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Effectiveness of Screening for Life-Threatening Chest in Children

WHAT’S KNOWN ON THIS SUBJECT: in children is an AUTHORS: Susan F. Saleeb, MD, Wing Yi V. Li, BA, Shira Z. extremely frequent complaint, with generally benign causes. Warren, BA, and James E. Lock, MD Referrals to cardiologists are increasing in volume, although the Department of Cardiology, Children’s Hospital Boston and frequency of cardiac causes is exceedingly low. Harvard Medical School, Harvard University, Boston, Massachusetts WHAT THIS STUDY ADDS: This study demonstrates that thorough KEY WORDS history assessments, physical examinations, and chest pain, standardized clinical assessment and management electrocardiograms can be used effectively in initial screening to plan, congenital heart disease determine when higher-level care and testing are needed. This ABBREVIATIONS technique allowed for no cardiac deaths over a 10-year period. CP—chest pain SCAMP—standardized clinical assessment and management plan ECG—electrocardiogram EST—exercise stress test SVT—supraventricular abstract ICD-9—International Classification of Diseases, Ninth Revision www.pediatrics.org/cgi/doi/10.1542/peds.2011-0408 OBJECTIVE: We sought to determine the incidence of sudden cardiac doi:10.1542/peds.2011-0408 death among patients discharged from the cardiology clinic with pre- Accepted for publication Jul 29, 2011 sumed noncardiac chest pain (CP). Address correspondence to Susan F. Saleeb, MD, Children’s METHODS: The records of children Ͼ6 years of age who presented to Hospital Boston, Department of Cardiology, 300 Longwood Ave, Children’s Hospital Boston between January 1, 2000, and December 31, Boston, MA 02115. E-mail: [email protected] 2009, with a complaint of CP were reviewed for demographic features, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). clinical characteristics, resource utilization, and presumed diagnosis. Copyright © 2011 by the American Academy of Pediatrics Patients were searched for in the US National Death Index and Social FINANCIAL DISCLOSURE: The authors have indicated they have Security Death Index. no financial relationships relevant to this article to disclose. RESULTS: Data for a total of 3700 patients with CP (median age at evaluation: 13.4 years [range: 7–22.3 years]) were reviewed. The me- dian follow-up period was 4.4 years (range: 0.5–10.4 years), for total of 17 886 patient-years of follow-up data. CP with exertion occurred in 1222 cases (33%), including 15 with associated syncope. A cardiac cause was determined in 37 cases; the remaining 3663 patients (99%) had CP of unknown (n ϭ 1928), musculoskeletal (n ϭ 1345), pulmonary (n ϭ 242), gastrointestinal (n ϭ 108), -related (n ϭ 34), or drug-related (n ϭ 4) origin. visits for CP were documented for 670 patients (18%), and 263 patients (7%) had cardi- ology follow-up visits related to CP. There were 3 deaths, including 2 suicides and 1 spontaneous retroperitoneal hemorrhage. CONCLUSION: CP in children is a common complaint and rarely has a cardiac cause. Review of 1 decade of cardiology visits (nearly 18 000 patient years) revealed that no patient discharged from the clinic died as a result of a cardiac condition. Pediatrics 2011;128:e1062–e1068

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Chest pain (CP) in children is a com- source utilization in assessing CP. Pa- tivity, during which the heart rate mon complaint in general pediatric tients enrolled in the SCAMP are re- would be elevated significantly above clinics, emergency departments, and evaluated continuously, and modi- baseline. Minor activity such as walk- pediatric cardiology clinics and leads fications to the SCAMP are made in ing or climbing stairs was not consid- to a fair amount of school and sports accordance with gained knowledge, on ered exertional. find- absenteeism, as well as patient, par- an ongoing basis. Given the increases ings considered relevant included ent, and physician anxiety.1–4 As op- in health care costs and impending inflammatory disorders, malignan- posed to adults, for whom CP often sig- health care reform, quality improve- cies, hypercoagulable state, connec- nals a cardiac problem, multiple ment initiatives such as the SCAMP tive tissue disorders, and . studies have demonstrated that the project are vitally important. The re- Family history findings considered rel- most common causes of CP among sults of this study should either sup- evant included sudden unexplained children are benign idiopathic, muscu- port or challenge our current practice death, pulmonary hypertension, car- loskeletal, gastrointestinal, pulmo- of evaluating pediatric CP with the use diomyopathy, hypercoagulable state, nary, or psychogenic, with cardiac