Overview
Definition:
Chest pain in adolescents is a common presentation with a broad differential diagnosis, ranging from benign musculoskeletal or gastrointestinal causes to serious cardiac etiologies
A thorough evaluation is crucial to identify potentially life-threatening conditions, necessitating timely cardiology consultation when cardiac involvement is suspected.
Epidemiology:
Chest pain accounts for 1-3% of all pediatric emergency department visits
While cardiac causes are rare (estimated <5% of cases), they carry significant morbidity and mortality
Prevalence varies by age and risk factors, with higher incidence in older adolescents and those with a family history of cardiac disease or known cardiac conditions.
Clinical Significance:
Accurate assessment and timely referral for adolescent chest pain are vital to prevent misdiagnosis, delayed treatment, and potential adverse cardiac events
Understanding the triggers for cardiology consultation ensures appropriate management and improves patient outcomes
This topic is frequently tested in DNB and NEET SS examinations for pediatric residents.
Clinical Presentation
Symptoms:
Substernal or precordial pain
Sharp, stabbing, or pressure-like pain
Radiation to jaw, arm, or back
Dyspnea or shortness of breath
Palpitations
Syncope or near-syncope
Diaphoresis
Nausea or vomiting
Associated fever or cough (suggesting non-cardiac causes)
Pain related to exertion or emotion
Pain exacerbated by deep breathing or positional changes.
Signs:
Tachycardia or bradycardia
Irregular heart rhythm
Murmurs, rubs, or gallops on auscultation
Jugular venous distension
Peripheral edema
Pallor or cyanosis
Apprehension or distress
Abnormal vital signs (hypotension, tachypnea)
Muffled heart sounds
Signs of poor perfusion.
Diagnostic Criteria:
No single diagnostic criterion exists for all causes
Diagnosis relies on clinical assessment, history, physical examination, ECG, cardiac biomarkers, and imaging
Red flags for potential cardiac causes include exertional onset, association with syncope, radiation to the left arm/jaw, family history of premature CAD or sudden cardiac death, presence of a murmur, or abnormal ECG findings
Consult cardiology when these red flags are present or when other serious causes are ruled out and cardiac origin is suspected.
Diagnostic Approach
History Taking:
Detailed pain characteristics (onset, duration, location, character, radiation, alleviating/aggravating factors)
Associated symptoms (dyspnea, palpitations, syncope)
Past medical history (congenital heart disease, Kawasaki disease, myocarditis, arrhythmias, syncope)
Family history (sudden cardiac death, arrhythmias, hyperlipidemia, cardiovascular disease)
Medications and substance use (cocaine, stimulants)
Recent illnesses or infections
Activity level and relation to exercise
Emotional stressors.
Physical Examination:
Full cardiovascular examination: assess heart rate, rhythm, and character of pulses
Auscultate heart sounds for murmurs, rubs, gallops
Palpate precordium for thrills or heaves
Assess for jugular venous distension, peripheral edema
Examine lungs for breath sounds
Assess for signs of systemic illness, fever, or distress
Evaluate for musculoskeletal tenderness.
Investigations:
Electrocardiogram (ECG): assess for ST-segment changes, T-wave abnormalities, arrhythmias, conduction delays, Q waves
Cardiac biomarkers: Troponin I/T (elevated in myocardial injury), CK-MB
Chest X-ray: assess for cardiomegaly, pulmonary edema, pleural effusion, mediastinal abnormalities
Echocardiogram: assess cardiac structure and function, wall motion abnormalities, valvular function, pericardial effusion
Holter monitor: for suspected arrhythmias
Cardiac MRI: for structural abnormalities, inflammation, or scarring
Coronary angiography: for suspected coronary artery anomalies or vasculitis.
