05/16/2016
Pediatric Chest Pain, Is it the Heart? Hassan Farra, MD Assistant Professor, University of Missouri, Department of Child Health-Cardiology
Cardiac cause of pediatric chest pain ?? • 1% • 5% • 10% • 20% • 40%
Chest pain and syncope in children: A practical approach to the diagnosis of cardiac disease. Kevin G. Friedman, MD, and Mark E. Alexander, MD. The journal of pediatrics. Vol 163, No3. 2013.
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• Pediatric chest pain is very common • 650 000 physician visits annually in patients aged 10-21 years • Usually benign (non cardiac) 99% of the cases • May lead to school absences, restriction of activities and causes considerable anxiety in patients and their families Brenner JI, Ringel RE, Berman MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? Pediatr Clin North Am 1984;31:1241-58. Selbst SM, Ruddy RM, Clark BJ, Henretig FM, Santulli T Jr. Pediatric chest pain: a prospective study. Pediatrics 1988;82:319-23.
Musculoskeletal • Costochondritis/costosternal syndrome • Tietze syndrome • Precordial catch (Texidor’s twinge) • Nonspecific or idiopathic chest-wall pain • Slipping rib syndrome • Trauma and muscle strain–overuse injury • Xiphoid pain (xiphoidalgia) • Sickle cell vaso-occlusive crisis • Pectus excavatum or carinatum Pulmonary or Airway-related • Bronchial asthma • Exercise-induced or cough variant asthma • Chronic cough • Bronchitis • Pleurisy • Pneumonia • Pneumothorax • Pulmonary embolism • Acute chest syndrome
Gastrointestinal • Gastroesophageal reflux disease • Esophageal spasm • Peptic ulcer disease • Esophagitis/gastritis • Cholecystitis Cardiac Psychaitric • Anxiety/Panic disorder with or without Hyperventilation • Conversion disorder • Depression • Hypochondriasis • Somataziation Idiopathic Miscellaneous • Fibromylagia • Breast-related conditions • Herpes zoster • Spinal cord or nerve root compression
Saleeb et al. Effectiveness of screening for life threatening chest pain in children. Pediatrics. Vol 128, number 5, 2011
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Kevin G. Friedman, MD, and Mark E. Alexander, MD. The journal of pediatrics. Vol 163, No3. 2013
History • • • • • • • •
Onset Duration Quality Severity Location Radiation Precipitating factors Relieving factors
History Associated symptoms
syncope, palpitations, fever, respiratory, GI , joints Past medical history
asthma, sickle cell disease, Kawasaki disease, cardiac disease, rheumatologic disease, immobility, oral contraceptive use, central catheters, hypercholesterolemia, History of trauma, drug abuse, stress Family history
early/sudden cardiac deaths arrhythmias cardiomyopathy hyperlipidemia connective tissue disorders: Marfan syndrome, Ehlers-Danlos syndrome coagulopathy
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Physical Examination •
Vital signs
•
Dysmorphic features
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Chest inspection, chest wall deformity
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Palpation of the costochondral junctions
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Cardiac exam: hyperdynamic precordium, irregular heart beats, distant heart sounds, heave, abnormal loud second heart sound, systolic clicks or murmurs, gallops, rub, absent femoral pulses
•
Lungs exam: respiratory distress, diminished breath sounds, rales, wheezing, rub, subcutaneous emphysema, hyperventilation
•
Abdominal exam: Epigastric pain, hepatomegaly, ascites, and peripheral edema
Costochondritis • Costosternal syndrome, and anterior chest wall syndrome • Few seconds to a few minutes • Movements and deep breathing aggravate the pain • Multiple areas of tenderness without signs of inflammation • Usually self limited with intermittent exacerbations for months to years
Precordial catch syndrome • Texidor's twinge • The cause is unknown • Brief episodes (seconds to a few minutes) of sharp pain • Localized with the fingertip to one interspace • The pain has a sudden onset, typically at rest or during mild activity • Increases with inspiration often leading to shallow breathing in an effort to alleviate pain
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Cardiac causes of chest pain • • • • • • •
Inflammatory: Pericarditis, Myocarditis Cardiomyopathies: HCM, DCM Coronaries Structural heart disease: MVP, LVOTO Arrhythmias Aortic dissection Pulmonary embolism, PHTN
Pericarditis • Preceded by viral illness • Respiratory, GI symptoms, fever • Chest pain >95% of patients • Friction rub, muffled heart tones • Cardiac tamponade • ECG
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Myocarditis • Preceded by viral illness • Respiratory, GI symptoms, fever • Tachycardia, tachypnea, poor perfusion, diminished heart sounds, a gallop rhythm, murmur of mitral regurgitation • ECG: Tachycardia, non specific ST and T changes, ectopy, low voltages • Elevated Troponin
Cardiomyopathies • Hypertrophic and dilated • Chest pain, exercise intolerance and fatigue • HCM is the first cause of sudden cardiac deaths in adolescents • Murmurs of left ventricular outflow tract (LVOT) obstruction and mitral regurgitation
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Coronaries •
Anginal chest pain
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Tachycardia, tachypnea, diaphoresis, nausea, new murmur or gallop
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ST depression or elevation, T wave changes, Q waves
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Troponin may be elevated
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Congenital anomalies of the coronary artery, coronary artery fistulas, and stenosis or atresia of the coronary artery ostium
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Kawasaki, cardiac surgery, transplant, arteriopathy (Williams)
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Familial hypercholesteremia
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Drugs: Cocaine, sympathomimetics
Coronaries • Coronary artery abnormalities are second only to hypertrophic cardiomyopathy in causing sudden cardiac deaths in adolescents • Chest pain or syncope usually associated with exertion • Sudden death may be the first and only presentation of coronary artery abnormalities
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Arrhythmia • Young children may be unable to describe palpitations and may complain of chest pain and point to the sternum • Atrial, ventricular, SVT, etc.