of the SCAMP. , disor- causes being quite rare.2–10 Pantell et ders, and congenital heart disease. Ad- al2 reported that 44% of adolescents METHODS ditional family history findings re- were concerned that a heart attack Identification of Subjects corded included early coronary was the cause of their CP, a concept disease. The physical examination re- Patients were identified on the basis of echoed in other studies.3,8,11 This com- sults were screened for pathologic International Classification of Dis- mon misperception by the lay public murmurs, abnormal second heart eases, Ninth Revision (ICD-9), dis- that CP in children represents similar sounds, gallops, rubs, and stigmata of charge billing codes for initial CP as- connective tissue disease. pathologic conditions, compared with sessment (at Ͼ6 years of age) in those seen among adults, accounts for outpatient clinics at Children’s Hospi- Results of electrocardiograms (ECGs) the frequency of seeking medical eval- tal Boston between January 1, 2000, performed for all patients and uations and the difficulty physicians and December 31, 2009. Assessment higher-level testing performed at the face in relieving parental concerns. and documentation were not stan- discretion of the cardiologist, includ- These misperceptions are perpetu- dardized at the time of this study and ing echocardiography, cardiac MRI, ated by the tragic, although truly rare, were at the discretion of the evaluating exercise stress tests (ESTs), sesta- instances of sudden cardiac death cardiologist. Patients were excluded if mibi stress tests, Holter monitoring, among young people, which are broad- they had normal cardiac evaluation re- and extended loop monitoring, were cast widely by the media. sults for CP at another institution, in- ascertained. Benign findings, includ- The purpose of this study was to as- complete records, known significant ing RSR=/interventricular conduc- sess whether any patients evaluated in , or extensive tion delay or early repolarization on our clinics for CP and discharged with cardiac evaluations because of sys- ECGs, clinically insignificant ectopy in a presumed diagnosis of noncardiac temic illness or a family history of car- ESTs and rhythm monitoring, and mild CP subsequently died as a result of a diac disease. The institutional review tricuspid or pulmonary regurgitation cardiac condition. Given the high fre- board for clinical research at Chil- on echocardiograms, were not re- quency of CP among children and the dren’s Hospital Boston approved the corded. Vital status and cause of death low incidence of associated cardiac use of patient medical records for this were ascertained through queries of pathologic conditions, our group de- retrospective review. both the National Death Index (main- veloped guidelines, in the form of stan- tained by the Centers for Disease Con- dardized clinical assessment and man- Chart Review trol and Prevention; current through agement plans (SCAMPs), to facilitate The medical records were analyzed December 31, 2008) and the Social Se- appropriate resource utilization and with respect to demographic features, curity Death Index (maintained by the to reduce unnecessary testing while clinical characteristics, cardiac test- US Social Security Administration; cur- maintaining diagnostic accuracy and ing, presumed diagnosis, and fol- rent through July 2010). potentially improving care.12–15 Devel- low-up visits. Patients were catego- opment of the CP SCAMP was based on rized as having CP predominantly with Statistics previous studies that assessed known exertion or rest. Exertional CP was de- The primary outcome was death re- cardiac causes of CP, as well as re- fined as occurring during intense ac- lated to cardiac causes. Clinical symp-

PEDIATRICS Volume 128, Number 5, November 2011 e1063 Downloaded from www.aappublications.org/news by guest on September 24, 2021 toms and numbers of cardiac tests TABLE 1 Medical and Family History Findings cally insignificant ventricular septal were expressed as counts and propor- n (%) defects (n ϭ 15), repaired or small tions. Continuous variables were rep- Pertinent medical history patent ductus arteriosus (n ϭ 10), mi- resented by median values and findings tral valve prolapse (n ϭ 4), small atrial Asthma 565 (15.3) ϭ ranges. Data were analyzed by using Gastroesophageal reflux 65 (1.8) septal defects (n 3), mild pulmonary standard statistical methods, with MS- Minor congenital heart 42 (1.1) stenosis (n ϭ 2), bicuspid aortic valves Excel 2003 (Microsoft, Seattle, WA). disease (n ϭ 2), and unspecified resolved Inflammatory disorder 39 (1.1) “holes in the heart” that did not re- RESULTS Connective tissue disorder 16 (0.4) Hypercoagulable state 15 (0.4) quire intervention (n ϭ 6). Three