Chest Pain

Question 1

What is the average age of presentation for pediatric chest pain?

Answer 1

13 years

Question 2

What are the top 3 most common causes of pediatric chest pain?

Answer 2

• Trauma/muscle strain of chest wall
• Costochondritis
• Respiratory illness with cough

Question 3

What percentage of chest pain is cardiac in nature?

Answer 3

< 5 %

Question 4

Describe chest pain due to costochondritis

Answer 4

• More common in girls than boys
• Sharp, anterior chest pain
• Usually unilateral, occasionally bilateral
• Exaggerated by physical activity or breathing
• Radiation to chest, back, abdomen

Question 5

How to diagnose costochondritis?

Answer 5

*

Question 6

What is the natural history of costochondritis?

Answer 6

• Benign condition
• Pain may persist several months

Question 7

What is Tietze’s syndrome?

Answer 7

• Rare form of costochondritis
• Large, tender, fusiform, nonsuppurative swelling at costochondral junction
• Usually affects upper ribs, especially second and third costochondral junctions

Question 8

List a differential for pediatric chest pain

Answer 8

• Idiopathic
• Costochondritis
• MSK strain
• Respiratory: lung pathology, pleural irritation, pneumothorax
• Exercise induced asthma
• GERD
• Precordial catch
• Slipping rib syndrome
• Mastalgia
• Pleurodynia
• PE
• Hyperventilation

Question 9

What is slipping rib syndrome?

Answer 9

• Excess mobility of 8th-10th ribs which do not directly insert into sternum
• Ligaments holding ribs to upper ribs are weak
• Pain when ribs slip down

Question 10

What percentage of pediatric chest pain is cardiac in origin?

Answer 10

0-5%

Question 11

List the cardiac causes of chest pain

Answer 11

• Myocardial ischemia associated with obstructive congenital heart disease
• Mitral valve prolapse
• Cardiomyopathy
• Coronary artery disease
• Cocaine abuse
• Aortic dissection/aneurysm
• Pericarditis
• Myocarditis
• Arrythmias

Question 12

What is the cause of chest pain with severe obstructive lesions?

Answer 12

• Increased myocardial oxygen demands from tachycardia and increased pressure work on the ventricle
• Pain usually associated with exercise and anginal pain

Question 13

What percentage of patients with mitral valve prolapse experience chest pain?

Answer 13

20%

Question 14

Describe chest pain associated with mitral valve prolapse

Answer 14

• Vague, non exertional chest pain of short duration located at the apex without a constant relationship to emotion or effort

Question 15

How does cocaine cause chest pain?

Answer 15

• Blocks reuptake of norepinephrine in the CNS and peripheral nervous system
• Increased sympathetic output and catecholamines causes coronary vasoconstriction
• Cocaine activates platelets, increases endothelin production and decreases NO production
• Increases HR, increases BP, increases myocardial O2 consumption
• Can cause anginal pain, arrythmias, infarction and sudden death

Question 16

Which children are at risk for aortic dissection or aneurysm?

Answer 16

• Turner’s
• Marfan’s
• Noonan’s

Question 17

Describe chest pain due to pericarditis

Answer 17

• Sharp stabbing precordial pain worsens with lying down and improves when sitting up and leaning forward

Question 18

What physical exam findings are consistent with pericarditis?

Answer 18

• Distant heart sounds
• Neck vein distenstion
• Friction rub
• Paradoxical pulse

Question 19

Describe classic ECG findings associated with pericarditis

Answer 19

• Low QRS voltages
• ST-T wave changes

Question 20

When to refer chest pain to cardiology?

Answer 20

• Chest pain triggered or worsened by physical activity
• Chest pain associated with dizziness, syncope, palpitations
• Abnormal cardiac exam, ECG, CXR
• • FHx cardiomyopathy, long QT syndrome, sudden unexpected death
• Highly anxious family - otherwise will just keep presenting with same issues

Question 21

What is the management of costochondritis?

Answer 21

• Reassurance
• NSAIDs
• Limit backpack weight
• Avoid physical activities requiring shoulder girdle use