Effectiveness of Screening for Life-Threatening Chest Pain in Children WHAT’S KNOWN ON THIS SUBJECT: Chest pain 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 tachycardia 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), anxiety-related (n ϭ 34), or drug-related (n ϭ 4) origin. Emergency department 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 e1062 SALEEB et al Downloaded from www.aappublications.org/news by guest on September 24, 2021 ARTICLES 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. Medical history 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 asthma. 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. arrhythmia, connective tissue 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 artery 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 cardiovascular disease, 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