Pulmonary embolism Pulmonary hypertension • Acute pain, dyspnea • Right ventricular heave and a single loud S2, tricuspid or pulmonary regurgitation murmur • ECG: tachycardia, RV strain, RAD, ICRBBB, S1Q3T3 • D Dimers • CT angio • Echocardiogram
Aortic dissection • Extremely severe and tearing midsternal chest pain radiating to the back • Connective tissue disease • Dilated aorta (bicuspid aortic valve, Turner, idiopathic, familial)
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Structural heart disease Left ventricular outflow obstruction • Harsh systolic murmur • Ejection click Mitral valve prolapse • Midsystolic click • Apical mid-to-late systolic murmur.
Evaluation • • • • • • •
Chest X ray ECG Cardiac enzymes, D Dimers Echocardiogram Stress test Ambulatory ECG: Holter/event monitor Cardiac CT/MRI
Chest radiograph • When suspecting pulmonary disease • Respiratory distress • Pleuritic chest pain • Suspected foreign body
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Electrocardiogram • When chest pain etiology is unclear • When suspecting cardiac causes • Arrhythmia, LVH, RVH, axis deviation, strain pattern, ST changes, T wave changes, Q waves
Echocardiogram • • • • • • •
Pericardial effusion Left-sided obstructive lesions Mitral valve prolapse Cardiomyopathy/myocarditis Pulmonary hypertension Coronary abnormalities Aortic dissection
• Echocardiography is low yield and is considerably more likely to uncover incidental findings than the etiology of chest pain
Stress test • Ischemia • Arrhythmias • Exercise-induced asthma • Extremely low yield in this population, as evidenced by 3 recent studies of more than 600 pediatric patients with chest pain in whom EST detected no cardiac disorders Danduran MJ, Earing MG, Sheridan DC, Ewalt LA, Frommelt PC. Chest pain: characteristics of children/adolescents. Pediatr Cardiol 2008;29: 775-81. Friedman KG, Kane DA, Rathod RH, Renaud A, Farias M, Geggel R, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics 2011;128:239-45. Kyle WB, Macicek SL, Lindle KA, Kim JJ, Cannon BC. Limited utility of exercise stress tests in the evaluation of children with chest pain. Congenit Heart Dis 2012;7:455-9
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Ambulatory ECG • Patients with chest pain associated with palpitations, or syncope
• Boston Children’s Hospital • Children between January 1, 2000, and December 31, 2009, with a complaint of CP • Total of 3700 patients with CP • median age at evaluation: 13.4 years [range: 7–22.3 years] • The median follow-up period was 4.4 years (range: 0.5–10.4 years), for total of 17 886 patient-years of follow-up data • A cardiac cause was determined in 37 cases=1% •
There were no cardiac deaths
Effectiveness of Screening for Life-Threatening Chest Pain in Children. PEDIATRICS Volume 128, Number 5, November 2011
Echos on 38% of patients – Positive finding related to CP 0.8% – 11.1% incidental findings
Stress test on 20.8% of patients Positive finding 0% Abnormal spirometer 11.7% of all stress tests Rhythm monitoring 29.6% – Positive 0.4% Effectiveness of Screening for Life-Threatening Chest Pain in Children. PEDIATRICS Volume 128, Number 5, November 2011
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• Boston Children’s Hospital • Kane et al identified 171 patients with a serious cardiac condition who presented with chest pain over 10 years (41 outpatient and 130 ED) • All patients who presented through outpatient clinics were identifiable by the presence of at least one of the following: • • • •
Exertional chest pain (n = 20), Abnormal physical exam findings (n = 12) Abnormal ECG findings (n = 5), Severe underlying systemic illness (n = 1).