pa- Study Group Depression/anxiety 15 (0.4) tients who presented with CP in ado- Malignancy 13 (0.3) Of 4165 patients who were identified SVT 3 (0.08) lescence had a remote history of initially on the basis of ICD-9 discharge Pertinent family history findingsa supraventricular tachycardia (SVT), billing codes for CP at the first cardiol- Congenital heart disease 91 (2.5) without recurrence. Other positive Arrhythmia 77 (2.1) medical history findings included hy- ogy clinic visit, 3700 constituted the Cardiomyopathy 15 (0.4) final cohort. Patients were excluded Sudden death 13 (0.3) perlipidemia that did not require ther- because of known cardiovascular dis- Connective tissue disorder 5 (0.1) apy for 34 patients (0.9%), systemic hy- Hypercoagulable state 5 (0.1) pertension for 28 (0.8%), and diabetes ease (n ϭ 164), miscoding (n ϭ 123), Pulmonary hypertension 1 (0.02) mellitus for 15 (0.4%). incomplete records (n ϭ 107), previ- a First-degree relatives only. ous extensive cardiac evaluations un- Among first-degree relatives, arrhyth- related to CP (n ϭ 38), and second mias included long QT syndrome in 2 nantly at rest for 2072 (56%), and in opinions after normal evaluation re- cases and ventricular tachycardia in 3 unknown circumstances for 406 sults (n ϭ 33). The median age at the cases; the remaining (11%). Accompanying symptoms in- clinic visit was 13.4 years (range: were of supraventricular origin or cluded for 828 patients 7–22.3 years), and the median were unspecified. The cardiomyopa- (22%), for 576 follow-up period after the clinic visit thies consisted of dilated cardiomyop- (16%), dizziness for 389 (11%), and was 4.4 years (range: 0.5–10.4 years), athy (n ϭ 6), hypertrophic cardiomy- syncope for 49 (1.3%), including exer- for a total of 17 886 patient-years of opathy (n ϭ 5), left ventricular tional syncope with CP for 15 (0.4%). follow-up monitoring. Between 235 and noncompaction (n ϭ 2), arrhythmo- Emergency department visits for CP 500 patients were evaluated per year, genic right ventricular dysplasia (n ϭ before the cardiology clinic visits were with generally increasing numbers of 1), and unspecified cardiomyopathy documented for 670 patients (18%). referrals with time (Fig 1). (n ϭ 1). The causes of sudden death Significant medical and family history were sudden infant death syndrome (n Clinical Characteristics findings for first-degree relatives are ϭ 3), stillbirth (n ϭ 2), and unspeci- CP occurred predominantly with exer- presented in Table 1. Minor congenital fied causes (n ϭ 8). Not included in tion for 1222 patients (33%), predomi- heart disease included hemodynami- Table 1 are data for 48 families with premature in 500 first-degree relatives and an addi- 450 tional 151 families with findings for 400 more-distant relatives. Distant rela- 350 tives also had reported sudden unex- 300 plained death in 59 cases (sudden infant 250 death syndrome: n ϭ 6; unspecified: n ϭ 200 53), cardiomyopathy in 39, and arrhyth- 150 Number of Patients mias in 38. 100 50 Physical Examination and ECG 0 Findings 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Notable physical examination and ECG FIGURE 1 findings were uncommon and are pre- Number of initial cardiology evaluations per year. sented in Table 2. No patients pre-

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TABLE 2 Physical Examination and ECG TABLE 3 Incidental Echocardiographic patient presented with CP at rest with- Findings Findings out additional symptoms and demon- n (%) n strated abnormal ECG findings, with Physical examination findings Mild dilated aortic root/ascending aorta 27 diffuse ST segment elevations. Echo- Clicks 52 (1.4) Mild mitral regurgitation 27 Pectus excavatum or carinatum 42 (1.1) 27 cardiographic results were normal; Pathologic murmurs 31 (0.8) Mild LV dilation 14 however, the EST demonstrated poor Abnormal second heart sound 12 (0.3) Mild aortic regurgitation 10 tolerance, which led to sestamibi scan Rub 9 (0.2) Bicuspid aortic valve 10 Joint hyperlaxity 5 (0.1) Mild LV hypertrophy 8 with suspicion of lateral wall . ECG findings LV hypertrabeculation/noncompaction* 8 The patient was lost to follow-up mon- Left ventricular hypertrophy 93 (2.5) Atrial septal defect 6 itoring. Sestamibi stress tests were Abnormal ST segments or T waves 27 (0.7) Mild LV dysfunction 5 Right ventricular hypertrophy 23 (0.6) Small ventricular septal defect 5 performed for an additional 17 pa- Preexcitation 11 (0.3) Trivial or mild subaortic stenosis 4 tients, and all findings were normal. Complete right bundle branch block 8 (0.2) High takeoff of right coronary artery 3 Atrial enlargement 3 (0.08) Patent ductus arteriosus 3 Holter monitors were used for 491 pa- Second-degree heart block 1 (0.02) Right ventricular dilation (no identified 