Chest Pain: A Guideline for Primary Care Physicians

Joy Johnson MD & Christopher MD

Division of Pediatric Cardiology, University of Utah, located at Primary Children’s Medical Center

Background and Introduction

Chest pain is a common reason for referral to pediatric cardiologists. In contrast to adult populations, chest pain in childhood is related to cardiac pathology in less than 5% of cases. Despite the fact that pediatric chest pain is rarely attributable to serious cardiac pathology (Table 1), Pediatric cardiology consultation is common and usually results in unnecessary extensive and costly evaluation.

Table 1. Causes of chest pain in children

Considering the paucity of cardiac conditions identified as a cause of chest pain, referral to pediatric cardiology should be limited to patients in whom a cardiac condition is more likely. Using the Primary Care Provider algorithm below, referring physicians can identify appropriate patients for referral for pediatric cardiology consultation. Recommended Algorithm for the Primary Care Provider Evaluating Chest Pain

Chest pain in pediatric clinic

Chest pain in setting History and physical of recent viral illness, exam suggest non- fever, or pain that is cardiac cause of chest worse when supine pain History and or improved with physical exam

sitting up concerning for cardiac cause of Other cause chest pain Cause of chest found - No pain Patient stable – cardiology indeterminate Patient ill- referral obtain ECG, CXR and appearing – refer necessary then contact to ER for ECG, CXR cardiology for and potential Obtain 12 further pediatric lead ECG recommendations cardiology Cardiology consultation referral

ECG normal – no ECG abnormal – cardiology referral necessary at this refer to time, continue to cardiology monitor

In patients presenting to a primary care provider with chest pain, we recommend the following:

Complete history and physical exam:

1. Concerning findings from the history:

a. Chest pain that is acute in onset, occurs with exertion, or is associated with palpitations or syncope or is

associated with cough and symptoms of an acute respiratory illness and/or fever.

b. : Underlying systemic inflammatory diseases ( e.g. Systemic Lupus Erythematosus, Juvenile Rheumatoid

Arthritis, Inflammatory Bowel Disease, Kawasaki disease, etc).

c. 1st -degree relative with sudden or unexplained death, aborted sudden death, known cardiomyopathy or

pulmonary hypertension.

2. Concerning findings on physical examination:

a. Presence of unexplained tachycardia, hepatomegaly, prominent S2, gallop, pathologic murmur, presence

of a rub, thrill, precordial lift, or jugular venous distention, diminished femoral pulses. 3. Reassuring historical features include: history of reproducibility of chest pain by palpation, extremity movement, or

respiration, chest pain that varies with respiration in the absence of a febrile/viral illness, chest pain that is described as

sharp or stabbing, chronic chest pain (>6 months), and chest pain at rest in the absence of diaphoresis, pallor,

lightheadedness, or palpitations.

4. Reassuring physical examination findings include reproducibility of the chest pain by palpation of the chest or

movement of the extremities and an otherwise normal cardiovascular examination

5. An ECG may be useful in evaluating a child or adolescent with chest pain. However, the isolated presence of

intraventricular conduction delay, early repolarization, sinus arrhythmia, or isolated premature atrial contractions is

rarely of clinical significance in this setting. Patients with an ECG that shows premature ventricular contractions should

be referred to cardiology but this is rarely an emergency.

Acute chest pain (over course of hours/days), associated with a viral prodrome and/or fever may be of concern due to

possible underlying myocarditis or pericarditis. In this case, patients typically describe the pain as worse when supine

and improved upon sitting up or leaning forward. Patients with pericarditis often describe pleuritic pain that is worse

with inspiration. Other clues from the history or physical examination should help steer the clinician towards the need

for further testing or referral for subspecialty evaluation.

Summary

Chest pain in pediatric patients is not commonly related to underlying heart disease. As a result, primary care

clinicians evaluating children and adolescents with chest pain should consider the broad differential diagnoses and

undertake selective referral for pediatric cardiology consultation.

References

1. Fyfe et al Chest pain in Pediatric Patients Presenting to a Cardiac Clinic. Clinical Pediatrics : vol 23, No 6, June 1984,

321-324

2. Kane et al Needles in Hay: Chest Pain as the Presenting Symptom in Children with Serious Underlying Cardiac

Pathology Congenit Heart Dis 2010;5:366-373

3. Pantell et al. Adolescent Chest Pain: A Prospective Study Pediatrics 1983:71;881

4. Saleeb Effectiveness of Screening for Life-Threatening Chest Pain in Children Pediatrics 2011:128:e1062-e1068

5. Selbst Pediatric Chest Pain: A Prospective Study Pediatrics 1988:82; 319