echo examination (see Chapter 19).

Arrhythmias. Chest pain may result from a variety of arrhythmias, especially with sustained tachycardia resulting in myocardial ischemia. Even without ischemia, children may consider palpitation or forceful heartbeats as chest pain. When chest pain is associated with dizziness and palpitation, a resting ECG and a 24-hour Holter monitor should be obtained. Alternatively, an event recorder with telephone transmission device may be used to record the ECG rhythm while the patient experiences symptoms.

Diagnostic Approach

The first goal of evaluating children with a complaint of chest pain is to rule out a cardiac cause of chest pain, which is usually the main concern to the child and parents, and to look for three common noncardiac causes of chest pain—costochondritis, musculoskeletal causes, and respiratory diseases—which account for 45% to 65% of chest pain in children.

A thorough history taking and careful physical examination suffice to rule out cardiac causes of chest pain and often to find a specific cause of the pain. To rule out cardiac causes of chest pain, physicians need chest radiographs and an ECG. (Cardiologists, in addition, obtain an echocardiogram to accomplish the same.) Cardiac causes of chest pain can be ruled out by the nonexertional nature of the pain, negative cardiac examination findings, and normal results of other investigations, with the exception of cardiac arrhythmia as the cause of the pain. Even if physicians cannot find a specific cause of chest pain, it is relatively easy to rule out cardiac causes of chest pain by following the steps outlined below. Most patients and parents will be relieved and satisfied to learn that the heart is not the cause of chest pain. Finding a specific, benign, or noncardiac cause of pain establishes the diagnosis of noncardiac chest pain.

History of Present Illness

The initial history should be directed at determining the nature of the pain in terms of the duration, intensity, frequency, location, and points of radiation. An important history is whether the chest pain occurred during or after heavy physical activities, at rest, or while sitting in class. It is important to remember that ischemic cardiac chest pain is described as a pressure or squeezing sensation, not a sharp pain. Associated symptoms, concurrent or precipitating events, and relieving factors may help clarify the origin of the pain.

The following are some examples of questions to ask.

• When did the pain begin?

• Acute onset of pain (within 48 hours) is more likely to have an organic etiology.

• In young children, a sudden onset of chest pain should raise the possibility of a foreign body (coin or button battery) in the esophagus.

• Those with chronic pain are more likely to be idiopathic or psychogenic, although some children with costochondritis may have chronic pain.

• How often have you had similar pain (frequency and chronicity)?

• What is the location (e.g., specific point, localized or diffuse)?

• How severe is the pain?

• What is the pain like (e.g., sharp, pressure sensation, squeezing)?

• The character of the pain is usually nonspecific in children and does not help much in identifying the cause.

• Although the classic description of cardiac pain in adults is that of pressure, crushing, or a squeezing sensation, it is uncertain whether this classic description is typical in pediatric cases.

• How long does the pain last (seconds, minutes)?

• What triggers the pain (e.g., exercise, eating, trauma, emotional stress)?

• Chest pain precipitated by running or exercise may relate to cardiac disease or more commonly exercise-induced asthma.

• Midsternal or precordial pain that worsens after eating or when lying down may be esophageal.

• History of recent workouts, trauma, or fighting may point to the musculoskeletal system.

• A recent stressful event may be an important clue to a psychogenic etiology of pain (after ruling out organic causes).

• What makes the pain better or worse?

• Pain that worsens with moving, deep breathing, or cough may suggest chest wall pain, pleural pain, or lung pathology.

• Pain that improves by sitting up and leaning forward may be caused by pericarditis.

• Are there associated symptoms, such as cough, fever, syncope, dizziness, or palpitation?

• Pain associated with palpitation or syncope may suggest arrhythmia or other cardiac disease.

• History of fever suggests an infectious process (e.g., pneumonia, myocarditis, pericarditis).

• Has there been an injury while playing, or have the arms been used excessively for any reason?

• Is there any important medical history, such as Kawasaki’s disease, asthma, sickle cell disease, diabetes, or Marfan’s syndrome (or other connective tissue disease)?

• Is there a family history of heart disease, sudden death, or other conditions?

• What treatments for the pain have been tried?

Past and Family Histories

After gaining some idea about the nature of the pain, the clinician should focus on important past and family histories. Examples of questions are as follows.

1. Does the child have any known medical conditions (e.g., congenital or acquired heart disease, cardiac surgery, infection, asthma)?

2. Is the child taking medicines, such as asthma medicines or birth control pills?

3. Has there been recent heart disease, chest pain, or a cardiac death in the family?

4. Does any disease run in the family?

5. What is the patient or family member concerned about?

6. Has the child been exposed to drugs (cocaine) or cigarettes?

Physical Examination

1. A careful general physical examination should be performed before the focus turns to the chest. The clinician should note whether the child is in severe distress from pain, is in emotional stress, or is hyperventilating.

2. The skin and extremities should be examined for trauma or chronic disease. Bruising elsewhere on the body may indicate chest trauma that cannot be seen.

3. The abdomen should be carefully examined because it may be the source of pain referred to the chest.

4. The chest should be carefully inspected for trauma and asymmetry. The chest wall should be palpated for signs of tenderness and subcutaneous air. Special attention should be paid to the possibility of costochondritis as the cause of chest pain, which is a quite common identifiable cause of the pain. Physicians should use the soft part of the terminal phalanx of a middle finger to palpate each costochondral andchondrosternal junction, not with the palm of a hand; using the palm may frequently miss the diagnosis. The pectoralis muscles and shoulder muscles should be examined for tenderness, which may be caused by excessive weightlifting or other work requiring the use of these muscles.