3 tients (13.3%), event recorders for 363 shunt) (9.8%), and loop monitors for 242 Small LV aneurysm 2 (6.5%). Cumulatively, the rhythm mon- sented to the clinic with documented Mild dilated pulmonary root 2 Tricuspid valve prolapse 2 itor results were positive for 13 (0.4%) gallop, fever, , peripheral Peripheral pulmonic stenosis 1 of 3700 patients, diagnosing SVT (n ϭ edema, or hepatomegaly. Miscella- Mild left coronary dilation (no fistula) 1 9), ectopic atrial tachycardia (n ϭ 1), Mild tethering tricuspid valve leaflet 1 neous ECG findings included first- nonsustained ventricular tachycardia degree heart block (n ϭ 21) and QTc Nonobstructive cor triatriatum 1 Dysplastic pulmonary valve 1 (n ϭ 1), wide complex tachycardia (n ϭ prolongation that ultimately was con- Sinus venosus defect 1 1) not inducible in atrial and ventricu- sidered normal (n ϭ 12). LV indicates left ventricular. * Normal LV function. lar stimulation studies, and significant Selective Testing ventricular ectopy accounting for 42% of beats (n ϭ 1), with normal echocar- Echocardiography was performed for diographic results. All except 2 of the 1410 patients (38%), and findings were graphic diagnoses in all cases except 13 patients complained of palpitations, normal for 1242 (88.1%). Positive find- 2, in which right ventricular dilation 1 with left axis deviation on ECGs for ings potentially related to the com- was noted on cardiac MRI scans and whom ectopic atrial tachycardia was plaint of CP were detected in 11 cases not echocardiograms. Of the 1222 pa- diagnosed and 1 with no positive phys- (0.8%), including a right coronary ar- tients with exertional symptoms, echo- ical examination or ECG findings for tery arising from the left sinus with an cardiography was performed for 696 whom SVT was diagnosed. interarterial course in 3 cases, peri- (57%). cardial effusion in 5 cases (small: n ϭ ESTs were performed for 769 patients Diagnoses 4; moderate: n ϭ 1), moderate left ven- (20.8%) and were notable for changes tricular dysfunction in 1 case with suggesting ischemia in only 1 case The presumed causes of CP are dem- , and hypertrophic and di- (0.1%), which ultimately was consid- onstrated in Fig 2. Musculoskeletal lated cardiomyopathy in 1 case each. ered a false-positive result. The patient causes included , pre- The remaining 157 echocardiograms presented with exertional CP and pal- cordial catch syndrome, trauma, and (11.1%) had incidental findings that pitations and demonstrated inferior unspecified chest wall pain. Gastroin- were unlikely to be related to CP (Table ST segment depressions on the EST, testinal causes consisted of gastro- 3), including 2 atrial septal defects, 2 with normal echocardiographic and esophageal reflux disease, gastritis, cases of patent ductus arteriosus, sestamibi stress test results. The re- , and constipation. Asthma and 1 sinus venosus defect that were maining findings were predominant- dominated the pulmonary causes, repaired surgically. Suspicion was ly respiratory, including obstructive which also included pleuritic pain, re- raised regarding anomalous coronary and/or restrictive spirometric pat- spiratory infections, and hyperventila- for 4 other patients, which terns in 90 cases (11.7%). Hyperten- tion. A cardiac cause was determined were confirmed as normal through sion was diagnosed for 6 patients, and for 37 patients (1%). CP for patients cardiac MRI. Cardiac MRI was per- 2 patients had notable QTc prolonga- with diagnosed occurred formed for an additional 23 patients tion, considered normal findings after at rest in all cases and was associated and was confirmatory of echocardio- further evaluation in both cases. One with positional changes or radiation to

PEDIATRICS Volume 128, Number 5, November 2011 e1065 Downloaded from www.aappublications.org/news by guest on September 24, 2021 Pulmonary 2 years. She had a known history of (n = 242, 7%) anxiety, depression, and bipolar disor- Gastrointestinal (n = 108, 3%) der. Her cardiac evaluation results Anxiety were normal, and no additional infor- (n = 34, 1%) mation was available. The third patient Musculoskeletal Cardiac (n = 37, 1%) (n = 1345, 36%) underwent a cardiac evaluation with Pericarditis (n = 10) normal results 4 years before his Myocarditis (n = 4) Anomalous right coronary artery (n = 3) death and experienced fatal retroperi- Hypertrophic cardiomyopathy (n = 1) toneal bleeding while attending a Dilated cardiomyopathy (n = 1) dance party. Supraventricular tachycardia (n = 14) Unknown Ectopic atrial tachycardia (n = 1) (n = 1934, 52%) Nonsustained ventricular tachycardia (n = 1) DISCUSSION Cardio-inhibitory syncope (n = 2) CP in children is the cause of tremen- dous anxiety and resource utilization FIGURE 2 Causes of CP. despite generally