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 something that is dangerously worrisome and a Z, another housekeeping measure. I have no disclosures, so I have no interest in seeing one way or the other, just just the fax. 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. It's possible for this assessment. 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 tests. And 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. So most of us who have done some assessments of chest pain with pediatric patients understand that the non cardiac ideologies 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 costume and itis. Sometimes one can use, um, the specific phrase of Ricardo catch syndrome. If one could get illicit, ate the exact history for that oftentimes muscle trauma strain can be a new ideology. There is an ideology called it hypersensitive site boy syndrome, which is very, very, very rare but can occur, and sickle cell disease, for sure, can cause cause chest pain. Ah, lot of pulmonary causes that many of us are familiar with. Asthma infections and authorities. Palmer embolisms. Well, what about the cardiac ideologies? Well, thankfully, they tend to be the minority of cases, and this is my gestalt in terms of the ranked, um, frequencies. So para crudities, I would say, is probably the most common cardiac ideology that one faces on follow myocarditis. Thankfully, aortic dissection is extremely, extremely, extremely rare, and there are specific patient populations for which to be aware of, and that's Marfan syndrome and other connective tissue disorders. A times take a cardiac arrhythmia could be a could present with chest pain. Although it's far more likely that young person will start by saying, My heart 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 gonna be those individuals who have dealt with Kawasaki disease in the past. We have the gestalt of Williams syndrome. And then there's the final one to discuss his anonymous coronaries from Inter arterial course. And we'll get into all these, um, ideologies a little bit later. So going back into history, our understanding about the cause of the chest pains have progressively gotten better with better data. So this is from the 19 eighties, and you can see just based on the number of patients at their reporting on it's not too terribly high. But even way back in the 19 eighties, the vast majority of chest pain in pediatric patients were non cardiac and non worry. Someone's in the nineties. I didn't change too much the ideologies percent house or about the same. And this led Thio, 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 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 Oh, in the two thousands, the Children's Hospital, Boston. Then, um, started this initiative to have a standardized assess for chest pain and with multiple goals, one to really articulate. How frequent were the different causes of chest pain. And this is some of the data, which I'll refer to a future slides as well. Thankfully, the frequency of having a cardiac cause of chest pain and pediatric is really, really small. 1% in fact. So in this study on Lee, 37 patients in their Siri's 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 toe, cause someone to die particularly there picked up in a reasonable time manner. Okay, Yeah, So I like this because it is just looking at the same data from a different vantage point. And they took all the different potential causes of chest pain. Cardio cause the chest pain and the presentations. And then they looked at the data from different Vantage Point and said, We'll have often times we did they present with chest pain and the interesting things. Or for me, the reassuring things are while these air 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 in and of itself is something that should be, uh, extremely anxiety provoking for the practitioner. So this is another study which try to look more specifically in terms of the underlying cause. The 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 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, he 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 for 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 active 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 that to make that assessment so certainly would want to know if someone had a history of Kawasaki syndrome are or Williams syndrome those patients are far more likely or at risk of having coronary ischemia. So it's being pretty pretty helpful to understand that certainly knowing if someone has Marfan syndrome will be helpful. Because, uh, Eric, this section can be deadly. And that could necessitate a expedited evaluation on the context in which the patient sparing test now I think, is extremely important. Um, some ladder 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 than a primary pulmonary commission should be considered. If the patient's able to convey that palpitating on those specific sites worsens the pain, then Moscow skeletal ideology should be considered eso, she said. This can be helpful. Certainly, palpitations may, uh prompt one to investigate whether it's attack product arrhythmia and whether or not a monitor may be needed. If there's shortness of breath, how much shortness of breath that may 1 point you to an ideology, but to also help you dispose the patient as to whether that this is someone who needs somewhere expedited assessment view symptoms certainly understand. Someone has upper restaurant infection. I'm sure all of us are very, very sensitive today during this pandemic Family history model card 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 in of elderly age. Having sustained a monetary scheming, 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 visit with some my patients, and they're doing with a lot of stress. They're also experience a lot more chest pain. Uh, during this time are noticing Moscow sculpted chest and during this time, so those are all different things that air helpful on bond can help direct us in terms of providing the best care for these patients. So the other part to this substance, of course, is the physical exam. 