Approach to the child with chest pain

Bodily sensations and quality of life in adolescents with non-cardiac chest pain: a comparative study for the undetermined part of a frequent health problem

BACKGROUND

Chest pain in adolescents represents a considerable burden for health services and is rarely associated with cardiac disease. Since chest pain could be related to psychosocial factors there is a need for exploring the relationships among stressful situations, drug consumption, suicidal behaviors, accompanying bodily symptoms and health-related quality of life in adolescents with non-cardiac chest pain.

METHODS

In this study, we assessed these determinants in 108 adolescents with non-cardiac chest pain (NCCP) and a control group of 77 patients using a structured interview applied to the patients presented to the cardiology outpatient clinics of Tepecik Training and Research Hospital, İzmir, Türkiye, between 30 October 2018 and 30 June 2019. After the interview, the adolescents were given a self-administered pediatric quality of life inventory and the body sensations questionnaire for assessing aspects of fear.

RESULTS

Adolescents with NCCP expressed more panic associated bodily symptoms and reported worse subjective physical, academic, and emotional functioning in addition to more suicidal ideation.

CONCLUSIONS

NCCP could be accepted as a warning sign of an underlying psychosocial problem and requires a more interdisciplinary collaborative care by pediatricians, psychologists, and psychiatrists.

Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis

OBJECTIVE

This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain.

BACKGROUND

Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology.

METHODS

This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review.

RESULTS

A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]).

CONCLUSIONS

The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.

Investigation of the presence of atopy in children visiting the paediatric cardiology department due to chest pain

BACKGROUND

The cases of chest pain in children are usually not of cardiac origin.

OBJECTIVES

To investigate asthma and other atopic diseases in children with chest pain not of cardiac origin.

PATIENTS AND METHODS

Children aged 6-18 years who were seen for chest pain were included in the study. Haematologic parameters, pulmonary function tests, and skin prick tests were performed. Atopic diseases and environmental factors were investigated.

RESULTS

The non-cardiac chest pain group (Group 1) included 88 children (female: 53.4%) with a mean age of 11.9 ± 3.4 years; the control group (Group 2) included 29 children (female: 53.8%) with a mean age of 11.4±2 years (p > 0.05). A family history of atopy (22.7%) and skin prick test positivity (28.4%) was more common in Group 1 than Group 2 (p = 0.006 and p = 0.017, respectively). The rate of presence of all environmental factors except stove use and mould was significantly higher in Group 1 (54.5%) than Group 2 (3.4%) (p < 0.001). Asthma was diagnosed in 44.3% and allergic rhinitis in 9.1% of patients in Group 1. Idiopathic chest pain, musculoskeletal system disorders, gastroesophageal reflux, and pneumonia were identified in 23.9%, 11.4%, 8%, and 3.4% of patients in Group 1, respectively.

CONCLUSIONS

In this study, the most common cause of non-cardiac chest pain was asthma. The local prevalence of asthma is higher than normal, and this may have affected the results of this study. A detailed history and physical examination will accurately establish the cause of chest pain in most children.

Assessment of Body Posture of Children With Chest Pain

Objective: An increase in the appearance of chest pain among children is observed globally. The authors present various reasons for their appearance. As can be seen from numerous observations, the majority of cases are not related to the pathology of the circulatory system. Increasingly, studies on the causes of chest pain in children show their association with musculoskeletal disorders. Aim: of the work was assessment of body posture in children with chest pain using the Diers Formetric 4D system. Methods: The study involved a group of 184 female and male children, aged 7-12 years. The study group consisted of 64 patients with chest pain. The children from this group were diagnosed with functional chest pain by a cardiologist. The control group consisted of 120 patients without chest pain. The study included the assessment of body posture using the DIERS Formetric system. Results: The analysis of the results obtained during the study showed that among the children with chest pain, there are statistically significant irregularities in the parameters determining body posture compared to the control group. Comparing the study group with the control group, there is a statistically significant difference in the lateral deviation of VPDM (rms) (mm) (p = 0.001). Both children from the test group aged 9-10 and 11-12 obtained higher results than their peers from the control group. In the group of the youngest children in terms of the lateral deviation of VPDM (rms) (mm), increasing the number of children under study would contribute to significant differences in this variable. In the study group, among children aged 9-10 years, there were also statistically significant abnormalities regarding trunk imbalance and pelvic skewness compared to the children of the same age in the control group. Conclusions: Irregularities in the parameters determining body posture may cause chest pain in children.

