View source for Emergent stress testing in young people

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'''Editors-In-Chief:''' [[Brenna Southern]] ; Ernest Gervino, Ph.D.



==Overview==

Stress testing has frequently been used to assess adult patients with suspected or known coronary artery disease (CAD) based on pre-test probability. Pre-test probability is the assessment of a patient and their likelihood of CAD based on clinical history and symptoms. Stress testing to diagnose myocardial ischemic syndrome is usually indicated only in patients with an intermediate pre-test probability.<ref>Gibbons, RJ, Balady, GJ, Bricker, JT, et al. ACC/AHA 2002 guideline update for exercise  testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2002; 106:1883.</ref>

The average age of a patient who undergoes a stress test is typically between 45-60 years.  Increasing age is one of many positive risk factors for CAD.  However, there have been several cases in which young adults and adolescents have presented with chest pain and were found to have had a myocardial infarction (MI). <ref>Kocis, KC. Chest pain in pediatrics. Pediatr Clin North Am 1999; 46:189. </ref> Since chest pain can be a complaint among children, the question becomes whether or not an emergent stress test is needed.

The most common reason for stress testing is chest pain. All patients who present with acute or chronic chest pain need to be evaluated to determine the course or urgency of further non-invasive vs. invasive testing. Inpatient stress testing can be done if a recent MI or an acute unstable coronary syndrome has been excluded. . 

Among children presenting with chest pain, the symptoms often tend to be benign. <ref>Lane, JR, Ben-Shachar, G. Myocardial Infarction in Healthy Adolescents. Pediatrics 2007; 120 No.4: 938</ref> Given the fact that the majority of children have no probable cardiac risk factors, their pre-test probability is already very low. Yet there are several conditions that can cause ischemic chest pain and other cardiac abnormalities so a thorough careful history and physical examination should always be performed.  The presenting symptom can be secondary to congenital defects as well as acquired diseases. Kawasaki disease has a common manifestation of coronary artery aneurysms which can progress to coronary stenosis. <ref>Taubert, KA, Shulman, ST. Kawasaki Disease. Am Fam Physician 1999; 59 No.11: 3093</ref> Acute MI is one of the main causes of death in children with Kawasaki disease. Another acquired condition is sickle cell disease in which children can frequently present with chest pain, have an MI and have normal coronary arteries. <ref>Martin, CR, Johnson, CS, Cobb, C, et al. Myocardial infarction in sickle cell disease. J Natl Med Assoc 1996; 88:428.</ref> Other issues that could cause ischemic chest pain are coronary vasospasm, pericarditis or myocarditis, cocaine use, or other conditions causing anatomic congenital cardiovascular abnormalities. 

Acute symptoms in children should be dealt with accordingly to rule out an MI, congenital defects or diseases. Based on above indications, an emergent stress test may not be warranted. To help determine the etiology of the symptom, ECG, echocardiogram, MRI, cardiac enzymes, drug screening, blood testing for hypercoagulability and coronary angiograms may be more useful. Or for chronic chest pain associated with exertion, an outpatient stress test could also be helpful.
 
Whether or not stress testing is emergent in children should again be considered similarly to adult emergent stress testing. Comprehensive assessment of acute or chronic problems and the consideration of the child’s pre-test probability being significantly low are compelling points that an emergent stress test may not be necessary.

==References== 
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[[Category:Cardiology]]

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