Overview
Definition:
Chest pain with exertion in children is a symptom that necessitates careful evaluation due to its potential association with serious underlying conditions
Red flags are specific signs and symptoms that raise concern for life-threatening etiologies.
Epidemiology:
While the majority of exertional chest pain in children is benign (musculoskeletal, psychogenic), a significant minority can be due to cardiac, pulmonary, or other serious conditions
Prevalence varies by age and specific underlying causes.
Clinical Significance:
Prompt and accurate identification of exertional chest pain with red flags is critical for timely diagnosis and management of potentially fatal conditions such as acute myocardial infarction, pulmonary embolism, aortic dissection, or severe arrhythmias, thereby improving patient outcomes and preventing sudden cardiac death.
Clinical Presentation
Symptoms:
Pain typically occurs with physical activity and resolves with rest
Chief complaints may include: Sharp or dull chest pain
Radiation of pain to the arm, neck, jaw, or back
Associated symptoms such as shortness of breath (dyspnea)
Palpitations
Dizziness or lightheadedness
Syncope or near-syncope during exertion
Fatigue or reduced exercise tolerance
Nausea or vomiting
Sweating
A history of previous similar episodes.
Signs:
Vital signs may be abnormal during or after exertion, including: Tachycardia or bradycardia
Hypotension
Tachypnea
Physical examination may reveal: Murmurs (new or changing)
Gallop rhythms
Rubs
Signs of heart failure (rales, edema)
Evidence of trauma or musculoskeletal tenderness
Diminished peripheral pulses
Differential cyanosis
Abnormal lung sounds.
Diagnostic Criteria:
No single set of diagnostic criteria exists for exertional chest pain in pediatrics
Evaluation is guided by the presence of red flag symptoms and signs, risk factors, and findings from investigations
Guidelines from cardiology and pulmonology societies are often referenced.
Diagnostic Approach
History Taking:
A detailed history is paramount
Key areas include: Character, location, radiation, duration, and severity of pain
Precipitating and relieving factors, especially exertion
Associated symptoms (dyspnea, palpitations, syncope, nausea, diaphoresis)
Past medical history (congenital heart disease, asthma, sickle cell disease, hyperlipidemia)
Family history (sudden cardiac death, premature coronary artery disease, arrhythmias, connective tissue disorders)
Medications and allergies
Social history (activity level, substance use, emotional stressors)
Red flags to identify: Pain associated with syncope, significant dyspnea, arrhythmias, or diaphoresis during exertion
History of known cardiac or pulmonary disease
Family history of sudden cardiac death or genetic cardiac conditions.
Physical Examination:
A thorough head-to-toe physical examination is essential
Focus on: General appearance (distress, cyanosis)
Cardiovascular examination: Palpation for thrills, auscultation for murmurs, gallops, rubs, rhythm assessment, peripheral pulses
Respiratory examination: Auscultation for breath sounds, crackles, wheezes
Abdominal examination: Palpation for tenderness
Musculoskeletal examination: Palpation of chest wall, assessment of range of motion.
Investigations:
Initial investigations may include: Electrocardiogram (ECG): To identify arrhythmias, ischemia, or structural changes
Chest X-ray (CXR): To assess for cardiomegaly, pulmonary abnormalities (pneumonia, effusion, mass), or rib fractures
Laboratory tests: Complete Blood Count (CBC) for anemia, cardiac biomarkers (troponin, CK-MB) if acute coronary syndrome is suspected, D-dimer if pulmonary embolism is considered
Further investigations based on initial findings and suspicion: Echocardiogram: To assess cardiac structure and function, valvular integrity, and wall motion abnormalities
Holter monitor or event recorder: For suspected arrhythmias
Stress ECG or echocardiogram: To evaluate for exertional ischemia or arrhythmias
Pulmonary function tests (PFTs): For suspected reactive airway disease or other pulmonary pathologies
CT angiography of the chest: If pulmonary embolism is highly suspected
Cardiac MRI: For detailed assessment of cardiac structure, function, and myocardial viability
Coronary angiography: If significant coronary artery disease is suspected (rare in children without specific risk factors).
Differential Diagnosis:
Consider a broad differential diagnosis including: Cardiac causes: Myocardial ischemia (rare, but possible with Kawasaki disease sequelae, anomalous coronary arteries, hyperlipidemia), hypertrophic cardiomyopathy, dilated cardiomyopathy, valvular heart disease (aortic stenosis, mitral regurgitation), pericarditis, myocarditis, arrhythmias (SVT, VT, bradycardia), anomalous coronary arteries
Pulmonary causes: Asthma, exercise-induced bronchoconstriction, pneumonia, pleuritis, pneumothorax, pulmonary embolism
Musculoskeletal causes: Costochondritis, muscle strain, trauma, precordial catch syndrome
Gastrointestinal causes: Gastroesophageal reflux disease (GERD), esophageal spasm
Psychogenic causes: Anxiety, somatic symptom disorder
Other: Sickle cell crisis, cystic fibrosis exacerbation, mediastinitis.
