Chest pain Flashcards
What are some potentially life-threatening cardiac and pulmonary conditions that must be considered in the work-up of patients with chest pain?
How often are these diagnosed in children presenting with chest pain?
potentially life-threatening cardiac conditions (eg, hypertrophic cardiomyopathy, myocarditis, or myocardial ischemia) and serious pulmonary conditions (eg, acute chest syndrome in patients with sickle cell disease, spontaneous pneumothorax, or pulmonary embolus) are found in 1 to 6 percent of pediatric patients with chest pain depending upon the setting
Differential diagnosis of non-traumatic chest pain in children and adolescents?
Symptoms which may suggest cardiac cause of chest pain?
- chest pain occurs during exertion or is associated with palpitations
- syncope with exertion
- decreased exercise tolerance
- FHx of cardiomyopathy/cardiac arrhythmia/sudden death in close relatives before age of 50 years
Factors associated with risk for myocardial ischemia?
- known congenital heart disease
- heart transplant
- substance abuse
- prior Kawasaki disease
Hypertrophic cardiomyopathy history findings?
Positive family history
Exercise intolerance
Exertional chest pain
Syncope and/or arrhythmia
Hypertrophic cardiomyopathy exam findings?
Dynamic systolic murmur
Hypertrophic cardiomyopathy ECG findings?
Left ventricular hypertrophy or left axis deviation
ST segment or T wave changes
Q waves
Arrhythmias, ventricular premature beats
Ventricular pre-excitation (Wolff-Parkinson-White)
Dilated cardiomyopathy history findings
Family history
Decreased exercise tolerance, syncope
Heart failure symptoms
Dilated cardiomyopathy exam findings
Gallop
Mitral regurgitation murmur
Dilated cardiomyopathy ECG findings?
Intraventricular conduction delay
High or low QRS voltages
Arrhythmia, premature beats
Anomalous coronary artery origin history findings
Exertional chest pain
Exertional syncope
Anomalous coronary artery origin exam findings
usually normal
Anomalous coronary artery ECG findings
usually normal
Coronary ischaemia history findings?
Predisposing conditions:
History of Kawasaki disease
Cardiac surgery or heart transplant
Systemic arteriopathy (Williams syndrome)
Severe familial hypercholesterolemia
Drug use: Cocaine, sympathomimetics
Anginal chest pain
coronary ischaemia exam findings
tachycardiac
tachypnoea
new murmur or gallop
coronary ischaemia ecg findings
ST segment depressions or elevation
T wave changes
Q waves
severe left ventricular outflow tract obstruction history findings?
Exertional symptoms
Exertional syncope
Severe left ventricular outflow tract obstruction exam findings
loud systolic murmur
Severe left ventricular outflow tract obstruction ecg findings
Left ventricular hypertrophy
Left ventricular strain pattern
arrhythmia history findings?
Palpitations
Syncope
Positive family history
arrhythmia exam findings
irregular rhythm
arrhythmia ecg findings
Atrial arrhythmia
Ventricular arrhythmia
Premature contractions
Ventricular pre-excitation (Wolff-Parkinson-White)
pericarditis history findings?
Positional chest pain
Predisposing factors:
Rheumatologic conditions
Malignancy
Mediastinal radiation
Infection (HIV, tuberculosis, viral)
Renal failure
Recent cardiac surgery
pericarditis exam findings
Cardiac rub
Tachycardia/tachypnea
Distant heart sounds, JVD
pericarditis ecg findings
Diffuse ST segment changes
T wave inversions
myocarditis history findings
Fever
Viral prodrome
Short duration of symptoms
New onset heart failure symptoms
myocarditis exam findings
Tachycardia
Tachypnea
With or without gallop rhythm, ventricular ectopy
Cardiovascular collapse
myocarditis ecg findings
Diffuse ST segment changes
T wave inversions
PR depression
Ventricular ectopy
Low QRS voltages
aortic dissection history findings
Personal or family history of bicuspid aortic valve or connective tissue disorders (Marfan, Loey-Dietz, Ehlers-Danlos type IV, others)
Acute onset sharp or tearing type of pain
aortic dissection exam findings
marfanoid body habitus
aortic dissection ecg findings
ST segment depressions or elevation
T wave changes
Q waves
PE history findings
Pain description: Acute onset, pleuritic, associated dyspnea
Personal or family risk factors (inherited thrombophilia, hypercoagulable states, immobilization, medications)
PE exam findings
Right ventricular heave (elevated right ventricular pressure)
Loud and/or unsplit S2 (if right ventricular pressure elevated)
PE ECG findings
Right ventricular hypertrophy
Right ventricular strain pattern
How might CHD with LV outflow obstruction cause chest pain in kids? Which lesions might cause this?
Hypertrophic cardiomyopathy, aortic stenosis (subvalvar, valvar, or supravalvar), or coarctation of the aorta may cause decreased coronary blood flow and angina
Describe how coronary artery anomalies might cause chest pain in children
- congenital and acquired conditions (eg, coronary artery aneurysm or stenosis caused by Kawasaki disease) and may present with chest pain on exertion.
- Anomalous origin of the left coronary artery from the main pulmonary artery usually presents in infancy, but can become symptomatic later in childhood. In that disorder, left ventricular ischemia usually results in cardiomyopathy and mitral regurgitation.
- Origin of a coronary artery from the contralateral sinus of Valsalva and coursing of the anomalously positioned coronary artery between the aorta and pulmonary artery can be associated with exertional chest pain. In these patients, the pain is caused by compression of the coronary artery between the distended great arteries with the increased cardiac index associated with exercise with the following anatomic variants:
●Slit-like coronary orifice
●Acute angle of take-off of the coronary artery
●Presence of an intramural segment
Risk factors for classic angina?