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 patient saying, Hey, this person is taking really, really a long way Thio exam They really listening to what I'm saying. Yes, they found exactly where that pain is. This person really knows kind of You know what's going on, and that's oftentimes very helpful in terms of that reassurance. Certainly lying Sands. Very helpful. Um, noticing there's any chest hold deformities and whether or not one needs to be assessed for Marfan syndrome, Facialist Martin is, um, um is important to notice, because I can sometimes 0.1 to establishing diagnosis of Williams syndrome. And 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 sand is the rest card rate and work of breathing. So why is that? Well, because one of the dangerous card it causes of chest pain can be myocarditis, if that's the case. Ah, lot of other issues aside from Chest Man gonna be evident. Cardia Lethargy, restaurant distress, Paul Minimalism. Very, very important to be assistant in terms of chest pain and the work of breathing is very, very important. So you look at this study, which is predominantly done with patients who were presenting initially to the emergency department and then we followed through after admission. You can 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, and 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 they were very specific patient populations for which Palma embolism was to be there to be suspected. One thing similar to the ongoing corporate pandemic is if one is heavy, excessively heavy. Um then that was increased risk factor for millions of embolism. E think many of us remember from medical school the contraceptive use was also important risk factors. But the other things which are how awful to understand. And I'm sorry about that hopeful to understand and could be reassuring in terms of the patient who does not have these other issues are yeah, patients who have been sick, who had 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 formalism is much, much, much, much, much less. Um so where is the presentation of palm 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 timer 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 the original thing, it's not just any one thing. It's what are the other symptoms that can be differentiating 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 mild car ischemia? Certainly it's a different type of chance. It uses a pressure like heavy and squeezing on the e K G. For all three of these different religions are very different. There's a very distinct pattern for mild cardi skinny 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 worse. It's different with positional changes in such. And the changes on the K G are typically diffuse and are everywhere. And then contrast that to both ideologies to a paltry embolism sharp and stabbing. Um, differing with with aspirations. But contracting to the other to the e k G abnormalities are a bit more localized there, more predominant on the right side of the right side of forces on the e k g. Well, hopefully I'm convincing you. Ast time goes on that the e k G is 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 conceal on E K G and a chest, actually, oftentimes can pick up on 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, is going to point to myocarditis going back to electrocardiogram. What are the changes? And I'll show you on the next few slides. Of what a few examples of a K changes for these conditions. Mark card itis typically is gonna have diffuse low voltage amplitude of the cure s Andi sometimes or often times gonna have some tea wave inversions and pericarditis. On the other hand, the cure s vault example tunes are going to be pretty much normal, but you're gonna But they're oftentimes diffuse S t segment elevations everywhere on the e k G. Sometimes it can be to be a virgin, depending upon what other are how impactful the pericarditis whether associate conditions there are Cathcart arrhythmias left. I'll show you an example of a couple of those and then mild car schema. As unlikely as it is to present this way or in this patient population, more specifically, have localized SC seven either elevation and depressions and very, very specific, depending upon which coronavirus affected our findings. So, mark, arthritis. Uh, this is a pretty reasonable example. You can see throughout the theme entire E k G that the Q. R s complex is extremely, extremely, extremely low. There is what some people determine why cure s a T wave angle. That is to say, there's some T wave inversions with this. Here's another example where things is a patient who had Lupus, who I took care of years years ago and when that person went off, their medications had mark our eyes and poor heart function and not so bad to cause the q r s complex, curious amplitude to be so low, but certainly enough to make the T ways all flip contrast to pericarditis. Um, throughout all the electro 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. A swell on This is a real life example of patient pericarditis. Um, you see the S T segment elevations and changes throughout all the electro grams. Um, this patient got got, which was treated in a timely matter and and got some ibuprofen for about a month and got much better. This is an example of 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 child is sometimes the vocabulary much more limited. So sometimes it's just pain. And sometimes which eyes? Probably not unusual. Sometimes you have patients coming said, 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 example of world Parkes and Weiss syndrome, and you can deduce that they there's a decent chance that they may have had episodes SBT. And they're just not having it in your office. So this is an example of someone having anti estrogenic cause of a corner injury. So this is example of patient who underwent, uh, E P study and that the Catholic ablation fortunately the operator of the time injured the right corner artery. You can see that there's a distinct pattern here, So the inferior S T segments are elevated with reflected S T depressions in the right side of forces. Andi, this is an example of a patient who had an abnormal origin, the coronary arteries. And when that rest with this resting a K g well, the work being asked or the mark Our demand is very low. But contrast that to what happens when the exercise and this is a patient had 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. So Well, I did show you that one case there with an e k g changes of someone. Um, who's had an abnormal coronary artery in that going to be found on Annette exercise test. Well, when should we be