What is the appropriate workup for a teenager presenting with chest pain?

Chest Pain Workup for Teenagers

The appropriate workup for a teenager presenting with chest pain should include a focused history, physical examination, and a 12-lead ECG to rule out cardiac causes, with additional testing based on specific clinical findings. 1

Initial Assessment

• A focused history should include characteristics and duration of symptoms, associated features, and cardiovascular risk factor assessment 1
• Physical examination should focus on identifying potentially serious causes of chest pain (cardiac, pulmonary, or gastrointestinal) 1
• A 12-lead ECG should be performed for all teenagers with chest pain unless a clear non-cardiac cause is evident 1
• Chest radiography is useful to evaluate for potential cardiac, pulmonary, and thoracic causes when clinically indicated 1

Key Clinical Considerations

• Most chest pain in teenagers is non-cardiac and non-life-threatening in nature, with cardiac etiology found in only about 1.2% of cases 2
• Chest pain characteristics that increase suspicion for cardiac origin include central location, pressure-like quality, exertional onset, and retrosternal location 1
• Red flag symptoms warranting immediate evaluation include severe prolonged pain, syncope, palpitations, exertional chest pain, family history of sudden cardiac death, or abnormal cardiac examination 1
• Women who present with chest pain are at risk for underdiagnosis, and potential cardiac causes should always be considered 1

Diagnostic Algorithm

1. Initial Evaluation:

   • Complete history and physical examination 1
   • 12-lead ECG for all patients 1, 2

2. If abnormal findings on history, exam, or ECG:

   • Abnormal ECG findings require comparison with previous ECGs if available 1
   • Serial ECGs should be performed if symptoms are ongoing 1
   • Consider echocardiography for murmurs, abnormal ECG, or concerning family history 2, 3

3. If normal initial evaluation but concerning symptoms:

   • Consider additional cardiac testing based on risk factors 2
   • Exercise stress testing may be appropriate for exertional symptoms 2
   • Event monitoring for palpitations or arrhythmia concerns 2

4. If normal initial evaluation and low-risk features:

   • Teenagers without cardiac history, with normal ECG, and no cardiac risk factors have <1% risk of acute coronary syndrome 4, 5
   • Consider non-cardiac causes including musculoskeletal pain, anxiety, gastrointestinal disorders 6

Common Pitfalls to Avoid

• Overreliance on a single normal ECG to rule out cardiac causes - serial ECGs may be necessary if symptoms persist 1
• Failure to consider non-cardiac causes when cardiac evaluation is negative 1
• Missing psychological causes of chest pain, which are common in teenagers 1, 6
• Unnecessary extensive cardiac testing in low-risk patients with typical non-cardiac chest pain 6, 2
• Delayed transfer to emergency department for patients with concerning symptoms seen in office settings 1

Special Considerations

• For teenagers with sickle cell disease and chest pain, emergency transfer to an acute care setting is recommended 1
• Cultural competency and addressing language barriers are important when evaluating chest pain in diverse patient populations 1
• For recurrent presentations with negative prior workups, referral to cognitive-behavioral therapy may be reasonable 1
• Standardized assessment approaches can reduce unnecessary testing while still identifying cardiac causes 2