Chest pain

Question 1

Red flags for cardiac cause of chest pain

Answer 1

Exertional cardiac-type chest pain
Exertional syncope
Significant family history e.g. Brugada/long QT syndrome/sudden cardiac death <35y
Connective tissue disorders
History of cocaine/amphetamine use
Abnormal cardiovascular examination/ personal history of congenital heart disease (e.g., arterial switch or truncus arteriosus repair)

Question 2

Investigations for chest pain

Answer 2

• ECG to look for ischaemic changes or hints for arrhythmic cause (e.g., LQTS)
• CXR to exclude other causes
• Troponin – beware in neuromuscular, previous extensive surgery, arrhythmias
• Echocardiogram
• CTA if considering CTD / dissection

Question 3

Hint that chest pain might relate to pericarditis

Answer 3

o Think weight loss (rheum/malignancy) and viral symptoms

Question 4

Hint that chest pain might be due to arrhythmia

Answer 4

o ECG outside arrhythmia might or might not be useful

Question 5

Hint that chest pain may relate to ischaemia

Answer 5

o Coronary artery anomalies (congenital and acquired e.g. Kawasaki). Beware of thrombosis within coronary aneurysms in Kawasaki
o Inadequate coronary perfusion secondary to left ventricular outflow tract obstruction e.g. aortic stenosis/ hypertrophic cardiomyopathy / intracardiac tumor / large vegetation
o Vasospasm e.g. following cocaine use
o Early-onset atherosclerotic disease e.g. familial hypercholesterolaemia (extremely unlikely in paediatric population)
o High demand: severe HCM
o Coronary artery thrombosis: most commonly from endocarditis vegetations
o Anomalous left coronary artery from the pulmonary artery (ALCAPA) – associated with recurrent respiratory infections or heart failure and failure to thrive

Question 6

Kawasaki disease diagnosis

Answer 6

Fever >5 days AND 2+ of
Polymorphous rash
Oral mucosa changes
Cervical lymphadenopathy
Bilateral red eyes
Peripheral erythema, desquamation, edema

OR Fever 7+ days without explanation

Question 7

Labs in Kawasaki

Answer 7

High CRP
High ESR
Anaemia, Plt high, low Alb, high ALT, WCC high, high urine WCC

Question 8

Scoring system for Kawasaki for IVIG requirement

Answer 8

Kobayashi score - early disease, high ALT, low plt, high CRP, low age, low Na, high neutrophils, risk of IVIG resistance

Question 9

When are steroids given in KD

Answer 9

Givein in high risk features - severe disease, <12 months, severe inflammation, HLH or shock, already present or evolving CA aneurysms

Methylprednisolone

Question 10

Resistance risk factors for IVIG

Answer 10

Resistance risk factors: >48h fever from presentation, enlarged Cas at presentation, <12 months of age, shock and MAS at presentation, Kobayashi score > 5

Question 11

High dose aspirin in KD

Answer 11

Not recommended

Question 12

Treatment of KD

Answer 12

IVIG, + steroid if high risk