doing different tests? And this was going back to that Boston study from the, uh, early mid two thousands. This was all rolled into their into their studies, saying, Well, let's try Thio. Let's just try to have this regulated and and standardize and try to figure out well, when is the right time to do in that cardigan for these patients? Because there had already been a lot of data saying that those that the chance of finding something abnormal that was causing a chest it was really, really small. One of things, I think, is a real determining factor in terms of that assessment is chest pain either early in exercise, peak exercise or with Cincotti knowing the different realities? These are the 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 were their findings that they published and what was interesting is even using their standardized protocol and doing the test for the most part when it was recommended. So out of 420 plus patients, there was only two patients who had a NAB normal finding on the echocardiogram is pericarditis and an anomalous coronary, and I was still contending 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 national coronary. In fact, this was reflected in the recent public, uh, five years of publication of the journalist of the American College of Cardiology in terms of all who should get, you know, echocardiograms and what was telling was well, knowing that well, if they have exertion of chest pain, yeah, there's a possibility having enormous 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 Siri's 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, 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 hint, anything really, really terrible happened to them and follow. So just a little plug here in terms of exercise testing one. It's helpful in terms off assessing the nomis corny as to how impactful it is and whether or not any intervention is helpful. Theme. 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 have them undergoing arduous actually is possible. Oftentimes, there's no chest pain whatsoever, and patients feel much better. Oftentimes, Sometimes there is chest pain and then the e k g uys completely normal, and we can tell them that there's nothing really, really dangerous going on. So 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 test we ask our patients to undergo. Um, now this. That is perhaps about five years old, but I can't imagine inflation of being too terribly. But 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 there are a lot of very good information can be obtained from the K G. It's pretty reasonable. $85. Echocardiogram. Well, painless. It 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 re fairly cost me getting a chest X ray. Uh, not to Charlie enough, but still 700 bucks is, uh, it's It's quite investment. Exercise, testing, and when it's hospital based, particularly is $3000 thio to start with. But And when you start adding in some other components to it in terms of polling function or, God forbid, nuclear Montecarlo profusion get pretty right on expensive on then if one were to get a memory to look for scarring on the heart that those dogs climb very quickly. So in my assess in, in my opinion, going through all the data, knowing all the different ideologies, knowing what are the risks that are ongoing for these several patients. To me, the most important thing to do is provide reassurance, particularly if, um the you get a very detailed history and you get a very detailed physical and you can find those findings and say, You know, this is Moscow skeletal? No, this is hardly unlike be related to your heart, but providing that reassurance in is efficient way possible is very helpful. And I think being able to look at all this different literature that's been published in a few decades, I think it's really helpful. It's very helpful to current view that with patients, if one were to do testing, I think any K G is very reasonable to kind of start with, particularly in the context of knowing worldwide that other countries do universal kg screens. I think it's a very reasonable thing to offer for patients depending upon the snow. Sometimes I am truly rhythm. Ajit can be helpful, particularly for the patients who are coming and say, You know, I have it a certain different times, but 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 unethical let's say it's 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 am of dependent after looking all the different testing I am of the opinion that image ing should be rarely rarely done for patients unless there are adjunct history. Our physical exam findings add normal 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 costume dryness and muscle skeleton ideology on dstets are very helpful. So overall in terms, assessment, 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 patients when they're experiencing, it's really your anxiety provoking. We have to be open with patients that were not encyclopedia. We don't always have the answers in 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 are oftentimes the most wars 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 the chest pain. So far, mortality has not been reported, particularly with the larger scale studies, and this is mostly, 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 always, always was appropriate to me. And 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 test order. And with that, I've been thinking 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 on number are there many way different ways. Um, and to to be told, the forthright this tell one silver lining about this pandemic is it's, uh, really helped us in terms of understanding utility of telemedicine and providing that as, ah, lot easier option for a lot of patients. Um, honestly, this, uh, I was doing telehealth medicine. Uh, medicine visits before this talk. Sometimes they're really helpful. I've had even one of my patients, um, call me on a Friday and is one of those things where they weren't too sure about the kids breathing and during the panic. They're also afraid to go to emergency department and we were able to actually set up Ah, telemedicine visit through video pretty much within the hour and save that kid from a visit to emerge department. So, um yeah, that's one of the silver linings, so please feel free to kind of reach out if you ever should. You one of us?