While most chest pain in children isn’t caused by heart trouble, pediatricians keep patients safe when they ask the right questions and include certain steps in the physical exam. This guide from pediatric cardiologist Walter Li, MD, sets out a clear, cost-effective path to diagnosis, with a breakdown of the many causes of chest pain and when (and which) tests are helpful.
what has been the practice for many decades. And that is chest pain in Children is seldomly, um, something that is dangerously worrisome and uh, another housekeeping measure. I have no disclosure. So I have no interest in seeing one way or the other. Just just the facts. So the objectives of this talk just to review the potential cause of chest pain. Children also understand the relative prevalence is of the different ideologies. Hopefully I'll be able to convey some key piece of information so as to make the history taking, physical exam is targeted as possible for this assessment. Um, there are some potential limiting factors depending upon different patients. Hopefully we can elucidate some of those. And one of the things I hope to impress upon everyone is appropriate. Use criteria and the limitations of testing. So, hopefully, with um, chest pain in pediatrics, as is in the case of all types of medicine, we're using the exact right test for our patients and for the conditions. Were trying to assess. Yeah. So most of us who have done some assessments of chest pain with pediatric patients understand that the non cardiac theologies tend to be the predominant ones. Musculoskeletal ideologies tend to be the predominant cause. The vast majority of them. Oftentimes you can get to a physical exam where you're very committed, cautioned itis. Sometimes one can use um, the specific phrases ricardo Catch syndrome. If one can get elicit, ate the exact history for that. Oftentimes must with trauma strain can be an ideology. There is an ideology called hyper sensitive boy syndrome, which is very, very, very rare but can occur. And simple cell disease for sure can cause, can cause chest pain. A lot of pulmonary causes that many of us are familiar with. Asthma infections and authorities palma embolisms. Well, what about the cardiac ideologies? Well, thankfully they tend to be the minority of cases and this is my good stall in terms of the ranked um frequencies. So pericarditis, I would say it's probably the most common cardiac ideology that one faces fallout. Myocarditis, thankfully aortic dissection is extremely, extremely, extremely rare and there are specific patient populations for which to be aware of and that smartphones syndrome and other connective tissue disorders uh times to cardiac arrhythmia could be a could present with chest pain, although it's far more likely that a young person will start by saying my heart rate is going crazy fast and then thankfully the minority of cases, even among cardiac ideologies of myocardial ischemia and specific patient populations to be concerned about are going to be those individuals who have dealt with Kawasaki disease. In the past we have the consult of Williams syndrome and then there's the final one to discuss his anonymous coronaries for my inter arterial course. And we'll get into all these um ideology is a little bit later. So going back into history, Our understanding about the causes of chest pains has progressively gotten better with better data. So this is from the 1980s and you can see just based on the number of patients that they're reporting on, its not too terribly high. But even way back in the 1980s, the vast majority of chest pain and pediatric patients were non cardiac and non worrisome ones In the 90s, that didn't change too much. The ideologies percent house are about the same. And this led to the cardiology pediatric cardiology textbook, which talked about chest pain. And it only included seven pages. And this was in the textbook that we're using usually has uh somewhere between 1400 and 1600 pages, depending upon the addition. So, thankfully, in terms of conditions that need active treatment or persistent treatment, they're pretty, pretty darn smallest evidence by the number of pages devoted to in a textbook In the 2000s of the children's hospital Boston then um, started this initiative to have a standardized assessment of chest pain and with multiple goals, want to really articulate how um frequent were the different causes of chest pain. And this is some of the data, which I'll refer to in a future slides as well. Um, thankfully the Frequency of having a cardiac cause of chest pain and pediatric is really, really small, 1%, in fact. So in this study, only 37 patients in their series had a cardiac cause of chest pain. And then the other reassuring thing about this is looking through the specific ideologies, the vast majority that while worrisome and do need to be treated are typically not necessarily inherently going to cause someone to die, particularly. They're picked up in a reasonable time manner. Okay, yeah, so I like this because this is just looking at the same data from a different vantage point and they took all the different potential causes of chest pain, cardiac causes chest pain, and the presentations, and then they looked at the data from different vantage point and said, well, often times did they present with chest pain and the interesting things? Or for me, the reassuring things are while these are certainly worrisome conditions, each of these with three of the four of these should have multiple other symptoms. So it's not a situation where isolated chest