OFFICIAL ABP TOPIC:

Distinguish between cardiac and non-cardiac causes of chest pain and evaluate appropriately

BACKGROUND

Chest pain is a common symptom in children and adolescents, often causing significant anxiety for patients and their families due to its association with heart disease in adults. However, the majority of pediatric chest pain cases have benign, non-cardiac etiologies. Distinguishing between cardiac and non-cardiac causes is crucial for appropriate evaluation and management.

EVALUATION HISTORY

HISTORY

Key features in the history that suggest a cardiac etiology include:

• Exertional chest pain or exercise intolerance
• Syncope or near-syncope, particularly during exertion
• Family history of sudden death, cardiomyopathy, or early-onset heart disease
• Known congenital heart disease or Kawasaki disease
• Hypercoagulable state or risk factors for pulmonary embolism

Features more suggestive of non-cardiac etiologies include:

• Musculoskeletal tenderness or reproducible pain with movement
• Acute-onset pleuritic pain with sharp pain in a specific location worse with coughing or breathing
• Gastrointestinal symptoms such as reflux, dysphagia, or epigastric pain
• Respiratory symptoms like cough, wheezing, or dyspnea
• Anxiety, stress, or other psychosomatic complaints

PHYSICAL EXAMINATION

Most children with chest pain have no history suggestive of life-threatening conditions and either a normal physical examination or findings consistent with a musculoskeletal etiology. However, it is important to recognize signs and symptoms of serious cardiac conditions.

Cardiac findings of concern:

• Tachycardia or irregular rhythm
• Murmur, gallop, or rub
• Decreased perfusion or pulse quality
• Elevated jugular venous pressure or peripheral edema

Non-cardiac findings:

• Reproducible chest wall tenderness
• Wheezing, crackles, or decreased breath sounds
• Abdominal tenderness or organomegaly
• Normal exam in patients with idiopathic or psychogenic pain

ANCILLARY STUDIES

• Electrocardiogram (ECG) for suspected cardiac etiology or concerning history/exam findings, which may show arrhythmia, conduction abnormality, chamber enlargement, or ischemic changes
• Echocardiogram for abnormal ECG, pathologic murmur, exertional symptoms, or family history of cardiomyopathy or sudden death
• Holter monitoring or event recorder for suspected arrhythmias
• Exercise stress testing for exertional symptoms
• Cardiac MRI for suspected coronary anomalies or myocarditis
• Chest radiograph for evaluating respiratory causes, cardiac enlargement, or mediastinal masses
• Bedside ultrasound for rapidly assessing pneumothorax or pericardial effusion in unstable patients
• Troponin: Consider if suspecting myocardial infarction or ischemia

For patients with suspected non-cardiac etiologies, additional evaluation may include:

• Barium swallow or endoscopy for gastrointestinal etiologies
• Pulmonary function tests for asthma
• Psychiatry referral for psychogenic causes

DIFFERENTIAL DIAGNOSIS

CARDIAC CAUSES

• Hypertrophic cardiomyopathy: Systolic murmur that increases with Valsalva, abnormal ECG with left ventricular hypertrophy and ST-T wave changes
• Anomalous coronary artery origin: Exertional syncope or chest pain, abnormal ECG with ischemic changes or ventricular arrhythmias
• Myocarditis: Tachycardia out of proportion to fever, gallop rhythm, abnormal ECG with diffuse ST-T wave changes and low QRS voltage
• Pericarditis: Positional chest pain that improves with sitting up and leaning forward, pericardial friction rub, abnormal ECG with diffuse ST elevation and PR depression
• Pulmonary embolism: Tachypnea, hypoxia, right ventricular strain on ECG (abnormal T waves in anterior leads, right axis deviation)
• Aortic dissection: Severe, tearing chest pain radiating to back, associated with connective tissue disorders, widened mediastinum on chest radiograph
• Mitral valve prolapse: Mid-systolic click, late systolic murmur

NON-CARDIAC CAUSES

• Musculoskeletal (costochondritis, muscle strain, slipping rib syndrome): Reproducible tenderness on palpation
• Gastrointestinal (reflux, esophagitis, peptic ulcer disease): Epigastric pain, dysphagia, relief with antacids
• Respiratory (asthma, pneumonia, pleurisy): Cough, wheezing, crackles, pleuritic pain
• Pneumothorax: Acute onset pleuritic pain, decreased breath sounds, hypoxia
• Psychogenic (anxiety, panic attacks, conversion disorder): Associated stress or anxiety, normal physical exam
• Esophageal foreign body: Choking, drooling, wheezing, abnormal chest radiograph
• Esophageal rupture: Severe retrosternal pain, vomiting, subcutaneous emphysema, pneumomediastinum on chest radiograph
• Idiopathic: No clear etiology after thorough evaluation

REFERENCES

https://www.uptodate.com/contents/causes-of-nontraumatic-chest-pain-in-children-and-adolescents

https://www.uptodate.com/contents/nontraumatic-chest-pain-in-children-and-adolescents-approach-and-initial-management