Adolescents with unexplained chest pain reported depression and impaired emotional and social functioning

AIM

Chest pain is common in adolescence, but there are no established criteria for managing this problem, which is rarely associated with cardiac disease. This study addressed the gaps in the literature by evaluating psychosocial factors that could be associated with medically unexplained chest pain.

METHODS

We consecutively selected 100 patients (68% girls) aged 13-18 who were diagnosed with unexplained chest pain when they presented to the cardiology outpatient clinics of Tepecik Research Hospital, İzmir, Turkey, between 30 September 2015 and 30 June 2018. The controls were 76 age- and sex-matched adolescents (69% girls) aged 13-18 who were undergoing routine cardiology assessments before joining sports clubs. We assessed their health-related quality of life and any depression and physical symptoms.

RESULTS

Regression analysis showed some adolescents were a number of times more likely to report chest pain. These included those who reported boredom (4.1 times), felt stressed or anxious (2.2) and those who experienced sleep disturbance (2.6), co-morbid headaches (2.0), back pain (3.1) and impaired social functioning (1.2).

CONCLUSION

The results indicated a significant association between unexplained chest pain and physical symptoms, depression and impaired emotional and social functioning. These factors warrant further evaluation.

Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department

OBJECTIVE

To evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization.

METHODS

Motivated by perceived overuse of cardiology consultation for non-cardiac chest pain in the ED, clinicians from the Divisions of Cardiology and Emergency Medicine collaboratively developed a chest pain clinical pathway, educated staff, and implemented the pathway on March 1, 2014. We reviewed records of children aged 3 to 18 years without prior diagnoses of heart disease who presented to the ED with chest pain between March 1, 2013, and April 22, 2015. We compared diagnostic testing rates, ED length of stay, and cardiology consults before and after implementation of the pathway.

RESULTS

A total of 1687 patients were pathway eligible (675 patients preimplementation and 1012 postimplementation). Resource utilization was lower than expected before pathway implementation and remained low after implementation. There was a statistically significant reduction in rates of chest x-ray ordering after pathway implementation and ED length of stay but no change in other diagnostic testing or cardiology consultation. Follow-up in our health care system for pediatric chest pain increased from 15% to 29% with implementation, but none of these visits resulted in the diagnosis of a new cardiac condition. There were no instances identified where use of the pathway resulted in missed cardiac disease.

CONCLUSIONS

Implementation of a clinical pathway for pediatric chest pain did lead to a reduction in chest x-ray ordering in the ED and was associated with a higher rate of outpatient follow up for non-pathologic chest pain. Preimplementation utilization was lower than the prepathway perceptions of overuse suggested.

Anxiety, depression, suicidal ideation, and stressful life events in non-cardiac adolescent chest pain: a comparative study about the hidden part of the iceberg

Chest pain in adolescents is rarely associated with cardiac disease. Adolescents with medically unexplained chest pain usually have high levels of anxiety and depression. Psychological stress may trigger non-cardiac chest pain. This study evaluated risk factors that particularly characterise adolescence, such as major stressful events, in a clinical population. The present study was conducted on 100 adolescents with non-cardiac chest pain and 76 control subjects. Stressful life events were assessed by interviewing patients using a 36-item checklist, along with the Children's Depression Inventory and Spielberger's State-Trait Anxiety Inventory for children, in both groups. Certain stressful life events, suicidal thoughts, depression, and anxiety were more commonly observed in adolescents with non-cardiac chest pain compared with the control group. Moreover, binary logistic regression analysis showed that trouble with bullies, school-related problems, and depression may trigger non-cardiac chest pain in adolescents. Non-cardiac chest pain on the surface may point to the underlying psychosocial health problems such as depression, suicidal ideas, or important life events such as academic difficulties or trouble with bullies. The need for a psychosocial evaluation that includes assessment of negative life events and a better management have been discussed in light of the results.

