ORIGINAL ARTICLEChest pain in children: diagnosis through history and physical examination☆
Section snippets
Structural anomalies
Chest pain in a child with a murmur may suggest an obstructive lesion such as aortic stenosis or cardiomyopathy. Sharkey and Clarke (1991) explained that children with significant aortic stenosis can have chest pain during exercise. The aortic stenosis causes limited ability to increase cardiac output. This limited response in cardiac output causes a fall in systemic vascular resistance during exertion, thus resulting in coronary artery underperfusion and subsequent myocardial ischemia.
Pericardial or myocardial inflammatory processes
Myocarditis usually follows a viral illness. Many children have fever, respiratory distress, nonspecific chest pain, anorexia, and malaise. Often they have an S3 gallop on examination. The electrocardiogram can reveal ST segment depression and T-wave abnormalities, and a chest x-ray may reveal cardiomegaly. In contrast, pericarditis resulting from infection or autoimmune disorders frequently appears with acute onset of sharp chest pain that is lessened by leaning forward. Physical examination
Arrhythmias
Arrhythmias can also be manifested as chest pain in children. Chest pain may result from a rhythm disturbance based on alterations in cardiac output. Sharkey and Clarke (1991) report that the most common arrhythmia in infants and children is supraventricular tachycardia (SVT). Findings include a rapid heart rate of approximately 200 beats per minute, pallor, grayish coloration, diaphoresis, and in significant episodes, hypotension and syncope. Electrocardiogram findings can include narrow
Methods
This prospective study was designed to diagnose the cause of chest pain in children. Aconvenience sample of 50 consecutive children referred to the cardiology clinic with the chief complaint of chest pain was included in the study. Data were collected during a 4-month period. The children were determined to be eligible for the study if they had no prior cardiology evaluations, did not have a pre-existing cardiac diagnosis, and were referred by their primary care provider because of the sole
Results
The findings of the cardiac examination for all subjects were within normal limits. Twenty-nine percent of the subjects had innocent murmurs that were noted on examination. Thirty-six percent of the subjects had easily reproducible chest pain. On average, the chest pain began 2 weeks to 2 months before referral, occurred on a daily to weekly basis, lasted seconds to minutes, and was self-limited. Of the 50 electrocardiograms obtained for the children with chest pain, 4 (8%) were read as
Discussion
Chest pain in children is a common complaint with an often benign origin. Common noncardiac causes include musculoskeletal/costochondritis, a pneumonic process, a gastrointestinal cause, or a psychogenic cause. However, some cardiac abnormalities in children result in chest pain. Therefore, the most important tools for assessing a child with chest pain are thorough history taking, including a history of present chest pain complaints and family history, and physical examination. This systematic
Limitations
Because every child in the study did not receive an echocardiogram, some subtle structural abnormalities may have been overlooked, such as mild MVP, mild mitral regurgitation, or mild pulmonic stenosis. However, these trivial diagnoses generally do not produce or precipitate chest pain. In addition, children with complaints of associated rapid heartbeats with their chest pain may not have had a documented arrhythmia while participating in the study. However, it is reassuring that at 1 year
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Reprint requests: Juli-anne K. Evangelista, MS, RNc, CPNP, Cardiovascular Program, Children's Hospital, Boston, 300 Longwood Ave, Boston, MA 02115.