Pediatric chest pain and syncope: Know when to refer
What causes chest pain and syncope in children and adolescents, and how can pediatricians recognize and eliminate the causes that may lead to significant morbidity or even death?
What causes chest pain and syncope in children and adolescents, and how can pediatricians recognize and eliminate the causes that may lead to significant morbidity or even death?
Barbara J Deal, MD, Getz professor of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, addressed these questions in a presentation titled “Chest pain and syncope: functional or fatal” at the American Academy of Pediatrics National Conference and Exhibition in Chicago, Illinois, on September 17.
As suggested by the title, a key goal of Deal’s session was to help pediatricians recognize life-threatening causes of chest pain that should prompt concern and be addressed urgently from common nonthreatening causes. Her talk centered on nontraumatic chest pain related to cardiac concerns in the absence of heart disease.
Deal focused her discussion on what to look for to recognize potentially life-threatening causes of nontraumatic chest pain that include congenital or acquired cardiac conditions and arrhythmias and chest pain associated with common medications such as antidepressants and stimulants. For example, children presenting with acute life-threatening myocarditis may show exercise intolerance, fatigue, poor weight gain, vomiting, or change in appetite.
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Deal also provided information on syncope in childhood and how to distinguish syncope caused by cardiovascular problems, and especially when an episode of syncope in a child is cause for concern.
Of primary importance is for pediatricians to know when to refer children with suspected life-threatening chest pain and syncope to a cardiology specialist, and to understand the urgency of such a referral. She provided an algorithm for guidance.
Among the clinical presentations that Deal underscored as needing urgent referral to a cardiologist is in a child with chest pain or syncope that occurs during exertion. “These children require urgent evaluation and an [electrocardiogram (ECG)],” she emphasized. “Patients with known underlying cardiac disease should be presumed to have a cardiac and potentially life-threatening etiology until proven otherwise.”
Deal also discussed the more common causes of chest pain that are not life threatening and therefore do not require urgent referral, including postural orthostatic tachycardia syndrome (POTS), an increasingly common condition among adolescents.
She focused primarily on providing pediatricians with information on POTS given its diffuse symptomatology that can make diagnosis difficult. Even though the palpitations, chest pain, and fatigue associated with POTS are common complaints among adolescents, she emphasized that adolescents can go through multiple and unnecessary evaluations prior to an accurate diagnosis, and such a delay in diagnosis and subsequent treatment can prolong time to recovery. If a diagnosis is uncertain, she encouraged pediatricians to refer to a specialist and to avoid extensive testing and prescribing drug therapy.
Deal emphasized that once correctly diagnosed, POTS may be effectively managed with lifestyle changes.
NEXT: Commentary
COMMENTARY
Pediatric chest pain and syncope are common, account for a large number of provider visits and cardiac testing, and lead to a considerable amount of parental/patient anxiety.1-9 Pediatric chest pain and syncope share a difficult paradox in that both are common and benign in the vast majority of cases, but can be the cardinal symptoms for rare and serious cardiac conditions.4,5
The overwhelming majority of chest pain in otherwise healthy children has a noncardiac etiology.1-4,9-11 Numerous prior studies, in multiple practice settings, have shown a cardiac etiology in 0% to 5% of children and adolescents presenting with chest pain. In contrast to adults, in whom chest pain often signals a significant cardiac problem, the most common etiologies for chest pain in children are benign and include musculoskeletal, gastrointestinal, pulmonary, idiopathic, and psychogenic causes. The major cardiac causes of pediatric chest pain and key red flag exam and history findings associated with each diagnosis are listed in the Table.
Prior studies have shown that an approach based on targeted history, physical, and selective use of ECG can identify patients who need further evaluation by subspecialists and cardiac testing.3,4,9 Children with chest pain with an abnormal physical exam, abnormal ECG, or personal history of congenital heart disease, prior arrhythmia, severe familial hypercholesterolemia, or Kawasaki disease with coronary artery aneurysm warrant further evaluation.
Similar to chest pain, although syncope is common and usually benign, it frequently raises concern and anxiety for serious underlying cardiac pathology and sudden cardiac death. Syncope is an exceptionally common disorder, which has a bimodal incidence in children and adolescents peaking in females aged 15 to 19 years.5,6 Up to one-third of the population will have syncope at some point during their lifetime and 15% will have syncope prior to age 21 years.5-7
There are a number of systems for categorizing syncope, which broadly classify syncope as cardiac, neurocardiogenic (including reflex), metabolic, neurologic, and psychogenic.
Typical features of neurocardiogenic syncope are prominent prodromal symptoms, including nausea, dizziness, tunnel vision, pallor, brief loss of consciousness, and minimal residual symptoms.6
Features of cardiac syncope include acute collapse often with exertion and with few warning symptoms preceding the event.6 The traditional diagnostic screen of history and physical examination along with an ECG will identify the vast majority of patients with serious underlying cardiac disease.6,8,12,13
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The focus of history taking should be aimed at characterizing prodromal symptoms, details of the event, duration and frequency of events, residual symptoms after events, and symptoms associated with events. Syncope during exercise is highly concerning and should prompt urgent referral and further investigation, while postexertional syncope is often due to neurocardiogenic syncope (NCS) and related to vasodilation and shifting autonomic states. Syncopal events precipitated by noise or emotion are concerning for triggered ventricular arrhythmias, particularly long QT syndrome, and should also prompt evaluation.
For pediatric chest pain and syncope, an approach based on careful history and physical exam can optimize testing and referrals and reduce patient and parental anxiety while also ensuring detection of the rare cases of serious heart disease in this population.
-Kevin G. Friedman, MD, is a pediatric and fetal cardiologist, and assistant professor of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts.
REFERENCES
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3. Friedman KG, Kane DA, Rathod RH, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011;128(2):239-245.
4. Verghese GR, Friedman KG, Rathod RH, et al. Resource utilization reduction for evaluation of chest pain in pediatrics using a novel Standardized Clinical Assessment and Management Plan (SCAMP). J Am Heart Assoc. 2012;1(2):jah3-e000349.
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8. Brenner JI, Ringel RE, Berman MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? Pediatr Clin North Am. 1984;31(6):1241-1258.
9. Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J. Pediatr. 2013;163(3):896-901.e1-3.
10. Selbst SM, Ruddy RM, Clark BJ, Henretig FM, Santulli T Jr. Pediatric chest pain: a prospective study. Pediatrics. 1988;82(3):319-323.
11. Saleeb SF, Li WY, Warren SZ, Lock JE. Effectiveness of screening for life-threatening chest pain in children. Pediatrics. 2011;128(5):e1062-e1068.
12. Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologist's perspective. Pediatr Clin North Am. 1999;46(2):205-219.
13. Massin MM, Bourguignont A, Coremans C, Comté L, Lepage P, Gérard P. Syncope in pediatric patients presenting to an emergency department. J Pediatr. 2004;145(2):223-228.