Needles in Hay: Chest pain as the presenting symptom in children with serious underlying cardiac pathology. Kane et al. Congenital heart disease. 2010; 5; 366-373
• Children’s Hospital, MU • Office visits with chest pain from July, 2014 to May, 2016 • 151 patients • Mean age 12.6 years • 83 (55%) females, 68 (45%) males
160 140 120 100 80 60 40 20 0 Patients
ECG
ECHO
Stress
Event
Holter
CT/MRI
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• 1 patient with anomalous coronaries • 1 patient with SVT • Total yield 1.3 % • Incidental findings on ECG: 9.9% • Incidental findings on ECHO: 11.9%
Brothers, Marshall L. Jacobs and the Congenital Heart Registry. Anomalous Aortic Origin of a Coronary Artery: A Report From the Congenital Heart Surgeons Society. World Journal for Pediatric and Congenital Heart Surgery 2014 5: 22
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Evaluation • Chest X ray • ECG
Lung diseases Etiology of the pain is unclear, To “R/O” cardiac disease
• • • •
Echocardiogram Cardiac enzymes, Acute presentation D Dimers Stress test Exercise induced asthma, Work up of a cardiac disease • Ambulatory ECG Palpitations, syncope • Cardiac CT/MRI Myocarditis, coronaries
Indications for echocardiogram Chest pain characteristics
Exertional
Other cardiac symptoms
Syncope, heart failure, palpitations
Systemic symptoms and signs Fever Drug use
Cocaine, sympathomimetics
Abnormal cardiac exam Abnormal ECG History
Cardiac disease, cardiac surgeries, Kawasaki, transplant
Family or personal history Diseases that predispose to a cardiac cause
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Chest pain and syncope in children: A practical approach to the diagnosis of cardiac disease. Kevin G. Friedman, MD, and Mark E. Alexander, MD. The journal of pediatrics. Vol 163, No3. 2013.
Kevin G. Friedman, MD, David A. Kane, MD, Rahul H. Rathod, MD, Ashley Renaud, RN, Michael Farias, MD, Robert Geggel, MD, David R. Fulton, MD, James E. Lock, MD, and Susan F. Saleeb, Md. Management of Pediatric Chest Pain Using a Standardized Assessment and Management Plan. PEDIATRICS Volume 128, Number 2, August 2011
2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology. JACC VOL. 64, NO. 19, 2014
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2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology. JACC VOL. 64, NO. 19, 2014
Summary • Chest pain is a common symptom in children and adolescents • The underlying cause is typically benign • Cardiac causes are rare but may be serious • Cardiology consultation is warranted in patients with exertional chest pain, abnormal cardiac exam, abnormal ECG, concerning personal or family history, or with associated symptoms
REFERENCES Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: a prospective study. Pediatrics 1988; 82:319. Driscoll DJ, Glicklich LB, Gallen WJ. Chest pain in children: a prospective study. Pediatrics 1976; 57:648. Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr 2013; 163:896. Danduran MJ, Earing MG, Sheridan DC, et al. Chest pain: characteristics of children/adolescents. Pediatr Cardiol 2008; 29:775. Selbst SM. Chest pain in children. Pediatrics 1985; 75:1068. Selbst SM. Approach to the child with chest pain. Pediatr Clin North Am 2010; 57:1221. 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; 43:231. Collins SA, Griksaitis MJ, Legg JP. 15-minute consultation: a structured approach to the assessment of chest pain in a child. Arch Dis Child Educ Pract Ed 2014; 99:122. Porter GE. Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature. Pediatrics 1985; 76:810. Coleman WL. Recurrent chest pain in children. Pediatr Clin North Am 1984; 31:1007. Evans DA, Wilmott RW. Pulmonary embolism in children. Pediatr Clin North Am 1994; 41:569. Asnes RS, Santulli R, Bemporad JR. Psychogenic chest pain in children. Clin Pediatr (Phila) 1981; 20:788. Kashani JH, Lababidi Z, Jones RS. Depression in children and adolescents with cardiovascular symptomatology: the significance of chest pain. J Am Acad Child Psychiatry 1982; 21:187. Pantell RH, Goodman BW Jr. Adolescent chest pain: a prospective study. Pediatrics 1983; 71:881. Nakao K, Ohgushi M, Yoshimura M, et al. Hyperventilation as a specific test for diagnosis of coronary artery spasm. Am J Cardiol 1997; 80:545. Kane DA, Fulton DR, Saleeb S, et al. Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology. Congenit Heart Dis 2010; 5:366. Saleeb SF, Li WY, Warren SZ, Lock JE. Effectiveness of screening for life-threatening chest pain in children. Pediatrics 2011; 128:e1062. Friedman KG, Kane DA, Rathod RH, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics 2011; 128:239. Glassman MS, Medow MS, Berezin S, Newman LJ. Spectrum of esophageal disorders in children with chest pain. Dig Dis Sci 1992; 37:663. Selbst SM, Ruddy R, Clark BJ. Chest pain in children. Follow-up of patients previously reported. Clin Pediatr (Phila) 1990; 29:374. Rowland TW, Richards MM. The natural history of idiopathic chest pain in children. A follow-up study. Clin Pediatr (Phila) 1986; 25:612. UpToDate
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