What is the appropriate management for a 13-year-old female presenting with chest pain?

Management of Chest Pain in a 13-Year-Old Female

In a 13-year-old female presenting with chest pain, cardiac causes are exceedingly rare (occurring in only 1.2% of pediatric cases), and the primary management strategy should focus on a targeted history and physical examination to identify the rare life-threatening conditions while avoiding unnecessary testing that burdens the patient without diagnostic yield. 1, 2

Initial Assessment Priorities

Obtain a focused history emphasizing specific red flags rather than ordering reflexive testing:

• Ask about exertional chest pain (pain occurring during or immediately after physical activity), as this is the single most important feature suggesting potential cardiac etiology in adolescents 2
• Inquire about syncope, palpitations, or family history of sudden cardiac death before age 50, cardiomyopathy, or arrhythmias—these constitute the clinically significant historical features that warrant further evaluation 2
• Characterize the pain: fleeting pain lasting only seconds is unlikely to be cardiac; sharp pain that increases with inspiration suggests musculoskeletal or pleuritic causes; positional pain points to musculoskeletal etiology 3
• Assess for accompanying symptoms in this female patient: while she is young, women across all ages present with accompanying symptoms like nausea, shortness of breath, and jaw/neck pain more commonly than males when cardiac disease is present 3

Physical Examination

Perform a focused cardiovascular examination looking for specific abnormalities:

• Palpate the chest wall systematically—costochondritis and musculoskeletal causes are the most common identifiable etiologies in pediatric chest pain 4, 1
• Auscultate for murmurs, abnormal heart sounds, or pericardial rubs that would indicate structural heart disease or pericarditis 5, 6
• Check for tachycardia, signs of respiratory distress, or hemodynamic instability that would elevate concern 5

Diagnostic Testing Algorithm

Order a 12-lead ECG only if any of the following are present 2:

• Exertional chest pain
• Syncope or presyncope with the chest pain
• Abnormal cardiac examination (murmur, abnormal heart sounds, arrhythmia)
• Significant family history of premature cardiac disease or sudden death
• History suggesting arrhythmia (palpitations, documented tachycardia)

If the ECG is normal and none of the above red flags are present, no further cardiac testing is indicated 2. Applying this targeted approach eliminates unnecessary echocardiography, stress testing, and rhythm monitoring in the vast majority of pediatric patients while still capturing all cardiac diagnoses 2.

Most Likely Diagnoses in This Age Group

Idiopathic chest pain is the most common diagnosis in pediatric populations, typically presenting as chronic, recurrent symptoms without identifiable pathology 1. Other common benign causes include:

• Musculoskeletal pain (costochondritis, chest wall trauma, overuse myalgia) 4, 1
• Respiratory causes (asthma, pneumonia) 6
• Gastrointestinal causes (reflux, esophageal spasm) 6
• Anxiety-related chest pain 1

Rare Life-Threatening Causes to Exclude

While uncommon in adolescents, immediately consider and evaluate for 6, 1:

• Pericarditis (2 of 5 cardiac diagnoses in one pediatric series) 2
• Arrhythmias (3 of 5 cardiac diagnoses) 2
• Pneumothorax or pneumomediastinum (sudden onset, respiratory symptoms) 6
• Pulmonary embolism (extremely rare in this age without risk factors) 6

Critical Pitfalls to Avoid

• Do not order extensive cardiac testing reflexively—echocardiography, stress testing, and prolonged rhythm monitoring are rarely diagnostic and create unnecessary cost and patient burden in low-risk pediatric patients 2
• Do not dismiss symptoms prematurely as anxiety until appropriate evaluation excludes cardiac and other serious causes, particularly in female patients who face higher rates of underdiagnosis across all age groups 3, 5
• Do not rely on pain character alone—while certain descriptors suggest lower cardiac probability, a thorough assessment of the complete clinical picture is essential 3

Disposition and Follow-Up

If the history, examination, and ECG (when indicated) are reassuring:

• Provide clear reassurance to the patient and family that serious cardiac disease is not present 1
• Establish a long-term, trusting relationship to address ongoing symptoms, as idiopathic chest pain often requires time and reassurance to resolve 1
• Educate about when to return: new exertional symptoms, syncope, or chest pain with different characteristics warrant re-evaluation 5
• Consider referral to cognitive-behavioral therapy if symptoms are recurrent and causing significant distress after cardiac causes are excluded 5