What is the appropriate evaluation and management for an 8-year-old boy presenting with chest pain (cardiac pain)?

Evaluation and Management of Chest Pain in an 8-Year-Old Boy

In an 8-year-old boy presenting with chest pain, a cardiac cause is identified in less than 5% of pediatric patients, but you must still obtain an ECG and focused cardiovascular examination to exclude life-threatening conditions before reassuring the family that this is likely benign. 1, 2, 3

Immediate Assessment Required

Mandatory Initial Evaluation

• Obtain a 12-lead ECG within 10 minutes unless a clearly noncardiac cause is evident (e.g., obvious trauma, reproducible chest wall tenderness with normal vital signs) 1, 4, 5
• Perform a focused cardiovascular examination to identify signs of acute coronary syndrome, pericarditis, myocarditis, or other life-threatening causes 1, 4, 5
• Check vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation 5, 6

Red Flag History Elements That Require Urgent Evaluation

• Pain precipitated by exercise or exertion 3, 6
• Associated syncope, presyncope, or dizziness 7, 6
• Associated palpitations or irregular heartbeat 1, 6
• Pain that interferes with sleep 6
• Shortness of breath or respiratory distress 6, 8
• Family history of sudden cardiac death, cardiomyopathy, or long QT syndrome 1, 9
• Personal history of congenital heart disease, Kawasaki disease, or prior cardiac surgery 1, 7, 6
• History of sickle cell disease (requires emergency transfer to ED) 1, 6

Algorithmic Approach to Diagnosis

Step 1: Identify Life-Threatening Causes

If any red flags are present, transport urgently to the ED by EMS 1, 4

Life-threatening conditions to exclude:

• Acute coronary syndrome (extremely rare but can occur with anomalous coronary arteries, Kawasaki disease sequelae) 7, 8
• Cardiac arrhythmias (most common cardiac cause in children, found in 65% of pediatric cardiac chest pain) 7
• Pericarditis (sharp pain worse when lying supine, improved sitting forward; look for widespread ST elevation with PR depression on ECG) 4, 9
• Myocarditis (fever, chest pain, heart failure signs) 4, 9
• Pneumothorax/pneumomediastinum (abrupt onset, continuous pain lasting 1-2 days, more common in older adolescents) 7, 8
• Pulmonary embolism (rare in children without risk factors) 9, 8

Step 2: Characterize the Pain

Obtain specific details about pain characteristics 9, 5:

• Location and radiation: Musculoskeletal pain is typically localized and reproducible with palpation 2, 3
• Quality: Sharp, stabbing pain is less likely cardiac; pressure or squeezing is more concerning 1, 9
• Duration: Fleeting pain (seconds) is unlikely cardiac; gradual buildup over minutes suggests ischemia 1
• Timing: Pain with meals suggests gastrointestinal cause; positional pain suggests musculoskeletal or pericarditis 1, 9
• Aggravating/relieving factors: Reproducible with chest wall palpation strongly suggests musculoskeletal, but 7% of patients with reproducible pain still have cardiac disease 4

Step 3: Physical Examination Findings

Examine for specific diagnostic clues 1, 4, 2:

• Costochondral tenderness: Suggests costochondritis (most common cause, 76% of cases) 2
• Fever with abnormal breath sounds: Consider pneumonia 4, 9
• Cardiac murmur, abnormal heart sounds, or S3 gallop: Requires echocardiography 1, 6
• Friction rub: Suggests pericarditis or pleuritis 4, 8
• Unilateral absent breath sounds with hyperresonance: Pneumothorax 4, 8

Most Likely Diagnoses in Pediatric Chest Pain

Benign Causes (>95% of cases) 1, 2, 3

1. Musculoskeletal/costochondritis (76-88% of cases): Reproducible tenderness, localized pain 2, 3
2. Idiopathic (no identifiable cause after workup): 73.6% in some series 7
3. Exercise-induced asthma (12% of cases): Associated with dyspnea during exertion 2
4. Gastrointestinal causes (3-8%): Burning pain related to meals, responds to antacids 1, 2
5. Psychogenic/anxiety (1-4%): Recurrent presentations, associated stress or anxiety 1, 2

Cardiac Causes (1-4% of cases) 3, 7

• Arrhythmias (most common cardiac cause): Palpitations, syncope, family history of sudden death 1, 7
• Pericarditis: Sharp, positional pain with ECG changes 4, 7
• Structural heart disease: History of congenital heart disease or Kawasaki disease 7, 6

When Additional Testing Is Indicated

ECG and Cardiac Troponin Required If: 1, 4, 5

• Any red flag symptoms present
• Abnormal cardiovascular examination
• Exertional chest pain
• Associated syncope or palpitations
• Family history of sudden cardiac death or cardiomyopathy

Echocardiography Indicated If: 3, 6

• Abnormal ECG findings
• Cardiac murmur or abnormal heart sounds
• History of congenital heart disease
• Exertional symptoms with concerning features

Ambulatory ECG Monitoring Considered If: 1

• Palpitations with chest pain (arrhythmia found in 10-15% of young patients with palpitations)
• Recurrent symptoms despite negative initial workup
• Note: AECG has limited yield for chest pain alone (most studies show no diagnostic yield) 1

Additional Testing NOT Routinely Needed: 3

• Exercise stress testing: Can be eliminated in low-risk patients (no cardiac diagnoses missed when algorithm applied) 3
• Holter monitoring: Low yield unless palpitations present 1, 3
• Chest X-ray: Only if respiratory symptoms, fever, or trauma 6

Management Based on Diagnosis

If Benign Musculoskeletal Pain (Most Common):

• Reassure the family that cardiac causes are excluded 2, 3
• NSAIDs for pain relief 9
• Activity as tolerated 2
• Follow-up with primary care for persistent symptoms 9

If Cardiac Cause Identified:

• Immediate cardiology referral for arrhythmias, structural disease, or pericarditis 9, 6
• Consider admission for unstable arrhythmias or myocarditis 1, 8

If Psychogenic/Anxiety-Related:

• Referral to cognitive-behavioral therapy for recurrent presentations without physiological cause 1
• Avoid repetitive cardiac testing once cardiac causes excluded 1

Critical Pitfalls to Avoid

• Do not delay ECG acquisition even if pain appears musculoskeletal—reproducible pain does not exclude cardiac disease 4
• Do not rely on nitroglycerin response as diagnostic (esophageal spasm also responds) 1, 5
• Do not assume young age excludes cardiac disease—arrhythmias and structural abnormalities can present in children 7, 6
• Do not miss pneumomediastinum—requires careful radiological examination 7
• Do not ignore syncope with chest pain—this mandates cardiac workup including rhythm monitoring 7, 6