and in and of itself is something that should be uh extremely anxiety provoking for the practitioner. So, this is another study which try to um look more specifically in terms of the underlying causes of chest name. From the vantage point of an emergency department physician. And this was done out of out of Turkey. And it was a pretty pretty involved study involving 380 Children and the involving a lot of testing. So I doubt this type of study could ever get done in the us. But every single patient they had the tests that were underlying um on the slide was interesting about it is like all the prior studies from the eighties nineties and the scam study in the two thousands. This study from 2013 also showed that the cardiac causes of chest pain in pediatric patient population was very very small. In fact In this study, out of 380 patients, it was one patient who had pericarditis and I would contend that this should have been picked up with the simple E. K. G. And all the additional tests. And they did cbc chest x ray echocardiogram were all unnecessary. So hopefully hopefully that is pretty convincing that in the vast majority of cases of chest pain and pediatric patients that without even doing further physical exam and history taking you'd be pretty pretty pretty pretty accurate most times by saying it's most likely not the heart. However, I would amend that by saying well when you do do your assessment, don't miss out on these three different such situations. So how do we come to this conclusion? Well history is still very important in the uh to make that assessment. So certainly would want to know if someone had a history of kawasaki syndrome, Mark or Williams syndrome. Those patients are far more likely or at risk of having coronary ischemia. So it'll be pretty pretty helpful to understand that. Certainly knowing if someone has Marfan syndrome will be helpful because uh eric dissection can be deadly and that could necessitate a expediting evaluation. The context in which the patient experience um, test that I think is extremely important. Um, some latter slides, I'll show you why that's the case. Um, the differential factors are going to be well, exertion. Well, if the chest pains reliably being caused or experienced during exertion, then one really should be concerning whether there is a coronary ischemic, uh, ideology going on. If it's exacerbated by respirations, then a primary pulmonary condition should be considered. If the patient's able to convey that palpitating on those specific sites, worsens the pain, then musculoskeletal ideology should be considered. Social systems can be helpful. Certainly, palpitations may uh, prompt one to investigate whether it's attack cardiac arrhythmia and whether or not a monitor may be needed. If there is shortness of breath, how much shortness of breath that may one point you to an ideology, but to also help you dispose the patient as to whether or not this is someone who needs some more expedited assessment. View of symptoms. Certainly understanding someone has upper restoration infection. I'm sure all of us are very, very sensitive during this pandemic family history mockery scheme is helpful in terms of understanding um where the patient the family um, mindset is during this time, because oftentimes there's maybe a recent history of other family member of an elderly age having sustained a monetary scheme that you can understand the anxiety that they're going through, in which case then it helps in terms of um counseling that family, understanding what types of information to provide them to reassure them. And certainly social history is very helpful because many of us are dealing with a lot of anxiety and a lot of stress during this time with the pandemic. I'll be very straightforward. Even just prior to this, uh to this call, I was doing some telehealth is with some my patients and they're dealing with a lot of stress. There are also experiencing a lot more chest pain uh during this time, are noticing muskal self and chest pain during this time. So those are all different things that are helpful uh and can help direct us in terms of providing the best care for these patients. So the other part to this section, of course, is the physical example. To me. One of the best things that we can be doing during this assessment is doing a very detailed localization of where that pain is and sometimes just finding that exact spot is very persuasive to the patients saying, hey, this person is taking really, really, uh, a long way to exam. They really listening to what I'm saying. Yes, they found exactly where that pain is. This person really knows kind of what's going on. And that's oftentimes very helpful in terms of that reassurance. Certainly lying sounds very helpful. Um, noticing there's any chest wall deformities and whether or not one needs to be assessed for marketing syndrome, facialist dwarfism. Um, It is important to notice because I can sometimes .1 to establish a diagnosis of Williams syndrome. Certainly, of course, the vital signs, sample, what's the heart rate? What's the blood pressure? And to me, the most important thing from the vitals portion of the physical stand is the risk free rate and work of breathing. So why is that? Well, because one of the dangerous cardiac causes of chest pain can be myocarditis if that's the case, a lot of other issues aside from chest then going to be evident. Tachycardia, lethargy, restaurant distress, paul minimalism is very, very important to be assistant in terms of chest pain and the work of breathing is