Differential Diagnosis:
Cardiac: Myocarditis, pericarditis, pericardial effusion, arrhythmias, congenital heart disease (e.g., anomalous coronary artery), hypertrophic cardiomyopathy, valvular heart disease, coronary artery spasm, myocardial infarction (rare)
Non-cardiac: Musculoskeletal pain (costochondritis, muscle strain), gastrointestinal (GERD, esophagitis, peptic ulcer disease), respiratory (pneumonia, pleuritis, asthma), psychiatric (anxiety, panic disorder), trauma, herpes zoster.
When To Consult Cardiology
Red Flags:
Chest pain associated with exertion
Syncope or near-syncope
Palpitations
Family history of sudden cardiac death or cardiomyopathy
Presence of a new or significant murmur
Abnormal ECG findings suggestive of ischemia, arrhythmia, or chamber enlargement
Suspicion of myocarditis or pericarditis
Pain radiating to the jaw or left arm
Persistent or worsening chest pain.
Specific Conditions Requiring Consult:
Known congenital heart disease
History of Kawasaki disease with coronary artery abnormalities
Known arrhythmias
Suspected hypertrophic cardiomyopathy
Suspected anomalous coronary artery origin
Persistent chest pain without a clear non-cardiac cause
Any suspicion of cardiac ischemia or infarction.
Guidelines For Referral:
Consult cardiology for any adolescent presenting with exertional chest pain, syncope, or significant palpitations
Refer for evaluation of any new or concerning cardiac murmur identified on physical exam
Urgent consultation is warranted if ECG suggests significant abnormalities or if cardiac biomarkers are elevated
When the differential diagnosis includes a serious cardiac condition, cardiology input is essential.
Management Principles
Initial Stabilization:
Assess ABCs (Airway, Breathing, Circulation)
Monitor vital signs closely
Provide supplemental oxygen if hypoxic
Establish IV access
Pain management as appropriate (e.g., acetaminophen for musculoskeletal pain, but avoid NSAIDs if myocarditis is suspected).
Risk Stratification:
Use a structured approach to stratify risk based on history, exam, and initial investigations
High-risk patients require immediate cardiology consultation and potentially admission
Low-risk patients may be managed with close observation and appropriate follow-up.
Further Management:
Management depends on the underlying cause
Cardiac conditions will require specific medical or interventional cardiology management
Non-cardiac causes will be treated symptomatically, with reassurance and education being key components
Cardiology consultation guides the workup and management of suspected cardiac etiologies.
Prognosis
Factors Affecting Prognosis:
The prognosis is highly dependent on the underlying etiology
Benign causes have excellent prognoses
Serious cardiac conditions like myocarditis, severe arrhythmias, or congenital anomalies can have significant morbidity and mortality if not diagnosed and managed promptly
Early diagnosis and appropriate treatment are critical.
Outcomes With Cardiology Consult:
Timely cardiology consultation improves the likelihood of accurate diagnosis, appropriate management, and better outcomes for adolescents with suspected cardiac chest pain
It ensures that serious cardiac conditions are not missed and that patients receive specialized care, thereby reducing the risk of adverse cardiac events and long-term complications.
Follow Up:
Follow-up care depends on the diagnosis
Adolescents with cardiac causes will require regular cardiology follow-up to monitor their condition, adjust medications, and manage long-term risks
Those with benign causes may only require reassurance and advice on managing triggers if identified.
Key Points
Exam Focus:
DNB/NEET SS questions often focus on differentiating cardiac vs
non-cardiac chest pain, identifying red flag symptoms for cardiac causes, and knowing when to consult cardiology
Understanding the common etiologies and diagnostic workup is crucial.
Clinical Pearls:
Always consider the cardiac differential in exertional chest pain, syncope, palpitations, or a positive family history
A thorough history and physical exam are paramount
Don't underestimate anxiety as a cause, but always rule out organic pathology first
ECG is a vital screening tool.
Common Mistakes:
Dismissing chest pain as purely anxiety or musculoskeletal without a thorough cardiac evaluation
Delaying cardiology consultation for concerning symptoms
Inadequate history taking, missing crucial family history or exertional clues
Misinterpreting ECG findings or cardiac biomarkers.