Pediatric Chest Pain and Syncope - Oklahoma State University ...

Pediatric Chest Pain and
Syncope:
Which Kids Should Worry You
Audrey Stanton, D.O., M.P.H.
St. John Health System

Objectives
• At the conclusion of this program,
participants will be able to:
• appropriately evaluate pediatric chest pain or
syncope patients presenting to the emergency
department.
• recognize and manage serious and dangerous
causes of pediatric chest pain or syncope.
• establish proper disposition of pediatric chest pain
or syncope patients presenting to the emergency
department.

How big is the
concern?
• Not common CC
• Rarely serious pathology
• But the serious causes are serious
• Good hx and physical are critical

Sebst et al 1988
• 407 ED presentations
• 60% had normal exam
• most common abnormality: chest wall TTP
• 4% had cardiac etiologies: arrhythmia,
pericarditis, MVP, pericardial effusion,
mitral regurgitation
• 1 pneumothorax with hx Marfans
• Final Dx: 21% idiopathic, 15%
musculoskeletal

Sebst et al 1990
• followed 149 for 6 months, 51 for 2+
years
• 34% had dx changed: MC idiopathic
• only 1 new cardiac dx: MVP
• 43% still had chest pain

Rowe et al 1990
• 336 ED presentations
• nearly half had chest wall TTP
• 5 had cardiac dx: myocarditis, ASD,
HCM, WPW, congenital heart block
• 28% dx with chest wall pain

Cohn et al 2012
• retrospective record review of 203 pts
sent to pediatric cardiologist for chest
pain
• exertional CP not assoc with higher risk
of CV dx
• most helpful studies: EKG and echo
• 93% did not have a CV dx

Anderson et al 2012
• retrospective review 627,489 ED visits
for pediatric syncope
• MCC neurocardiogenic syncope (vagal)
• serious causes: LQTS, Brugada, HCM,
congenital structural heart disease
• Overall low yield on testing except EKG
• neuroimaging appropriate if head injury,
HA, or associated seizure-like activity

What makes these
patients challenging?

What to do every time...
• get a very thorough:
• HPI
• medical history
• family history
• physical exam
• EKG and CXR
• risk stratification to determine if any further
testing or specialist follow up is needed

Chest pain equivalents
in children
• syncope or presyncope
• dizziness
• palpitations
• dyspnea
• seizure-like activity

How to rapidly mentally
categorize and recall the
serious causes...
• Structural
• Electrical
• Inflammatory/infectious

Structural
• Hypertrophic Cardiomyopathy
• Pneumothorax/Pneumomediastinum
• Aortic Dissection
• Pulmonary Embolism
• Coronary Artery Anomalies
• Mitral Valve Prolapse

Hypertrophic
Cardiomyopathy
• 14 year old male
• syncopal episode during football
practice
• no significant history
• normal exam
• describes sudden onset

• mutation in cardiac sarcomere protein genes
• leading cause of sudden death in young athletes
• common symptoms: chest pain, syncope,
palpitations, exercise intolerance
• can progress to heart failure at any age
• 1-2% per year rate of sudden death
• urgent pediatric cardiology referral, beta blockers

Pneumothorax/
Pneumomediastinum
• 17 year old girl presents with right sided
chest pain after playing basketball at
church
• reproducible on exam
• no medical history or family history
• normal EKG

Aortic dissection
• uncommon
• associated with Marfans, other
connective tissue diseases, aortic
stenosis, coarctation, cocaine use,
HTN, blunt chest trauma
• CT angiography
• emergent surgical intervention

Pulmonary Embolism
• almost always due to underlying
disorder, OCPs, or line-related
• unexplained persistent tachycardia,
hypoxemia, fever, leg/arm swelling
• clinical decision rules not useful
• D-dimer less useful in children
• V/Q vs CT

Coronary Artery
Abnormalities
• 7 year girl old presents after syncopal
episode during gymnastics
• history reveals previous episodes of
palpitations
• normal exam
• EKG shows ischemic changes

Mitral Valve Prolapse
• chest pain is uncommon with MVP
• may be due to papillary muscle
dysfunction or subendocardial ischemia
• midsystolic click +/- late systolic murmur

Electrical
• Supraventricular Tachycardia
• Wolff-Parkinson-White
• Brugada
• Long QT Syndrome

SVT
• 13 year old girl with 1.5 hrs of heart
racing. started during volleyball
practice
• no other symptoms
• no medical history, grandfather had
cardiac ablation

• adenosine
• cardioversion
• cardiology follow up
• may require cardiac ablation

Wolff-Parkinson
White
• 7 year old female presents with cough
• she reports history of “sometimes it
feels like my heart is beating really fast”
• no medical or family history
• normal exam, normal vitals

• treatment of tachycardic episodes
• vagal maneuvers, adenosine, verapamil,
cardioverson
• urgent cardiology referral
• some need emergent evaluation
• longer-term treatment
• Calcium channel blockers or beta blockers
• ablation

