Evaluation of Chest Pain in the Pediatric Patient

1
Evaluation of Chest Painin the Pediatric Patient

• Jennifer Thull Thull-Freedman, MD, MSCI,
  FAAP(PEM)
• Assistant Professor of Paediatrics
• University of Toronto
• Co Co-director, PEM Clinical Fellowship
• The Hospital for Sick Children

2
From my residency

• A 12-year year-old previously healthy boy
  presented to the ED after first seeking care at
  the neighborhood fire department for chest pain
• Told to take a warm bath for muscle aches
• Arrived several hours later alert but in pain
• HR130, BP not done
• CXR obtained
• Child waited in room for CXR to be reviewed

3
From my residency

• Child suddenly became unresponsive and pulseless
• Unable to be resuscitated
• CXR reviewed during resuscitation showed
• widened mediastinum
• Autopsy revealed dissection of the aorta

4
However

• Most cases of chest pain in children are not
  related to serious pathology
• History and physical exam often sufficient
  evaluation

5
The challengeObjectives

• Review relevant literature
• Review common causes of chest pain in children
• Discuss uncommon but serious causes
• Present an approach to the child with chest pain
• Summarize take take-home points

6
Etiology of chest pain in kids

• Very few studies
• Most retrospective
• Variable inclusion/exclusion criteria
• Limited detail provided

7
Selbst et al

• Objectives
• Identify causes of chest pain in children
• Assess value of echocardiogram
• Prospective
• Enrolled all patients with chest pain
• ECG and echo offered to those with ill
  ill-defined or suspected cardiac etiology
• PediatricsPediatrics1988 82 3191988
  319--323323

8
Selbst et al.

• Population
• 407 patients
• Philadelphia, Pennsylvania
• Median age 12.5 years
• 55 female, 90 African African-American
• 43 acute pain lt48 hours
• Did not exclude known disease
• PediatricsPediatrics1988 82 3191988
  319--323323

9
Selbst et al.

• ECG ECGs in 191/235 children
• 31 abnormal (16)
• 27 minor or previously known findings
• 3 dysrhythmias detected on physical exam
• 1 with known SLE had findings of pericarditis
• PediatricsPediatrics1988 82 3191988
  319--323323

10
Selbst et al.

• Echocardiograms in 139/235
• 17 abnormal (12)
• 12 mitral valve prolapse (8.6)
• Similar prevalence to general population
• 2 pericardial effusion
• 2 mitral valve regurgitation
• 1 poor LV function
• PediatricsPediatrics1988 82 3191988
  319--323323

11
Selbst et al.

• Chest radiographs in 137/407
• 37 abnormal (27)
• Most frequent infiltrates, atelectasis,
  hyperinflation
• 1 pneumothorax in a child with Marfan Marfans
  syndrome
• 1 clavicle fracture suspected clinically
• 1 child with SLE had pleural effusion, large
  heart
• PediatricsPediatrics1988 82 3191988
  319--323323

12
Selbst et al.

• Organic disease related to
• Age lt12 years
• Pain awakening child from sleep
• Acute onset
• Abnormal physical exam
• Not related to description or location of pain
• PediatricsPediatrics1988 82 3191988
  319--323323

13
Selbst et al. 2

• 6-month follow follow-up of 149/407 patients
• 43 had intermittent or persistent pain
• No significant disease identified
• 1 mitral valve prolapse
• 1 gastrointestinal disease
• 3 asthma
• Conclusion
• HP sufficient for identifying majority of
  significant etiologies
• Clinical PedsPeds1990 29 3741990 374--77

14
Rowe et al.

• Chest X X-rays done in 50
• 18/161 with positive result
• 15 infiltrates
• 2 pneumomediastinum
• 1 pneumothorax
• ECG done in 18
• 2/60 with significant new findings
• Tachycardia and ST changes suggested myocarditis
• WPW
• CMAJCMAJ1990 1433881990 388--9494

15
Massin et al.

• 9 cases cardiac etiology in 168 PED patients
• 3 SVT
• 2 MVP
• 4 sick sinus
• 1 myocarditis
• 1 pericarditis
• 1 cardiac hemochromatosis with ß-thalassemia
• 5 cases cardiac etiology in 69 card. clinic
  patients
• 5 SVT
• Clin Pediatr 200443231 231

16
Massin et al.

• Results
• Palpitations or abnormal auscultation predicted
  all
• cases of cardiac disease
• Conclusions
• Chest pain in children usually benign
• History and physical usually sufficient
• Laboratory testing guided by HP
• Clin Pediatr 200443231 231-

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Limitations of current literature

• Small numbers for characterizing rare events
• Limited detail
• Children with known disease not excluded
• Lack of follow follow-up
• No evidence evidence-based guidelines

18
Differential Diagnosis

• Chest wall
• Trauma
• Costochondritis
• Precordial catch
• Slipping rib
• Infection
• Mastalgia
• Zoster
• Gastroesophageal
• Reflux
• Foreign body
• Pulmonary
• Asthma
• Pneumonia/effusion
• Pneumothorax
• Pleurisy
• Pulmonary embolus
• Malignancy
• Hematologic

19
Differential Diagnosis

• Cardiac
• Angina
• Coronary abnormalities
• Hypercoagulable state
• Cocaine
• Obstructive heart disease
• IHSS, aortic stenosis
• Pericardial effusion/pericarditis
• Arrhythmias
• Myocarditis
• Aortic aneurysm

20
Cases

• Case
• A 12-year year-old girl presents to the emergency
  department with chest pain for 2 days
• Started gradually
• Worse with deep breath
• Had URTI last week
• Afebrile
• Tender on both sides of sternum
• Remainder of physical exam normal

21
Costochondritis

• Inflammation of costochondral cartilage
• Cause
• Overuse
• Preceding URTI with cough
• Idiopathic
• Sharp pain, worse with movement
• All ages
• Tenderness over costochondral joints

22
Case

• A 10 10-year year-old boy presents to the ED with
  recurrent episodes of left chest pain.
• Feels like a sudden stab
• Cant take a deep breath
• Lasts 2 2-3 minutes
• Occurs at rest
• Not reproducible
• Normal physical exam

23
Precordial Catch Syndrome

• Texidors twinge
• Sudden, brief
• Occurs at rest
• Localized
• Sharp
• Exacerbated by deep breath
• No associated symptoms
• No physical findings

24
Case

• A 6 6-year year-old girl comes to the emergency
  department after having chest pain at home.
• Stopped playing, became clingy, said chest hurt
• Mom thought she looked pale
• Now looks and feels better
• HR110, normal physical exam

25
SVT

• In children gt1 year
• 82 present with palpitations
• 14 with pain
• 14 perspiration
• 14 dizzy
• 4 pallor
• 1-3 of chest pain complaints in ED
• 6 of chest pain referred to cardiologist
• Median time from symptoms to diagnosis 138d

26
Case

• A 13 13-year year-old boy presents to the
  emergency department with sudden severe chest
  pain
• Sharp pain in anterior chest
• Appears anxious
• BP 80/40 in right arm
• Diastolic murmur

27
Marfan syndrome

• Caused by fibrillin gene mutation
• Manifestations
• Musculoskeletal Tall, long limbs and fingers,
  pectus
• Ocular Lens dislocation
• Cardiovascular Aortic root dilation, MVP
• Pulmonary Spontaneous pneumothorax
• 50 have aortic root dilation by age 10 years
• 90 have aortic root dilation by age 20 years

28
Aortic dissection

• Children at risk
• Marfan syndrome
• Ehlers-Danlos
• Coarctation
• Aortic stenosis
• Turner syndrome
• Endocarditis
• Cocaine use

29
Case

• A 17-year year-old female presents to the ED with
  chest pain that has lasted for 1 hour
• Pain began during soccer practice
• Has happened previously with exercise
• Midsternal, squeezing, radiates to left arm
• PMH Admitted to hospital for FUO at age 2 years

30
Kawasaki Disease

• Acute febrile vasculitis of childhood
• Features
• Fever (gt39 degrees for 5 days)
• Non Non-exudative conjunctivitis
• Erythema of oral mucosa and tongue
• Erythema and swelling of hands and feet
• Cervical adenitis gt1.5 cm
• Rash
• Leading cause of acquired heart disease in kids

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Cardiac sequelae of KD

• Acute and subacute
• Myocarditis (50 of patients)
• Pericarditis
• Mitral, aortic insufficiency
• Arrhythmias
• Coronary aneurysms
• 20 20-25 if untreated
• 5 if treated with IVIG
• Appear 7 days to 4 weeks after onset of fever

32
Cardiac sequelae of KD

• Long-term follow follow-up (gt 10 years) of 594
  untreated patients
• IVIG treatment standard since late 1980 1980s
• 24.6 had coronary aneurysms
• 49 had regression
• 19 developed stenosis (4 of total)
• 8 developed myocardial infarction (2 of total)
• Circulation1996941379-85

33
Myocardial ischemia in kids

• Anomalous coronary arteries
• Prevalence 21000
• Anomalous origin of L coronary from pulm. Artery
• Presents in first months of life
• Irritability, heart failure, cardiac enlargement
• Anomalous origin from incorrect sinus of Valsalva
• Presents later in childhood
• Compression between aorta and pulm Artery
• Hypoplastic coronary arteries

34
Myocardial ischemia in kids

• Sickle cell disease
• Myocardial infarction uncommon but described
• Perfusion defects in 5 children studied in a
  Paris sickle cell clinic ( Arch Dis Child
  200489359 359-62)
• Microvascular occlusion of small vessels
• Exchange transfusion may be helpful for acute
  ischemia ( Pediatrics 2003111e183 e183-7)

35
Myocardial ischemia in kids

• Nephrotic syndrome
• Thrombotic occlusion of coronary arteries
• Long Long-standing diabetes mellitus
• Familial hypercholesterolemia
• SLE, Antiphospholipid antibody syndromes
• Cardiac transplant
• Cocaine abuse

36
Case

• A 16-year year-old boy presents to the emergency
  department after fainting at a track meet
• Remembers having chest pain during his race
• Father died suddenly in his 30 30s
• Systolic murmur on exam

37
Hypertrophic cardiomyopathy

• Autosomal dominant
• Symptoms in 2 2nd nd decade
• May present with angina angina-like pain or
  syncope
• Impaired diastolic relaxation, increased O O2
  demand
• Risk of sudden death 6 in children

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Hypertrophic cardiomyopathy

• Case
• A 6-year year-old girl presents to the ED with
  cough for 3 weeks and chest pain for 1 week
• Feels very tired
• Illness began with URTI 3 weeks ago
• Afebrile
• Heart rate 160
• Liver palpable 3 cm below RCM

39
Myocarditis

• Usually viral etiology
• Enterovirus (coxsackie), adenovirus
• Presentation
• Heart failure
• Chest pain
• More likely in older kids and adults
• Ischemia or concurrent pericarditis

40
Myocarditis

• Physical findings
• Tachycardia, tachypnea
• Poor perfusion
• Muffled heart sounds, S3, murmur
• Hepatomegaly
• CXR
• Cardiomegaly
• Pulmonary edema

41
Myocarditis

• ECG
• Sinus tachycardia
• Decreased voltages (lt5 mm) limb leads
• LVH
• Prolonged PR interval, prolonged QT interval
• Echocardiogram
• Hypokinesis, impaired function

42
Hypertrophic cardiomyopathy

• Case
• A 6-year year-old girl presents to the ED with
  cough
• for 3 weeks and chest pain for 1 week
• Feels very tired
• Illness began with URTI 3 weeks ago
• Afebrile
• Heart rate 160
• Liver palpable 3 cm below RCM

43
Pericarditis

• Infectious etiology common in children
• Pain
• More common in older children and adolescents
• Worse when supine, relieved by leaning forward
• Physical findings
• Friction rub if effusion small
• Muffled heart sounds, pulsus paradoxus if large

44
Pericarditis

• ECG
• Low voltages
• ST elevation
• Usually leads I, II, V5, V6
• Electric alternans
• Produced by swinging motion of heart within
  effusion