very, very important to look at this study which is predominantly done with patients who were presenting initially to the emergency department and then we followed through after a mission. You see that yes, chest pain is a very important um presenting symptom in this uh for this ideology. However, there are certainly many, many, many, many other correlating factors and things that we noticed during the vital signs and physical exam. The other interesting thing from this study and the other thing that I found to be reassuring was that when they looked at the other factors, historical factors that there were very specific patient populations for which palma embolism was to be to be suspected. Um One thing similar to the ongoing covid pandemic is if one is heavy, excessively heavy um then that was an increased risk factor of pulmonary embolism. I think many of us remember from medical school the contraceptive use was also an important risk factors but other things which are helpful to understand and I'm sorry about that, helpful to understand and can be reassuring in terms of the patient who does not have these other issues are patients who have instant, who have indwelling catheters, who had previous pes who've had other surgeries. Are the heart surgeries? Yeah, those are the patients to be willing about. But in the absence of that their chance their risk of having populism is much much much much much less. Um So where is the presentation of palma? And listen in the emergency department? Oh sorry. Um Having these risk factors was very very helpful in understanding that risk for each of those different patients. And the addition of having the deep dime. Er um Assessment was very helpful in terms of the sensitivity of picking up these patients. Oh that's finally, well this slide was his help because again going back to Rachel thing. It's not just any one thing. It's what are the other symptoms that can be differentiated? And this was a very helpful table that the authors put together in terms of looking at the chest pain, the character and helping one um decide to delineate. Well what was more likely for Mile car esquina. Certainly it's a different type of chance. And usually the pressure like heavy and squeezing. Um And the E. K. G. For all three of these different lives are very different. Um There's a very distinct pattern for myocardial ischemia and where you can localize where the scheme is going on, contrast that to pericarditis. Well, the pain is very different. Um it's worse with inspiration. It's worth, it's different with positional changes in such and the changes on the E K. G are typically diffuse and are everywhere. And then contrasted that to both ideologies to palmer vandalism, sharp and stabbing, um, differing with with the aspirations, but contrasting to the other to the E. K. G, abnormalities are a bit more localized. They're more predominant on the right side of the right side of forces on the E K. G. Well, hopefully I'm convincing you as time goes on that the EKGs helpful. And this study um is I I find helpful in terms of saying, well, what should we do during these different kind of cases? And in this study, you can see, well, uh, E K. G. And a chest actually. Oftentimes can pick up an abnormal causes of chest pain, well going a little bit further. Well, how else can, what else can be helpful? Well, if one is worried based on their history and physical of other ideologies getting into opponent can be really, really helpful and most likely it's going if it's abnormal, it's going to point to myocarditis. Mhm. Going back to electric card game. What are the changes? And I'll show you on the next few slides of what a few examples of A KG changes for these conditions market Itis typically is going to have diffuse low voltage sample to use of the cure. S and sometimes, or often times going to have some T wave inversions and pericarditis. On the other hand, the QRS um, voltage sample tunes are going to be pretty much normal, but you're going to, but there are often times diffuse S. T segment elevations everywhere on the E. K. G. Sometimes it can be to emerge depending upon what other uh are how impactful the pericarditis, Whether associate conditions, there are cat card arrhythmias, I'll show you an example of a couple of those and then mile car schema as unlikely as it is to present this way or in this patient population more specifically um have low class sC seven, either elevation and depressions and very very specific depending upon which part is affected findings. So mark arthritis, uh this is a pretty reasonable example. You can see throughout the entire E. K. G. That the QRS complexes extremely, extremely, extremely low. There is what some people turn a wide curious that T wave angle, that is to say there's some T wave inversions with this. Here's another example where um this is a patient who had lupus who I took care of years years ago and when that person went off their medications had Mark Harris and poor heart function and not so bad to cause the curious, complex, curious sample. It used to be so low but certainly enough to make the key ways all flip. Yeah, contrast to pericarditis. Um Throughout all the electra grams on this E. K. G. All the S. T segments are all elevated pretty much every single electra graham that's recorded on here. Sometimes you can be so impactful as to cause the pr to be depressed as well. And this is a real life example of a patient or pericarditis. Um You see the S. T. Segment elevations and changes throughout all the electra grams. Um This patient got