What is the next step in managing an 11-year-old male patient with daily left chest pain, occurring at 4 am, who is already on aspirin (acetylsalicylic acid) and supportive treatments like vitamin D and calcium supplementation, with normal echocardiogram (echo), electrocardiogram (ECG), and computed tomography (CT) of the thorax?

Management of Non-Cardiac Chest Pain in an 11-Year-Old

Stop the aspirin immediately—this child does not have acute coronary syndrome and should not be on antiplatelet therapy. 1, 2

Why This is Not Cardiac

The combination of normal ECG, normal echocardiogram, and normal CT thorax effectively rules out any significant cardiac pathology in this age group. 3, 1 Acute coronary syndrome in an 11-year-old without congenital heart disease, Kawasaki disease history, or familial hypercholesterolemia is extraordinarily rare and would not present with this pattern. 4

The timing pattern (daily at 4 AM) is highly atypical for cardiac ischemia and instead suggests:

• Musculoskeletal pain (positional, related to sleep position) 3
• Gastroesophageal reflux (nocturnal acid reflux peaks in early morning hours) 3, 2
• