Overview
Definition:
Chest pain in adolescents is a common presenting symptom with a broad differential diagnosis
It is crucial to distinguish benign, often musculoskeletal causes from rare but potentially life-threatening cardiac etiologies.
Epidemiology:
Chest pain is reported by 10-30% of adolescents
Musculoskeletal causes account for the vast majority (up to 90%) of cases, with cardiac causes being significantly rarer, typically less than 1%
Risk factors for cardiac causes include family history of early cardiac disease, congenital heart disease, and certain genetic syndromes.
Clinical Significance:
Accurate differentiation is vital to avoid unnecessary anxiety, investigations, and interventions for benign conditions, while ensuring timely diagnosis and management of serious cardiac pathology
Understanding typical presentations and red flags is key for effective patient care and successful examination preparation for DNB and NEET SS.
Clinical Presentation
Symptoms:
Adolescent chest pain may manifest as sharp, stabbing, or dull aching pain
It can be pleuritic, exacerbated by breathing or movement
Duration can range from brief episodes to persistent discomfort
Associated symptoms might include cough, fever, limb pain, or joint swelling
Cardiac causes can present with exertional dyspnea, palpitations, syncope, or diaphoresis.
Signs:
Physical examination may reveal localized tenderness to palpation over the chest wall, costochondral joints, or intercostal muscles in musculoskeletal pain
Examination of the cardiovascular system should focus on heart sounds (murmurs, rubs), rhythm, peripheral pulses, and presence of edema
Pulmonary examination assesses for breath sounds, crackles, or wheezes.
Diagnostic Criteria:
There are no strict diagnostic criteria for most non-cardiac chest pain in adolescents
Diagnosis is primarily clinical, based on history and physical examination, often supported by exclusion of cardiac causes through appropriate investigations
Cardiac causes are diagnosed based on established criteria for specific conditions like myocarditis, pericarditis, or coronary artery anomalies.
Diagnostic Approach
History Taking:
Detailed history is paramount
Inquire about pain characteristics (location, quality, duration, radiation, exacerbating/alleviating factors), associated symptoms, recent trauma or illness, physical activity, family history of cardiac disease, and any substance use
Red flags for cardiac causes include exertional pain, syncope, palpitations, a history of Kawasaki disease or rheumatic fever, and known congenital heart disease.
Physical Examination:
A thorough physical examination should include vital signs, assessment of the chest wall for tenderness or abnormalities, and a complete cardiovascular and pulmonary examination
Palpation of the precordium, auscultation for murmurs, rubs, or gallops, and assessment of peripheral pulses are essential.
Investigations:
Initial investigations are often guided by suspicion of cardiac pathology
Electrocardiogram (ECG) is fundamental to assess for arrhythmias, ischemia, or pericarditis
Chest X-ray can identify pulmonary pathology (pneumonia, pneumothorax) or cardiomegaly
Cardiac enzymes (troponin I/T) are indicated if acute coronary syndrome or myocarditis is suspected
Echocardiography is crucial for assessing cardiac structure and function
In select cases, Holter monitoring, stress testing, or cardiac MRI may be warranted.
Differential Diagnosis:
Common differentials include musculoskeletal pain (costochondritis, muscle strain, Tietze syndrome), respiratory causes (pneumonia, pleurisy, asthma, pneumothorax), gastrointestinal causes (GERD, esophageal spasm), psychological causes (anxiety, panic attacks), and cardiac causes (myocarditis, pericarditis, coronary artery anomalies, hypertrophic cardiomyopathy, arrhythmias, exertional ischemia)
Rare but serious causes include pulmonary embolism and trauma.
Management
Initial Management:
The initial management focuses on risk stratification and pain relief
For suspected musculoskeletal pain with no red flags, reassurance and symptomatic treatment are often sufficient
If cardiac etiology is suspected, immediate ECG and cardiac biomarker assessment are indicated, and the patient should be monitored closely.
Medical Management:
For musculoskeletal chest pain, management involves analgesics like acetaminophen or NSAIDs
Topical analgesics may also be helpful
For cardiac conditions, treatment varies widely: anti-inflammatories for pericarditis, supportive care and potentially IV inotropes/vasopressors for severe myocarditis, antiarrhythmics for arrhythmias, and anticoagulation for pulmonary embolism
Specific cardiac disease management follows established protocols.
Surgical Management:
Surgical intervention is rarely required for primary chest pain in adolescents unless related to underlying cardiac pathology (e.g., repair of congenital anomalies, intervention for anomalous coronary arteries) or complications like tension pneumothorax requiring chest tube insertion.
Supportive Care:
Supportive care includes ensuring adequate pain control, emotional support, and reassurance
For cardiac causes, prolonged monitoring, rest, and activity restrictions may be necessary
Education for the adolescent and family about the diagnosis and prognosis is crucial.
Complications
Early Complications:
Rare complications of serious cardiac etiologies include arrhythmias, heart failure, tamponade, and sudden cardiac death
Musculoskeletal pain rarely leads to acute complications but can cause chronic discomfort and anxiety.
Late Complications:
Late complications of cardiac disease can include dilated cardiomyopathy, chronic heart failure, or recurrent pericarditis
Chronic musculoskeletal pain can impact quality of life and activity levels.
Prevention Strategies:
Preventing serious complications involves prompt identification and management of cardiac conditions
For musculoskeletal pain, education on proper posture, avoiding overuse, and appropriate stretching can help prevent recurrence.
Prognosis
Factors Affecting Prognosis:
Prognosis is generally excellent for benign musculoskeletal chest pain
For cardiac causes, prognosis depends heavily on the underlying condition, promptness of diagnosis, and adherence to treatment
Conditions like myocarditis and pericarditis often have good outcomes, but severe cases or those with significant fibrosis can lead to chronic dysfunction.
Outcomes:
Most adolescents with non-cardiac chest pain recover fully with symptomatic treatment and reassurance
Cardiac causes have variable outcomes, ranging from complete recovery to chronic management of heart disease.
Follow Up:
Follow-up is typically not required for uncomplicated musculoskeletal chest pain
For adolescents with confirmed cardiac pathology, regular cardiology follow-up is essential to monitor disease progression, treatment effectiveness, and potential complications, often for many years.
Key Points
Exam Focus:
Focus on differentiating benign from serious causes
Master red flag symptoms and signs for cardiac involvement in adolescents
Understand the role of ECG, echo, and cardiac enzymes in the workup
Differentiate common pediatric chest pain etiologies.
Clinical Pearls:
Always consider the psychosocial aspect of chest pain in adolescents
anxiety and stress are common contributors
A good history can often lead to a diagnosis without extensive investigations, especially for musculoskeletal pain
Do not dismiss chest pain in adolescents
a systematic approach is crucial.
Common Mistakes:
Over-investigation of benign musculoskeletal pain, leading to patient anxiety and increased healthcare costs
Conversely, underestimating the possibility of cardiac causes, especially in those with subtle risk factors or atypical presentations, leading to delayed diagnosis and potentially fatal outcomes.