Brugada
• 5 year old girl presents after syncopal
episode
• occurred at rest
• she has had a fever for 2 days
• her uncle had a sudden unexpected
death at age 18

• arrhythmogenic
disorder
• can be asymptomatic
until sudden cardiac
death
• fever can precipitate
symptoms
• managed in kids with
defibrillator or
quinidine
• emergent cardiology
evaluation

LQTS
• 14 year old male presents after a
syncopal episode
• He describes palpitations at onset,
otherwise sudden
• No medical history
• Family history of multiple family
members with early sudden
unexplained death

Other channelopathies that
can cause syncope or
sudden cardiac death
• Catecholeminergic Polymorphic
Ventricular Tachycardia
• Short QT Syndrome
• Congenital Sick Sinus Syndrome

Inflammatory/
Infectious
• Pericarditis
• Myocarditis
• Kawasaki Disease

Pericarditis
• 12 year old male presents with chest
pain
• recent URI symptoms
• pain is worse if laying flat, improves if
leaning forward
• no medical history or family history

• don’t routinely require labs
• CXR and/or US to evaluate for possible
pericardial effusion
• if no effusion or suspected bacterial
cause, can treat with NSAIDs
• can have concurrent myocarditis

Myocarditis
• 4 year old female with fever, shortness
of breath, tachycardia
• prolonged capillary refill
• EKG sinus tachycardia, nonspecific
ST/T changes
• CXR mild pulmonary edema

• Wide variation of severity from mild
presentation to acute fulminant illness
• no universally accepted definition
• if no preexisting heart disease, normal
troponin can be used to exclude myocarditis
• in one study, 83% of those with myocarditis
had abnormal EKG, mostly nonspecific
changes

Kawasaki Disease
• 3 year old male presents with chest pain,
difficulty breathing, and tachycardia
• hx of 1 week long febrile illness sometime
last month
• exam significant for peeling fingers and toes
• CXR shows cardiomegaly
• BSUS shows pericardial effusion
• EKG sinus tachycardia

• IVIG and ASA
• variations in incidence
• racial/ethnic
• seasonal

Summary
• Serious causes of pediatric chest pain are
rare
• Always get a good hx and physical exam
along with an EKG and CXR
• Mentally categorize
• Structural
• Electrical
• Inflammatory/infectious

References
Anderson JB, Czosek RJ, Cnota J, Meganathan K, Knilans TK, Heaton PC. Pediatric syncope: national hospital ambulatory medical care survey results. Journal of
Emergency Medicine. 2012; 43: 575-583.
Cohn HE, Arnold LW. Chest pain in young patients in an office setting: cardiac diagnoses, outcomes, and test burden. Clinical Pediatrics. 2012; 51: 877-883.
Davis JA, Cecchin F, Jones TK, Portman MA. Major coronary artery anomalies in a pediatric population: incidence and clinical importance. Journal of the American
College of Cardiology. 2001; 37: 593-597.
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang, VW. Cardiac troponin T as a screening test for myocarditis in children. Pediatric Emergency Care. 2012;
28: 1173-1178.
Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. Journal of Thoracic and
Cardiovascular Surgery. 2011; 142: e153-e189.
Ghelani SJ, Spaeder MC, Pastor W, Spurney CF, Klugman D. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to
2011. Circ Cardiovasc Qual Outcomes. 2012; 5: 622-627.
Moak JP, Kaski JP. Hypertrophic cardiomyopathy in children. Heart. 2012; 98: 1044-1054.
Patocka C, Nemeth J. Pulmonary embolism in pediatrics. Journal of Emergency Medicine. 2012; 105-116.
Probst V, Denjoy I, Meregalli PG, et al. Clinical aspects and prognosis of Brugada Syndrome in children. Circulation. 2007; 115: 2042-2048.
Probst V, Chatel S, Gourraud JB, Marec HL. Risk stratification and therapeutic approach in Brugada Syndrome. Arrhythmia and Electrophysiology Review. 2012;
1: 17-21.
Rowe BH, Dulbert CS, Peterson RG, Vlad P, Li MM. Characteristics of children presenting with chest pain to a pediatric emergency department. Canadian Medical
Association Journal. 1990; 143: 388-394.
Selbst SM, Ruddy RM, Clark BJ, Henretig FM, Santulli T. Pediatric chest pain: a prospective study. Pediatrics. 1988; 82: 319-323.
Selbst SM, Ruddy RM, Clark BJ. Chest pain in children follow-up of patients previously reported. Clinical Pediatrics. 1990; 29: 374-377.
Selbst SM. Approach to the child with chest pain. Pediatric Clinics of North America. 2010; 1221-1234.
Uehara R, Belay ED. Epidemiology of Kawasaki Disease in Asia, Europe, and the United States. J Epidemiology. 2012; 22: 79-85.
Zalstein E, Hamilton R, Zucker N, Diamant S, Webb G. Aortic dissection in children and young adults: diagnosis, patients at risk, and outcomes. Cardiol Young.
2003: 13: 341-344.