45
Case

• A 9-year year-old obese boy is brought to the ED
  at
• 11 pm complaining of chest pain since dinner
  preventing him from sleeping
• Has been having episodes for few weeks
• Described as burning
• Worse after big meals and when lying down
• Normal physical exam

46
Gastroesophageal Reflux

• Berezin et al.
• 27 children 8 8-20 years with idiopathic chest
  pain all received EGD, manometry, pH monitoring
• Not blinded, no control group
• Results 78 had gastroesophageal cause
• 16 of 27 (59) had esophagitis
• 4 of 27 (15) had gastritis
• 1 of 27 (4) with abnormal manometry

47
Gastroesophageal Reflux

• Accounts for 5 5-10 of PED chest pain visits
• Classic pain is temporally associated with meals
• Burning, retrosternal
• Trial of antacid, H2RA, PPI is appropriate
• Consider pH probe if diagnostic testing needed

48
Case

• A 3 3-year year-old boy is evaluated in the
  emergency department with chest pain for several
  hours
• Points to sternal notch
• Drooling
• Refusing juice
• Afebrile, well well-appearing
• Breath sounds equal

49
Esophageal foreign body

• Case
• An 8 8-year year-old boy is brought to the ED
  directly
• from a hockey practice during which he said his
  chest hurt and he couldn couldnt breathe
• Several similar episodes
• Feeling better since arrival to ED
• Tight cough
• Normal breath sounds, no murmur
• Normal CXR and EKG

50
Asthma

• May account for 10 10-20 chest pain in kids
• Personal or family history atopic conditions
• Associated with cough
• May be worse at night or with exercise
• Wheezing not always detectable
• Trial of bronchodilator
• Consider PFT for pain with exercise

51
Case

• A 17 17-year year-old boy presents to the
  emergency department with right chest pain
• Just returned hours ago from vacation in Cozumel
• Pain began one day ago
• Progressive dyspnea during flight home
•  

52
Pneumothorax/pneumomediastinum

• Children at risk
• Asthma, bronchiolitis
• Barotrauma
• Cough, choking, vomiting
• Crack, cannabis
• Cystic fibrosis
• Marfan syndrome
• Tall male teenagers

53
Case

• A 15-year year-old girl presents to the ED with
  chest
• pain
• Present for several days
• Reports feeling dizzy and short of breath
• Not associated with exercise
• Physical exam unremarkable
• Grandmother died last week of heart attack

54
Psychogenic

• Psychogenic
• 5-20 of chest pain in children
• More common in adolescents
• Recent or current stressful situation
• Family illness, especially cardiovascular
• Family history of chest pain
• Other somatic and sleep complaints
• Depression

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The approach History

• Description of pain
• Not as reliable in children as in adults
• Precipitating factors
• Exertion
• Eating
• Deep breathing
• Muscle use
• Trauma
• Emotional stress

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The approach History

• Frequency and chronicity
• Associated symptoms
• Fever
• Cough
• Shortness of breath
• Syncope
• Dizziness
• Palpitations

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The approach History

• The approach History
• Past medical history
• Known heart disease
• Asthma or atopic conditions
• Prothrombotic conditions
• Cancer
• SLE
• Nephrotic syndrome
• Medications and drugs
• Family history

58
The approach Physical exam

• General appearance
• Body habitus
• Vital signs
• Chest wall palpation
• Auscultation
• Abdomen
• Peripheral perfusion

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Red flags

• Pain associated with exercise, palpitations, or
  syncope
• Shortness of breath
• Pain limits daily activities or disturbs sleep
• Substance abuse
• Presence of prothrombotic conditions
• PMH consistent with Kawasaki disease
• Family history of sudden death or early cardiac
  death
• Abnormal vital signs or physical findings

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The approach

• Further evaluation
• CXR
• ECG
• Holter monitor
• Echocardiogram
• Cardiology consultation
• Therapeutic trials

61
Summary

• Chest pain in pediatrics usually due to benign,
• identifiable etiology
• Cardiac and other life life-threatening causes of
• chest pain rare but do exist
• Often can be ruled out by history and physical
  exam
• Diagnostic tests appropriate in presence of red
  flags