benign causes in the vast majority of cases, as demon- strated in this study and in many oth- the jaw (n ϭ 3), rub on examination normalities on an ECG. All except 3 ers.2–10,13 Fears of sudden cardiac (n ϭ 3), ECG changes (n ϭ 6), and effu- patients (13 [81%] of 16 patients) with death in both the lay public and sion on echocardiograms (n ϭ 4). CP tachyarrhythmias presented with ex- medical communities foster activity associated with myocarditis also oc- ertional CP, and 14 (88%) of 16 patients restrictions, elaborate evaluations, curred at rest and was diagnosed on had associated palpitations. ECG find- and excessive referrals, which are in- the basis of a history of preceding ill- ings were positive for 4 patients (pre- creasing with time. The estimated inci- ness (n ϭ 4), ectopy on examination excitation: n ϭ 3; left axis deviation: dence of pediatric sudden cardiac (n ϭ 2), ECG changes (n ϭ 1), and mod- n ϭ 2), and rhythm monitoring results death ranges from 0.6 to 6.2 deaths erate left ventricular dysfunction (n ϭ were positive for 12 (75%) of 16 pa- per 100 000, with hypertrophic cardio- 1) on echocardiogram, which resolved tients. The final 2 patients with car- myopathy, coronary artery anomalies, within 1 week. Few cases of myocardi- dioinhibitory syncope presented with and malignant arrhythmias being re- tis were detected in the cardiology longstanding histories of CP at rest sponsible for the majority of cases and clinic, because the majority of patients and associated palpitations and recur- deaths being more common during with myocarditis present to the emer- ring syncope; both underwent electro- athletic activities.16–24 Determining gency department. Two of 3 patients physiological studies and pacemaker which children are at risk for sudden with anomalous right coronary arter- placement. death is challenging, particularly be- ies from the left sinus and an intramu- cause there often are no preceding ral course had CP at rest, associated Death Registry Outcomes with use in 1 case. Results of In the cohort of 3700 patients, there symptoms. physical examinations and ECGs were were 3 deaths (0.1%), none related to The incidence of cardiac disease in our normal in all 3 cases. Echocardio- cardiac pathologic conditions. Two pa- population of 3700 children presenting grams were performed because of ex- tients (1 boy and 1 girl) committed sui- with CP was exceedingly low at only ertional symptoms, concerns regard- cide at 17 years of age. The boy pre- 1%. Our study had an intentional ascer- ing drug-induced ischemia, and sented to the clinic at 12 years of age tainment bias to select for patients not unrelated issues for the 3 patients. The with CP that occurred at rest every 2 to considered to have cardiac disease, first 2 patients have undergone un- 3 days for ϳ2 years, without associ- because patients for whom cardiac roofing of the coronary artery, and the ated symptoms. Echocardiography disorders were detected would more third is being monitored. Both patients was performed because of “ongoing likely be assigned diagnostic rather with cardiomyopathy presented with concern” and yielded normal results. than symptomatic ICD-9 billing codes. exertional CP. The patient with dilated No additional information on this pa- Our study serves as a counterpart to cardiomyopathy had an affected uncle, tient was available. The girl presented the recent report by Kane et al,12 in and the patient with hypertrophic car- to the cardiology clinic 4 months be- which patients were identified in the diomyopathy demonstrated left ven- fore her suicide, with a history of CP same decade of study on the basis of tricular hypertrophy and T wave ab- that occurred at rest infrequently over billing codes for 9 serious cardiac di-

e1066 SALEEB et al Downloaded from www.aappublications.org/news by guest on September 24, 2021 ARTICLES agnoses associated with sudden car- ings. If the CP SCAMP were applied to cardiac diagnoses, including life- diac death. Further analysis indicated this cohort, then resources would be threatening diagnoses, that were not that only 41 children with serious car- redistributed to generate potentially manifested during this study. In addi- diac diagnoses presented to outpa- higher yields of clinically relevant pos- tion, cardiac diagnoses that lead to tient cardiology clinics with com- itive findings and to decrease missed significant morbidity are not captured plaints of CP, which, if included in our diagnoses, ultimately improving pa- by the death indexes; in review of the study, would increase the incidence of tient care.13 The CP SCAMP in the hands entire medical record, however, no cardiac disease to 2%, not including of pediatric cardiologists would lead such instances were observed among