An Unusual Case of Chest Pain in an Adolescent Male: Important Cues to Differential Diagnosis

Chest pain is a common presenting symptom in the pediatric population, and in contrast to adults, the etiology is rarely cardiac or life-threatening. The majority of chest pain complaints in children and adolescents are benign and can be managed with reassurance and follow-up. The emergency care provider must obtain a comprehensive history and physical examination, as the differential diagnosis of pediatric chest pain is extensive and serious underlying organic pathology may be present. This article describes the case of an adolescent male with an unusual case of chest pain with a serious underlying medical condition. A systematic approach to the clinical decision-making process is discussed to identify those patients who may have a serious underlying organic cause. Information is also included to guide the provider in the identification of red flags for cardiac etiologies of chest pain and indications for a pediatric cardiology consultation.

Extra-adrenal paraganglioma presenting as acute chest pain mimicking acute myocardial infarction in a 10-year-old boy

Extraadrenal paragangliomas are rare pediatric tumors with variable symptoms that cause difficultly in diagnosis and delayed treatment. We report the case of a 10-year-old boy who presented to the pediatric emergency department with acute chest pain and dyspnea mimicking a non-ST-segment elevation acute myocardial infarction. He was subsequently found to have an extraadrenal paraganglioma after a series of imaging and laboratory examinations. The mass was subsequently removed, and the diagnosis of extraadrenal paraganglioma was confirmed histologically. Acute coronary syndrome as the presenting feature of extraadrenal paragangliomas in pediatric population is an even rarer clinical entity.

Clinical characteristics and causes of chest pain in 380 children referred to a paediatric cardiology unit

BACKGROUND

Chest pain is a common presenting complaint to paediatrics, paediatric cardiology, and paediatric emergency departments. In this study, we prospectively evaluated clinical characteristics and causes of chest pain in children referred to our paediatric cardiology unit.

METHODS

A total of 380 children were included. Associated symptoms and past and family histories were evaluated. All patients underwent physical examination. The following studies were performed: complete blood count in all patients; fasting lipid profiles in overweight and obese children and children with a family history of premature cardiovascular disease; and electrocardiogram, chest X-ray, and echocardiogram in all patients. If necessary, 24-hour electrocardiogram monitoring or exercise stress tests were performed. Patients with a history of positive psychological findings were evaluated by a child psychiatrist.

RESULTS

The most common causes of chest pain were musculoskeletal disorders (37.1%), idiopathic chest pain (29.2%), and miscellaneous disorders, for example precordial catch syndrome (15%), respectively. Only 1 of 380 (0.3%) patients had chest pain due to a cardiac disorder. Electrocardiograms were abnormal in 4 of 380 (1.1%) patients. A total of 9 of 380 patients (2.3%) had dyslipidaemia.

CONCLUSIONS

Although a paediatric cardiology referral may provide reassurance to the primary care and emergency department physicians, our results show that cardiac aetiologies for paediatric chest pain are very rare. We think that many patients in our study were adequately evaluated only by careful history, and physical examination. Therefore, we suggest that it may not be necessary to use echocardiogram in the routine evaluation of children with chest pain.

Intramedullary spinal cord cavernous malformations presenting with unexplained chest pain: case report and review of the literature

INTRODUCTION

Intramedullary spinal cord cavernous malformations are very uncommon in pediatric age, with only 26 cases reported within the available literature to date. The diagnosis of such lesions is often difficult and delayed because of their rarity and bizarre clinical presentation.

CASE REPORT

We report a case of intramedullary spinal cord cavernous malformation in a girl, in which sudden onset chest pain was the only presenting symptom, followed by appearance of neurological deficits after 5 days. We review the available literature discussing clinical features and principles of management of these lesions in children.