Chest pain is common in children and accounts for 10–15 % of ambulatory cardiology visits but in contrast to adult practice very rarely represents cardiac pathology and is usually musculoskeletal, pulmonary, gastrointestinal or pyschogenic in origin (Table 6.1). Cardiac causes of chest pain in children and adolescents are found in less than 5 % of presentations but one must remain alert to the possibility.

The lack of evidence-based standards for the evaluation of chest pain in paediatric patients has led to a widespread variation in practice among cardiologists, with exercise stress testing, echocardiography and ambulatory ECG commonly requested. In the absence of any cardiac history all appear to have a very low yield. Previous studies have shown that exercise stress testing was not able to detect any cardiac disorders in otherwise healthy children and adolescents. Ambulatory ECG is also low-yield, except in the presence of palpitations or syncope, and echocardiography is more likely to reveal incidental findings. However, in the presence of a concerning history such as previous cardiac surgery, exertional pain and/or collapse, together with clinical and ECG findings, echocardiography can lead to the diagnosis of significant cardiac lesions such as anomalous coronary artery from the pulmonary artery, cardiomyopathy, pulmonary hypertension, myocarditis, pericarditis, and left severe ventricular outflow tract obstruction. Cardiac biomarkers, including cardiac troponin, are not routinely recommended in the evaluation of chest pain in children. However, they are indicated for selected patients with suspected myocarditis, pericarditis and coronary ischaemia. Table 6.2 summarises the cardiac testing for paediatric chest pain.