Chest pain in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Synonyms and keywords: Chest pain in kids

Historical Perspective

Chest pain in children is a common symptom and have a broad etiology.

Classification

Chest pain in children can be classified to:

• Cardiac
• Non cardiac

Pathophysiology

• The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Common causes of Chest pain in childern include:

Non Cardiac Causes:

Idiopathic

Musculoskeletal

1. Muscle strain
2. Trauma
3. Costochondritis
4. Precordial catch syndrome

Respiratory

1. Asthma
2. Pneumonia
3. Pneumothorax
4. pulmonary embolism
5. inhaled foreign body.
6. Chronic cough

Gastrointestinal

1. Gastroesophageal reflux( GERD)
2. Esophagitis
3. Gastritis
4. Foreign body

Miscellaneous

1. Psychogenic and Anexity
2. Sickle cell disease
3. Herpes zoster

Cardiac Causes:

• Anomalous coronary arteries
• Kawasaki disease
• Dysrhythmias
• Pericarditis
• Myocarditis
• Hypertrophic cardiomyopathy
• Mitral valve prolapse
• Aortic stenosis
• Aortic aneurym

Epidemiology and Demographics

• Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years.
• Patients with chest pain account for 5.2% of all cardiology consultations in inpatient and emergency department. and 15% of all outpatient visits.
• Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology.

Natural History, Complications and Prognosis

• The majority of patients with chest pain have bengin non cardiac causes.
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• Cardiac troponin
• CBC
• CRP
• ESR

Electrocardiogram

An ECG should be obtained if cardiac disease is suspected and when a noncardiac etiology is not clear.

ECG abnormalities can help with diagnosis:

• Dysrrhythmia. However, in intermittent events the initial ECG will be normal.
• Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain.
• Pericarditis: generalized ST segment elevation followed by T wave inversion.
• Myocarditis: ST-T wave abnormalities.
• Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6.
• Pulmonary hypertension: signs of right ventricular hypertrophy and right axis deviation.
• Pulmonary embolism: nonspecific ST-T segment changes or sinus tachycardia.

X-ray

An x-ray may be helpful in the diagnosis of the cause of chest pain.

x-ray may showes:

• Cardiac enlargement in myocarditis and pericardial effusion
• Prominent main and central pulmonary arteries. in pulmonary hypertension
• infiltrates in pneumonia
• atelectasis
• Hyperinflation in asthma.
• Pneumothorax, pneumomediastinum, or pleural effusions.
• Radio-opaque esophageal foreign body (eg, button battery, or coin).

Echocardiography or Ultrasound

-Echocardiography may shows many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension.

-Echocardiography is indicated in the patients with the following:

• Exertional chest pain or syncope.
• Chest pain associated with fever.
• History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
• Family history of cardiomyopathy, sudden death.
• New murmur
• Distant heart sounds
• Pericardial friction rub
• Loud S2
• Peripheral edema
• Abnormal electrocardiogram.

CT scan

CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and disection, and tumors.

MRI

MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD) and tumors.

Other Diagnostic Studies

Holter monitoring to diagnosis arrhythmia as a cause of intermittent chest pain.

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].