Chest Pain
Debra Boyer
Approach to the Patient with Chest Pain
I. Definition of the Complaint
Chest pain is a relatively common complaint in children, with a frequency of 6
per 1,000 outpatient visits. It occurs equally in boys and girls, with a median
age at presentation of 12 years. Traumatic causes occur more often in boys, and
costochondritis and psychogenic causes are diagnosed more frequently in girls.
The most common causes of chest pain in children are generally benign, but this
complaint causes much anxiety among parents and patients due to concern for a
cardiac etiology (Table 14-1).
In understanding the multiple causes for chest pain, one must consider the
various innervation patterns that occur throughout the chest. As an example,
musculoskeletal pain is transmitted via intercostal nerves, whereas the vagus
nerve innervates the large bronchi and trachea. Pain fibers from the parietal
pleura travel via intercostal nerves, and the visceral pleura lacks pain
fibers. Diaphragmatic disease also is transmitted through intercostal fibers
and therefore can cause referred pain in the chest wall. The pericardium has
multiple innervations, including the phrenic, vagal, and recurrent laryngeal
nerves, as well as the esophageal plexus. Therefore, pericardial disease can
manifest with diverse sensations and can be difficult to diagnose. Finally,
cardiac pain itself transmits via the thoracic sympathetic chain and other
cardiac nerves. In summary,
“chest pain” is a very general term that can describe a variety of symptoms and causes. Only
by a very careful history and physical examination can one accurately determine
the cause of the patient
's discomfort.
II. Complaint by Cause and Frequency
Causes of chest pain in children can be separated on the basis of patient age
(Table 14-2) or etiology (Table 14-3). Chest pain is classified as idiopathic
in 23% to 45% of cases. Children younger than 12 years of age are more likely
to have a cardiac or respiratory etiology, whereas children older than 12 years
of age more often have psychogenic causes for their chest pain. Furthermore,
this is often a chronic complaint, with 20% of patients having chest pain for
longer than 3 years.
III. Clarifying Questions
A complete history and physical examination will often reveal the diagnosis in a
patient with chest pain. It is essential to have the patient describe the pain
in detail: time of onset, duration, frequency, intensity, location, radiation,
and precipitating and relieving factors. The patient
's activity at the time of diagnosis can often provide valuable information. The
following questions may provide clues to the diagnosis.
• Is the chest pain associated with exertion, syncope, or palpitations?
— Chest pain that is associated with exertion, syncope, or palpitations is more
concerning for cardiopulmonary disease and warrants further investigation. With
exercise, coronary artery blood flow is decreased; therefore, disease states
with abnormal coronary arteries often manifest symptoms at this time. In some
cases, syncope may also occur. Palpitations may indicate an underlying
arrhythmia such as supraventricular tachycardia or ventricular tachycardia.
• What is the duration of the pain?
— Pain caused by myocardial ischemia usually lasts for less than 1 hour. In
contrast, chest pain from a noncardiac origin may last for hours.
• Is there a family history of sudden death?
— Hypertrophic cardiomyopathy is inherited in an autosomal dominant fashion, so
there may be a family history of sudden death. These patients may have a murmur
that is augmented with standing or with Valsalva maneuver. Furthermore, chest
pain in these patients may be most severe with exercise. Similarly, in
congenital hyperlipidemia, patients may present at a young age with myocardial
infarction and may have a family history of sudden death.
• Is the pain relieved with changes in position?
— Patients with pericarditis often have precordial pain with radiation to the
left shoulder. The pain is worse while lying down and is improved with sitting
and leaning forward.
• Is there a history of precipitating trauma?
— In the trauma patient, tachycardia and hypotension may be secondary to a
hemothorax or other vascular injury. In patients with poor perfusion and
decreased cardiac output, myocardial contusion, tension pneumothorax, and
cardiac tamponade should be considered.
• Is there a prior history of cardiorespiratory disease?
— Patients with a history of asthma, cystic fibrosis, or a connective tissue
disorder have an increased risk of pneumothorax and pneumomediastinum.
• Can the pain be reproduced on physical examination?
— Musculoskeletal pain usually can be elicited by palpation of the chest wall.
Costochondritis, most commonly seen in teenage girls, is associated with
palpable pain over the rib cartilage. Muscle strain usually results in palpable
pain over the affected muscle.
• Is the child taking any medications?
— Oral contraceptives increase the risk of pulmonary embolism. Steroids and
nonsteroidal antiinflammatory medications (NSAIDs) increase the risk for
gastritis.
• Does the pain relate to meals?
— Chest pain caused by gastroesophageal reflux commonly occurs after meals.
Medication trials may be helpful to confirm the diagnosis.
• Have there been any recent stressors in the patient's life?
— Psychogenic chest pain may occur in patients with recent major stressful events
in their lives. These patients often have multiple somatic complaints in
addition to chest pain. A family history of depression or a somatization
disorder increases the likelihood that a child will develop psychogenic pain.
• Does the pain wake the child from sleep?
— Children who awake from sleep secondary to chest pain are more likely to have
an organic cause of their pain.
• Is there a history of substance use or abuse?
— Tobacco use may be associated with a chronic cough and chest pain. Cocaine and
methamphetamine abuse may lead to coronary artery vasospasm and ischemic chest
pain.
IV. References
1. Chest pain. In: Tunnessen WW, ed. Signs and symptoms in pediatrics. Philadelphia: Lippincott Williams & Wilkins, 1999:361–369.
2. Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am 1999;46:189–203.
3. Leung AKC, Robson WLM, Cho H. Chest pain in children. Can Fam Physician 1996;42:1156–1164.
4. Patterson MD, Ruddy RM. Pain—chest. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine. Philadelphia: Lippincott Williams & Wilkins, 2000:435–440.
5. Rosenstein BJ. Chest. In: Hoekelman RA, Friedman SB, Nelson NM, et al., eds.
Primary pediatric care. St. Louis: Mosby, 1997:888–890.
6. Selbst SM. Chest pain in children. Pediatr Rev 1997;18:169–173.
The following cases represent less common causes of chest pain in childhood.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Chest pain
Read excerpts from these other book chapters related to Chest pain:
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- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- "Pediatric Complaints and Diagnostic Dilemmas" (2003)
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest pain
» Next page: Chest Pain - Case 14-1: 17-Year-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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