got uh which was treated in a timely matter and and got some ibuprofen for about a month and got much better. This is an example the patient had super ventricular tachycardia so hopefully they'll articulate that they're feeling their heart rates really really fast. But uh sometimes particularly younger. The younger younger the trial is sometimes the vocabulary much more limited. So sometimes it's just pain and sometimes which is probably not unusual. Sometimes you have patients come and say you know I haven't come in and out in and out and pain and things like that. And then you get the E. K. G. And you find an example of ballparks in my syndrome and you can deduce that they there's a decent chance that they may have had episodes SPT and they're just not having it in your office. Yeah so this is an example of someone having an I. A. Transgenic cause of a corner injury. So this is an example of patient who underwent uh E. P. Study and the catheter ablation. Unfortunately the operator at the time um injured the right coronary artery. You can see that there's a distinct pattern here. So the inferior esti segments are elevated with reflected S. T. Depressions in the right side of forces. Um And this is an example of a patient who had an abnormal origin, the coronary arteries. And when that rest with this resting hkg. Well the work being asked um The market demand is very low. But contrast that to what happens when the exercise and this is a patient with an exercise test. So this is close to peak exercise. You can see a drastic difference in terms of the S. T. Segment um elevations here. And some T. Wave inversions here. Mhm. So, well I did show you that one case there with an E. K. G. Changes of someone um who's uh had an abnormal coronary artery. And that going to be found an uh an exercise test. Well when should we be doing different tests? And this was going back to that boston study from the um early mid two thousands. This was all rolled into their into their studies saying well let's try to let's just try to have this regulated and standardized and try to figure out well when is the right time to do an echocardiogram for these patients? Because there had already been a lot of data saying that those uh the chance of finding something abnormal that was causing a chest incredibly small. One of the things I think is a real determining factor in terms of that assessment is chest pain. Either early and exercise peak exercise or with sync api knowing the different realities. These are the different, these are the snares for me, that would make it much more likely that there could be anomaly causing the chest pain. Now, that said, they followed their standardized methodology to the T. And this is these where their findings that they published and what was interesting is even using their standardized protocol And doing the tests for the most part, when it was recommended. So, out of 420 plus patients, There was only two patients who had an abnormal finding on the echocardiogram was pericarditis and an anomalous corner. And I was still content of the pericarditis. They should have picked up on the E K G. So really it's one, so one out of 423. So even in that context, when you have symptoms that are potentially worrisome, not terribly likely to find a nominal coronary. In fact, this was reflected in the recent public last 95 years of publication of the uh journalism, the American College of Cardiology in terms of all who should get echocardiograms and what was telling was well knowing that well, if they have exertion of chest pain. Yeah, there's a possibility having anomalous coronary. Even in that context, At a 355 patients, 351 were normal and only two had an abnormality that was explaining their symptoms. What was additionally very reassuring from that whole series from that, that that that that whole series from that boston study, um, was this publication from it. So while it's commonly experienced after a decade of cardiology visits, even if there was either a cardiac cause of the chest pain or incidental finding. And I quote this all the time when when patients come see you for chest pain is none of the patients after a decade of follow up died or had anything really, really terrible happened to them and follow. So just a little plug here. In terms of exercise testing one. Uh it's helpful in terms of assessing the nam as corny as to how impactful it is and whether or not any intervention is helpful. The other thing that I find helpful with exercise testing is that it replicates what the patient is experiencing in a very controlled fashion. And oftentimes it can be extremely, extremely reassuring because under the monitor, a very trained personnel E. K. G monitoring throughout. You were going to be able to see and replicate. We're going to stress these patients out and and and and have them undergoing arduous actually as possible. Oftentimes there's no chest pain whatsoever and patients feel much better. Oftentimes sometimes there is chest pain and then the E. G. Uh is completely normal and we can tell them that there's nothing really, really dangerous going on. So yeah, getting reporting testing all into kind of context, particularly with the pandemic and financial crisis. We're finding ourselves, I think it's even more important that we really be thoughtful in terms of what types of tests we uh ask our patients to undergo. Um now this dad is perhaps about five years old, but I can't imagine inflation of being too terribly about in the past five years. So roughly on average this is the cost of