12 Chest Pain
12.1 Basics
Epidemiology
Patients who present with chest pain are more often children and adolescents between the ages of 12 and 14 years. Boys and girls are equally affected. Since chest pain in adults is a typical symptom of serious diseases (myocardial infarction, pulmonary embolism, etc.), chest pain in children is often perceived to be just as threatening, thus giving rise to anxiety. However, chest pain in children and adolescents only rarely has a cardiac cause.
Etiology
Most chest pain in childhood and adolescence is idiopathic. If any cause is found, it is usually a musculoskeletal or pulmonary disease. At most, only 1% to 3% of cases have cardiac causes. Psychogenic chest pain is more common in children over age 12 than in younger children.
Chest pains can also stem from the esophagus, stomach, or gall bladder. The most common causes of chest pain in childhood and adolescence are listed in Table 12.1.
Cause | Indicative findings |
Musculoskeletal | |
Excessive strain of the chest muscles (stiff muscles, e.g., from weight training or coughing), trauma, pulled muscle | Medical history, local palpation finding |
Costochondritis | Reproducible tenderness at the costosternal or costochondral junctions of the ribs, usually on one side, increased by deep breathing or physical exertion, duration up to several months; harmless illness, generally no treatment needed |
Tietze syndrome | Swelling at the costosternal junctions, usually affecting the upper ribs |
Pulmonary | |
Bronchial asthma | Dyspnea, retrosternal pain, auscultation, prolonged expiration, wheezing |
Pneumonia | Cough, fever, respiration-related pain, auscultation, fine moist rales over the lungs, X-ray |
Pleural effusion | Breathing-related pain (increase in pain on deep inspiration), effusion in ultrasound or X-ray |
Pneumothorax | Sudden onset of pain, dyspnea, weakened breath sounds on one side |
Pleurodynia | Chest pain after a virus infection, Coxsackie virus detected |
Pulmonary embolism | Sudden onset of breathing-related pain, hypocapnia, tachycardia, coagulation disorder, thrombosis, fever |
Aspiration of a foreign body | Medical history, sudden dyspnea and chest pain, possibly weakened breath sounds on one side, X-ray finding, bronchoscopy to confirm the diagnosis and remove the foreign body |
Gastrointestinal | |
Gastroesophageal reflux | Related to meals, coughing at night, possible failure to thrive, pH monitoring |
Esophagitis | Retrosternal pain, difficulty swallowing, radiating to the back, endoscopy |
Gastritis, ulcer | Epigastric pain, related to meals, endoscopy |
Cholecystitis | Postprandial pain in the right upper abdomen and chest, ultrasound, evidence of gallstones |
Pancreatitis | Upper abdominal pain, radiating to the chest, elevated serum lipase and amylase |
Other causes | |
Psychogenic | Stressful situation, family history of cardiac problems or chronic pain, girls more often affected, age over 12 years, psychological or psychiatric consultation |
Sickle cell crisis | African origin, Hb electrophoresis |
Herpes zoster | Stabbing pain, local blisters, previous chicken pox |
Cardiac causes of chest pain in children and adolescents are rare. However, an underlying cardiac disease is more probable if there are other cardiac symptoms such as syncopes or palpitations in addition to chest pain.
The most important cardiac causes of chest pain in childhood and adolescence are listed in Table 12.2.
Cardiac disease | Remark | Indicative clinical findings |
Myocardial ischemia | ||
Severe aortic stenosis | Myocardial ischemia especially during exertion due to increased oxygen demand of the hypertrophic myocardium and elevated pressure in the left ventricle | Loud systolic bruit, PMI in the parasternal 2nd right ICS, radiating to the carotids, signs of left heart hypertrophy in the ECG, confirmed by echocardiography |
Hypertrophic obstructive cardiomyopathy | Possible positive family history, possible signs of hypertrophy in the ECG, possibly systolic bruit, the murmur typically changes on inspiration and expiration, confirmed by echocardiography | |
Severe pulmonary stenosis | Considerably less frequent that aortic stenosis as the cause of myocardial ischemia | Loud systolic bruit, PMI in the parasternal 2nd left ICS, signs of right heart hypertrophy in the ECG, confirmed by echocardiography |
Mitral valve prolapse | Correlation with chest pain is disputed, possibly ischemia of the papillary muscle | Mid-systolic click, sometimes systolic bruit, possibly T wave inversion in leads II, III, aVF, often asthenic habitus, possibly anomalies of the bony thorax, confirmed by echocardiography |
Eisenmenger syndrome | Shunt defect, cyanosis, clubbed fingers, rounded nails, pronounced 2nd heart sound, signs of right heart hypertrophy in the ECG | |
Bland-White-Garland syndrome | Myocardial ischemia after the drop in pulmonary resistance, typically between the ages of 2 and 6 months | ECG: Q in I, aVL, V4–6 (anterolateral myocardial infarction), visualization of the coronary origins in echocardiography, if necessary coronary angiography |
Rare aberrant origins of the coronary arteries (e.g., origin of the left coronary artery from the right sinus of Valsalva) | Compression of the affected coronary artery between the aorta and the pulmonary artery, myocardial ischemia especially during exertion | Visualization of the coronary origins in echocardiography, if necessary coronary angiography |
Kawasaki syndrome | After coronary aneurysms, coronary stenoses can develop, the risk is greatest with very large aneurysms | Kawasaki syndrome in the patient history, evidence of myocardial ischemia in the ECG, confirmed by coronary angiography |
Inflammatory heart disease | ||
Pericarditis | Usually infectious or immunological cause, also traumatic or from tumors | Sharply defined pain that increases when lying down and subsides when sitting up and leaning forward; possible pericardial friction rub, weakened heart sounds, ECG may have low voltage and ST segment changes, confirmed by echocardiography |
Post-pericardiotomy syndrome | Immunologically caused pericardial effusion following open heart surgery | Findings similar to pericarditis, fever, pronounced discomfort |
Myocarditis | Usually infectious | Often after previous viral infection, weakness, arrhythmia, enlarged heart with impaired function |
Other causes | ||
Dissected aortic aneurysm | Especially feared in adolescent Marfan patients, less frequent than with Turner syndrome | Life-threatening emergency, intense chest pain, diagnosis by echocardiography, possibly chest CT or MRI scan |
Arrhythmias | Palpitations are sometimes described by children as “heart pain.” On the other hand, long lasting tachycardia in particular can lead to myocardial ischemia | Rapid heartbeat, palpitations, diagnosis confirmed by ECG, long-term ECG, or possibly event recorder |
Cocaine consumption | Possible symptoms: chest pain (coronary vasoconstriction, increased myocardial oxygen consumption), pneumothorax, arrhythmia, hypertension | Medical history, drug screening |
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