What is the management approach for a 16-year-old female presenting with chest pain and a short PR (P-R) interval?

Management of Short PR Interval in a 16-Year-Old Female with Chest Pain

A 16-year-old female with chest pain and short PR interval should undergo immediate cardiac evaluation to rule out Wolff-Parkinson-White syndrome and other potentially life-threatening causes, as this finding may indicate an accessory pathway that can lead to dangerous arrhythmias.

Initial Evaluation

History

• Characterize chest pain thoroughly:
  • Nature (pressure, tightness, sharp, etc.)
  • Onset and duration
  • Location and radiation
  • Precipitating factors (exercise, stress)
  • Relieving factors
  • Associated symptoms (palpitations, syncope, dizziness)
• Family history of sudden cardiac death, arrhythmias, or heart disease
• History of previous syncope or near-syncope episodes

Physical Examination

• Vital signs with particular attention to heart rate and rhythm
• Cardiovascular examination for murmurs, gallops, or other abnormal heart sounds
• Signs of hemodynamic compromise

Immediate Testing

• 12-lead ECG (within 10 minutes of presentation) 1
  • Evaluate for:
    • Delta waves (slurred upstroke of QRS)
    • QRS duration (normal vs. widened)
    • ST-T wave abnormalities
    • Other conduction abnormalities
• Cardiac troponin measurement 1, 2

Differential Diagnosis

1. Wolff-Parkinson-White (WPW) syndrome

   • Short PR interval with delta wave and widened QRS
   • Risk of sudden cardiac death (0.2%) 3

2. Lown-Ganong-Levine (LGL) syndrome

   • Short PR interval with normal QRS complex
   • Associated with paroxysmal atrial tachycardia 4

3. Enhanced AV nodal conduction

   • Short PR interval without accessory pathway
   • Generally benign

4. Catecholamine excess states

   • Can cause transient short PR interval 5

5. Coronary ischemia

   • Can unmask concealed accessory pathways 6

6. Other causes of chest pain

   • Myocarditis, pericarditis
   • Non-cardiac causes (musculoskeletal, pulmonary, gastrointestinal)
   • Anxiety or panic disorder

Management Algorithm

Step 1: Risk Stratification

• High risk features requiring immediate cardiology consultation:
  • Syncope or presyncope
  • Family history of sudden cardiac death
  • Evidence of pre-excitation (delta waves)
  • Documented tachyarrhythmias
  • Abnormal cardiac biomarkers

Step 2: Diagnostic Testing

• Echocardiography to evaluate:

  • Structural heart disease
  • Left ventricular function
  • Valvular abnormalities

• Consider ambulatory ECG monitoring (24-48 hour Holter)

  • To detect paroxysmal arrhythmias
  • To assess heart rate variability

Step 3: Electrophysiologic Evaluation

• Referral to electrophysiologist for patients with:

  • Confirmed pre-excitation on ECG
  • Symptoms suggestive of tachyarrhythmias
  • High-risk features

• Electrophysiologic study (EPS) to:

  • Confirm presence of accessory pathway
  • Determine risk of rapid conduction
  • Guide ablation therapy if indicated

Step 4: Treatment Based on Findings

• For WPW syndrome:

  • Catheter ablation of accessory pathway (first-line therapy for symptomatic patients)
  • Avoid medications that enhance AV nodal conduction (digoxin, calcium channel blockers, beta-blockers) if pre-excitation is present

• For LGL syndrome or enhanced AV nodal conduction:

  • Beta-blockers or calcium channel blockers for symptomatic patients
  • Regular follow-up with cardiology

• For non-arrhythmic causes of chest pain:

  • Treat according to specific diagnosis

Special Considerations for Adolescent Females

Women are at risk for underdiagnosis of cardiac causes of chest pain 1, 2. In adolescent females:

• Chest pain remains the predominant symptom in those with cardiac causes
• Associated symptoms like palpitations, jaw/neck pain, and back pain may be more common
• Traditional risk assessment tools may underestimate risk in females 1

Follow-up Recommendations

• Regular cardiology follow-up for patients with confirmed pre-excitation
• Restriction from competitive sports until comprehensive evaluation is complete
• Education about warning symptoms requiring immediate medical attention
• Genetic counseling if familial pattern is identified

Pitfalls to Avoid

• Do not dismiss chest pain as non-cardiac without appropriate evaluation
• Do not rely solely on relief with nitroglycerin as diagnostic for cardiac vs. non-cardiac pain 2
• Do not delay ECG or troponin testing 2
• Do not attribute symptoms to anxiety without ruling out cardiac causes first 2
• Remember that normal vital signs do not rule out serious cardiac conditions 2

A short PR interval in a young patient with chest pain should always prompt thorough evaluation, as early identification and management of accessory pathways can prevent life-threatening arrhythmias and sudden cardiac death.