- hyperlipidemia
- prior Kawasaki disease with coronary artery aneurysms or stenoses
- collagen vascular disease (eg, systemic lupus erythematosus)
Symptoms and ECGs findings of classic angina?
crushing or squeezing substernal chest pain with radiation to the jaw or left arm and associated with diaphoresis, nausea and vomiting, difficulty breathing, or altered mental status. An electrocardiogram (ECG) obtained while the patient has pain often shows ST wave elevation or depression
Describe variant angina. How does it present and what ECG findings are there?
Coronary vasospasm (variant angina) and myocardial infarction are rare causes of chest pain in children and adolescents. Coronary vasospasm is associated with angina, transient ischemic changes on ECG during episodes of pain, cardiac enzyme elevation, and ST-segment elevation on ambulatory ECG monitoring. Variant angina with myocardial infarction has been described after recreational use of cocaine, amphetamines, bath salts (methcathinones), marijuana, and synthetic cannabinoids in adolescents.
What are the major clinical manifestations of pericarditis?
●Chest pain that is typically sharp, increased with inspiration, improved by sitting up and leaning forward, worsened by lying down, and occasionally radiates to the left shoulder
●Pericardial friction rub described as a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border during the systolic, diastolic or both phases of the cardiac cycle
●Electrocardiographic (ECG) changes such as new widespread ST elevation or PR depression; later in the course there is T wave inversion
●Distant heart sounds and/or pulsus paradoxus suggesting pericardial effusion
What are some of the etiologies of pericarditis?
Pericarditis may be of infectious origin (eg, nonspecific viral, bacterial, tuberculous, or secondary to human immunodeficiency virus), associated with open heart surgery (post-pericardiotomy syndrome), or complicate an underlying condition such as collagen vascular disorder, uremia, neoplasm, or trauma
How might viral myocarditis present?
Viral myocarditis in children, which is usually painless, may occasionally cause chest pain when concomitant pericarditis is present. Children with myocarditis also may display tachycardia that is out of proportion to fever or persistent while quiet or asleep, respiratory distress, signs of heart failure, poor perfusion, and atrial or ventricular arrhythmias
What additional symptoms other than chest pain might dilated cardiomyopathy present with?
Children with dilated cardiomyopathy can develop chest pain in association with syncope, decreased exercise tolerance, and heart failure symptoms (eg, orthopnea or dyspnea on exertion). From 20 to 50 percent of patients with dilated cardiomyopathy have an inherited form. A family history of heart failure before the age of 60 years or sudden death suggests a genetic cause.
How might tachyarrhythmias present as chest pain?
Tachyarrhythmias (eg, supraventricular tachycardia with or without underlying Wolff-Parkinson-White syndrome, ventricular tachycardia) are usually painless, but, if sustained, may cause angina. Some children may also experience the sensation of palpitations associated with tachyarrhythmias or premature beats and report this sensation as chest pain
How might aortic root dissection present?
Aortic root dissection causes an abrupt onset of severe sharp or tearing pain that may be localized to the anterior chest (ascending aortic dissection) or posterior chest (descending aortic dissection) with radiation to other parts of the chest, back or abdomen. It is associated with Marfan syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome, homocystinuria, rare familial aortopathies, or cystic medial necrosis.
What is a ruptured sinus of valsalva aneurysm?
Ruptured sinus of Valsalva aneurysm is a rare condition caused by congenital absence of media in the aortic wall behind the sinus of Valsalva. The aneurysm typically ruptures into the right ventricle or right atrium but can affect the other chambers or pulmonary artery and cause a continuous murmur and heart failure
What are etiologies of chest pain that are non-cardiac?
Spontaneous pneumothorax
PE
Pulmonary HT
Acute chest syndrome (sickle cell) - chest pain plus new pulmonary infiltrate involving at least one complete lung segment (not atelectasis), temperature >38.5ºC, and tachypnea, wheezing, or cough
Airway foreign body
Tumor
Oesophageal rupture (boerhaave syndrome)
What are some of the common causes of paediatric chest pain?
Specific diagnoses, from most to least frequent, include the following:
●Musculoskeletal conditions (eg, costochondritis, muscle strain, or trauma)
●Psychogenic conditions (eg, panic attack, hyperventilation syndrome, or psychosomatic complaints)
●Respiratory conditions (eg, asthma, pneumonia, or pleuritis)
●Gastrointestinal disease (eg, gastroesophageal reflux, esophagitis, or gastritis)
●Breast disease
●Skin infections
List the more common MSK causes of chest pain in children
Costochondritis
Slipping rib syndrome
Precordial catch
pectus excavatum
pectus carinatum
List some GIT causes of chest pain in children
GORD
Medication-induced ‘pill’ oesophagitis
oesophageal foreign body
What is pleurodynia?
Pleurodynia refers to an acute illness with marked paroxysmal spasms of the muscles of the chest and abdomen and fever. It most commonly occurs in association with group B coxsackie viruses. In children, characteristic vesicular stomatitis and rash on the palms and soles of the feet are often present as well . Most patients are ill for four to six days
What neurological disorders may present as chest pain?
Chest pain rarely is caused by a neurologic disorder that affects one or more costal nerves. As an example, herpes zoster in a dermatomal distribution on the chest can cause pain, which may be manifest before lesions appear. Spinal cord compression, which may be caused by tumor or vertebral collapse, or epidural abscess is also a rare cause of radicular chest pain
What are some causes of elevated troponin?
Describe an approach to non-traumatic chest pain in children
What are some investigation to consider in chest pain work up?
ECG, TTE, bloods +/- including troponin
