Chest pain and syncope: Is it fatal?

Chest pain and syncope are common complaints in children. “The challenge is to determine when these symptoms are associated with benign etiologies as opposed to more concerning and life-threatening underlying conditions,” said Stuart Berger, MD, speaking on Sunday, October 12, at a session titled “Chest pain and syncope: functional or fatal.”

Berger, who is vice chair and professor of pediatrics and division chief of pediatric cardiology at the University of California, Davis, in Sacramento, reviewed the causes of chest pain and syncope in children and adolescents and discussed ways to recognize and eliminate the causes that might prove fatal or cause significant morbidity.

Most often, the causes of chest pain in children are benign. “The biggest fear is missing the rare cause that may be associated with myocardial ischemia,” he said. Similarly, most cases of syncope are not life threatening. Some episodes, however, might be a sign or symptom of an underlying serious cardiac abnormality, which could ultimately lead to cardiac arrest and death.

Chest pain is often recurrent or chronic and may be difficult to treat. Younger age at onset is associated with a higher incidence of organic disease, whereas onset at an older age may stem from psychogenic causes. The overall incidence of heart disease in children with chest pain is less than 5%, but among those referred to a cardiologist, it is 6% to 12%.

In the evaluation of chest pain, a detailed history and physical examination are the key steps. The etiology is usually clear from the history alone, Berger noted. If the history and physical findings are normal, serious organic disease is unlikely and routine tests are not helpful.

The pediatrician must develop a trusting relationship with the family of a child with chest pain and provide reassurance. Follow-up visits should be scheduled and specific causes treated. In some cases, referral to a specialist may be appropriate.

Like chest pain, syncope in children is common, typically benign, and usually resolves without intervention. A careful history will most often define the etiology. An electrocardiogram is helpful in screening, but additional tests are rarely needed. Most patients with neutrally mediated syncope improve with education and dietary changes, and outcomes are generally excellent. Berger warned, however, that “syncope without warning or during exercise implies a primary cardiac cause and mandates a thorough evaluation.” -Karen Rosenberg