Management
Initial Management:
Immediate management focuses on stabilizing the patient and addressing life-threatening causes
Assess ABCs (Airway, Breathing, Circulation)
Administer oxygen if hypoxic
Obtain IV access
Continuous cardiac monitoring
Rapid transport to a higher level of care if unstable.
Medical Management:
Treatment is directed at the underlying cause
For cardiac ischemia: Aspirin, beta-blockers, nitrates
For arrhythmias: Antiarrhythmics (e.g., amiodarone, beta-blockers, calcium channel blockers), cardioversion/defibrillation
For pulmonary embolism: Anticoagulation (e.g., heparin, LMWH, warfarin)
For asthma: Bronchodilators, corticosteroids
For GERD: Proton pump inhibitors (PPIs), H2 blockers
For pericarditis: NSAIDs, colchicine
For myocarditis: Supportive care, immunosuppression if indicated
For psychogenic pain: Reassurance, psychotherapy, anxiolytics if needed
Always consult pediatric cardiology or pulmonology for specific management plans.
Surgical Management:
Surgical intervention may be required for specific conditions such as: Coronary artery bypass grafting (CABG) or angioplasty for anomalous coronary arteries or severe atherosclerosis
Valvular repair or replacement for significant valvular heart disease
Pericardiectomy for constrictive pericarditis
Repair of congenital cardiac defects
Thoracentesis or chest tube insertion for significant pleural effusion or pneumothorax.
Supportive Care:
Supportive care includes: Pain management with appropriate analgesics
Rest and activity modification as needed
Nutritional support
Psychological support for the child and family
Close monitoring of vital signs and clinical status
Education regarding the condition and management plan.
Complications
Early Complications:
Acute myocardial infarction, stroke, pulmonary infarction, respiratory failure, cardiac tamponade, sudden cardiac death, hemodynamic instability
Worsening of underlying cardiac or pulmonary disease.
Late Complications:
Chronic heart failure, pulmonary hypertension, chronic pain syndrome, psychological sequelae (anxiety, depression), reduced quality of life, recurrent episodes
Long-term sequelae from conditions like Kawasaki disease (coronary aneurysms).
Prevention Strategies:
Prevention focuses on early identification and management of underlying risk factors and conditions
Regular screening for children with known cardiac or pulmonary diseases
Lifestyle modifications to promote cardiovascular health
Prompt evaluation of exertional chest pain, especially with red flag features
Genetic counseling for families with a history of inherited cardiac conditions.
Prognosis
Factors Affecting Prognosis:
Prognosis is highly dependent on the underlying etiology, promptness of diagnosis, and effectiveness of treatment
Children with benign causes generally have an excellent prognosis
Those with serious cardiac or pulmonary pathology have a more guarded prognosis.
Outcomes:
Outcomes range from complete resolution with no long-term effects for benign causes, to significant morbidity or mortality for severe cardiac or pulmonary conditions
Long-term follow-up is crucial for all patients diagnosed with significant underlying pathology.
Follow Up:
Follow-up schedules are tailored to the specific diagnosis
Children with congenital heart disease, arrhythmias, or acquired cardiac conditions require regular cardiology follow-up
Those with pulmonary conditions need pulmonary follow-up
Regular assessment of symptoms, medication adherence, and adherence to activity restrictions are key.
Key Points
Exam Focus:
Always consider cardiac causes of exertional chest pain in pediatrics, even if rare
Red flags: Syncope, significant dyspnea, palpitations, abnormal ECG, family history of SCD
Differentiate between benign (musculoskeletal, psychogenic) and serious (cardiac, pulmonary) etiologies
The role of ECG, echocardiogram, and stress testing in the workup.
Clinical Pearls:
Treat all exertional chest pain in children with a degree of concern until a benign cause is definitively established
Differentiate precordial catch syndrome (sharp, localized, brief pain, unrelated to exertion) from more serious etiologies
Inquire specifically about pain during or immediately after exercise cessation
Consider cardiac causes in athletes with unexplained decreased performance.
Common Mistakes:
Dismissing exertional chest pain as purely psychogenic or musculoskeletal without a thorough workup
Delaying cardiac or pulmonary investigations when red flags are present
Inadequate history taking, especially regarding family history and associated symptoms
Over-reliance on one diagnostic modality without considering the full clinical picture.