more-benign diagnoses such as SVT. to reductions in the costs of care; how- patients who continued to receive care More importantly, our study demon- ever, the reductions would be most at Children’s Hospital Boston. Lastly, strates that those children, who were dramatic with a modified CP SCAMP in we relied on the accuracy of the death evaluated in all cases with history as- the hands of general pediatricians, a registries, which may be incomplete, sessments, physical examinations, project that is currently underway. In to capture fatal events. Studies have and ECGs and in many cases with other theory, Ͼ50% of the patients in this shown that the National Death Index, tests and were deemed to have non- group would not necessarily need re- which is considered the standard, has cardiac disease, remain alive, with no ferral to a cardiologist with effective 92% to 98% accuracy in detecting incidents of sudden cardiac death. screening by the generalist. known decedents, with similar sensi- This finding should be reassuring and This study also brings to light a sus- tivity for Internet-based Social Security underscores the importance of edu- pected but underreported finding. registries.26–28 Given the low incidence cating the public and medical commu- There were 2 suicides among the co- of sudden cardiac death among chil- nities to allay fears and to pursue qual- hort of 3700 children. A history of de- dren, it is not surprising that no pa- ity improvement initiatives to limit pression and/or anxiety was reported tient was found in either registry to resource utilization in the evaluation for only 15 patients (0.4%), which likely have died as a result of a cardiac of pediatric CP. was a gross underestimate.25 Accord- cause, and rates of potential misses or The vast majority of patients identified ing to the Injury Surveillance Program near-misses are presumed to be low. as having a cardiac cause for their CP at the Massachusetts Department of CONCLUSIONS had suggestive symptoms (particu- Public Health, in 2008 there were 44 CP in children is a common complaint larly exertional CP), concerning medi- youth suicides (15–24 years of age) with rare cardiac causes and is asso- cal or family history findings, abnor- among Massachusetts residents, with ciated with tremendous anxiety and re- mal examination results, and/or a rate of 0.6 cases per 100 000 resi- source utilization. Review of nearly abnormal ECG findings, which led to dents. Practitioners should be aware 18 000 patient-years of data over the further investigation. Positive initial of somatization of complaints, includ- span of 1 decade revealed that no pa- history, physical examination, and ECG ing CP, in patients with underlying psy- tient discharged from the clinic died findings form the basis of the CP chiatric illnesses and should screen as a result of a cardiac condition. Fu- SCAMP currently being implemented in and refer the patients appropriately. ture studies should focus on quality our department. As described previ- There are several important limita- improvement initiatives to allay anxi- ously, the CP SCAMP suggests echocar- tions to this study. This study was per- ety, to reduce unnecessary referrals, diography as the diagnostic test of formed as a retrospective review and and to validate current practice man- choice in the majority of cases with relied on medical records for data on agement strategies for the evaluation positive screening results and elimina- patient symptoms, history findings, of CP, including the use of the CP tion of echocardiography and other and physical examination findings. SCAMP. higher-level tests, such as ESTs, for pa- This study was performed before initi- tients with negative screening results. ation of the use of the CP SCAMP and ACKNOWLEDGMENTS In this cohort of 3700 patients, approx- relied on assessments from various This research was supported by the imately one-third of patients pre- providers with different approaches to Boston Children’s Heart Foundation, sented with exertional symptoms, and CP. Patients underwent varied tests, at Program for Patient Safety and Quality, 1 of 10 patients had other relevant his- the providers’ discretion. We cannot and the General Cardiology Research tory, physical examination, or ECG find- account for any potentially missed and Education Fund.

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e1068 SALEEB et al Downloaded from www.aappublications.org/news by guest on September 24, 2021 Effectiveness of Screening for Life-Threatening Chest Pain in Children Susan F. Saleeb, Wing Yi V. Li, Shira Z. Warren and James E. Lock Pediatrics 2011;128;e1062 DOI: 10.1542/peds.2011-0408 originally published online October 10, 2011;

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