testing that the patient may have to endure. E. K. G. M. I I feel like a lot of very good information can be obtained from the A. K. G. It's pretty reasonable, $85 an echocardiogram. Well painless and doesn't cause any any problems with patients. That is a big big big big financial commitment for a lot of families. Uh Different monitors can be kind of helpful from that standpoint but still really fairly costly. Getting a chest x ray. Um um Not two trillion but still several 100 bucks is uh it's quite an investment exercise testing And when it's hospital based particularly is $3,000 to start with. But and when you start adding in some other components to it in terms of polling function or God driven nuclear myocardial profusion get pretty ready, aren't expensive. And then if one were to get an MRI to look for scarring in the heart yet those always climb very quickly. So in my success in my opinion, going through all the data knowing all the different ideologies, knowing what are the risks that are ongoing for these sort of patients. To me, the most important thing to do is provide reassurance, particularly if uh, the you get a very detailed history and you get a very detailed physical and you can uh find those findings and say, you know, this is Moscow skeleton. No, this is hardly unlikely related to your heart. Yeah, providing that reassurance in a sufficient way possible is very helpful. And I think being able to look at all this different literature that's been published over a few decades, I think it's really helpful. It's very helpful to review that with patients. If one were to do testing. I think an E K G is very reasonable to kind of start with, particularly in the context of knowing the world, why that other countries do universal kg screens. I think it's a very reasonable thing to offer for patients depending upon this narrow sometimes and troy rhythm mantra can be helpful, particularly for the patients who are coming and say, you know, I have a certain different times that I don't have right here in the office right now. Sometimes can be helpful exercise testing. Can we have a particularly if one is dealing with a uh an ethics, let's say this is the um uh this is the varsity basketball player and things like, Yeah, those are the patients you may want to be a little more careful. I I am of the opinion after looking all the different uh testing. I am of the opinion that imaging should be rarely rarely done for patients unless there are adjunct history, our physical exam findings, abnormal vitals that are very, very concerning. I think there's very, very, very seldom any role for imaging. And in terms of treatment, particularly if it's either costs arthritis and musculoskeletal radiology. Um and scents are, are very helpful. So overall, in terms of assessment and treatment, the important thing, our role in many respects is to basically help patients feel like they're okay. So all we're all conclusions wise. Yes, chest pain. I think we all have to be very understanding for the patients when they're experiencing. It's really your anxiety provoking. We have to be open with patients that were not in a psych located. We don't always have the answers and that in many respects, our jobs are to assess for any potential life threatening or dangerous conditions, thankfully the card it causes which are typically oftentimes the most worrisome and dangerous kind of conditions, thankfully the frequency of that being the cause is very rare and the other thing is somewhat reassuring is they oftentimes don't primarily present with chest pain. So far, mortality has not been reported, particularly with the larger scale studies. And uh this is mostly uh I think recently stopped but I think there's increasing data to support this is that I think overall we order too many tests and particularly in terms of pediatric chest pain. I think a history physical certainly are always, always is appropriate to me an E K G I think is um appropriate in this particular case. The other tests I think depends very specifically on the context. In terms of what exactly is the history, What is happening? What is the context? What else are risk factors for that patients? And I think we need to be very careful in terms of what tests to order and with that anything in a couple minutes I am open to any kind of questions. Uh did want to just acknowledge all my colleagues who have always been very supportive and I think um Uh actually I know that there are working very hard at the moment right now and in terms of patient referrals there are many, many different ways but we have a unifying way of accessing the pediatric access center which is that 877 you see child number. There are many many different ways. Um And to to be totally forthright this tele one silver lining about this pandemic is it's uh really helped us in terms of understanding utility of telemedicine and providing that as a lot easier option for a lot of patients. Um Honestly this uh doing telehealth medicine uh medicine visits before this talk um sometimes they're really helpful. I've had even one of my patients um call me on a friday and it's one of those things where they weren't too sure about the kids breathing and during the pandemic, they're also afraid to go to the emergency department. And we were able to actually set up a telemedicine visit through video pretty much within the hour and save that kid from a visit to the emergency department. So um yeah that's one of the silver linings so um please feel free to kind of reach out if you ever should need one of us mm.