5. The heart and lungs should be auscultated for arrhythmias, heart murmurs, rubs, muffled heart sounds, gallop rhythm, crackles, wheezes, or decreased breath sounds.

6. Finally, the child’s psychological state should be assessed.

Other Investigations

If the three common causes or other identifiable causes of chest pain are not found by physical examination, the clinician should obtain chest radiographs and an ECG and direct his or her attention to the cardiac causes of chest pain listed in Table 30-2, which summarizes important history, physical findings, and abnormalities of chest x-ray films and ECGs for cardiac causes of chest pain.

1. Cardiac examination is done to detect a pathological heart murmur. One must be careful not to interpret commonly occurring innocent murmurs as pathologic.

2. Chest radiographs should be evaluated for pulmonary pathology, cardiac size and silhouette, and pulmonary vascularity.

3. A resting 12-lead ECG should be evaluated for cardiac arrhythmias, hypertrophy, conduction disturbances (including Wolff-Parkinson-White preexcitation), abnormal T and Q waves, and an abnormal QTc interval.

If the pain is nonexertional, the family history is negative for hereditary heart disease (e.g., long QT syndrome, cardiomyopathies, unexpected sudden death), the history is negative for heart disease or Kawasaki’s disease, the cardiac examination is unremarkable, and the ECG and chest radiographs are normal, the chest pain is not likely to be of cardiac origin unless palpitation or dizziness is a prominent accompanying symptom. At this point, the clinician can reassure the patient and family of the probable benign nature of the chest pain. If any of the above aspects are found, a formal cardiac consultation may be indicated. An echocardiographic examination is usually obtained by cardiologists and will most likely rule in or out cardiac causes of chest pain.

If a cardiac cause and the three common noncardiac causes of chest pain are not found, the pain is likely due to a condition in other systems, such as gastrointestinal or respiratory systems, including psychogenic or idiopathic origin. Simple follow-up may clarify the cause. Drug screening for cocaine may be worthwhile in adolescents who have acute, severe chest pain and distress with an unclear cause.

Referral to Cardiologists

The following are some of the indications for referral to a cardiologist for cardiac evaluation.

1. When the history reveals that chest pain is triggered or worsened by physical activities, the pain suggests anginal pain, or chest pain is accompanied by other symptoms such as palpitation, dizziness, or syncope.

2. When there are abnormal findings in the cardiac examination or when abnormalities occur in the chest radiographs or ECG, cardiology referral is clearly indicated. The examiner’s ability to recognize common innocent heart murmurs minimizes the frequency of such referrals.

3. When there is a positive family history for cardiomyopathy, long QT syndrome, sudden unexpected death, or other hereditary diseases commonly associated with cardiac abnormalities

4. High levels of anxiety in the family and patient and a chronic, recurring nature of the pain are also important reasons for referral to a cardiologist.

Management

When a specific cause of chest pain is identified, treatment is directed at correcting or improving the cause.

1. Costochondritis can be treated by reassurance and occasionally by nonsteroidal antiinflammatory drugs (NSAIDs, e.g., ibuprofen) or acetaminophen. Ibuprofen is better than acetaminophen because the former is an antiinflammatory agent and the latter is only analgesic.

a. Ibuprofen 1 mg/kg three to four times a day for 7 days often improves the pain. The same course may be repeated two or three times with a 1-week period of no medicine in between the courses.

b. The weight of backpacks should be reduced to a minimum.

c. Physical activities requiring the use of shoulder girdle muscles should be avoided, which may include sports using arms, push-ups, pull-ups, certain house chores, and others.

2. Most musculoskeletal and nonorganic causes of chest pain can be treated with rest, acetaminophen, or NSAIDs.

3. If respiratory causes of chest pain are found, treatment is directed at those causes. Referral to a pulmonologist should be considered.

4. Exercise-induced asthma is most effectively prevented by inhalation of a β2-agonist 10 to 15 minutes before exercise. Inhaled albuterol usually affords protection for 4 hours. Other antiasthmatic agents have also been reported to be effective as well. Use of a muffler or cold weather mask to warm and humidify air before inhalation also is effective.

5. If gastritis, gastroesophageal reflux, or peptic ulcer disease is suspected, trials of antacids, hydrogen ion blockers, or prokinetic agents (e.g., metoclopramide [Reglan]) are helpful therapeutically (as well as diagnostically).

6. If serious cardiac anomalies, arrhythmias, or exercise-induced asthma is diagnosed, a referral is made to the cardiology or pulmonary service. Cardiac evaluation requires further specialized studies such as echocardiography, an exercise stress test, Holter monitoring, event recorder, or even cardiac catheterization or electrophysiologic study. Depending on the cause, treatment may be surgical or medical.

7. If organic causes of chest pain are not found and a psychogenic etiology is suspected, psychological consultation may be considered.

8. When cocaine-associated chest pain is suspected, one should follow the recent guidelines from the American Heart Association (McCord et al, 2008). If cocaine intoxication is suspected, benzodiazepines are recommended as the primary treatment for anxiety, tachycardia, and hypertension. Aspirin and nitrates continue to be strongly recommended. However, beta-blockers (including agents with mixed α-adrenergic antagonist effects, such as labetalol) are considered contraindicated because the unopposed α-adrenergic effect leads to worsening coronary vasoconstriction and increasing blood pressure. Calcium channel blockers are not recommended; they might increase mortality rates. Early percutaneous coronary intervention is indicated if myocardial infarction is likely the diagnosis.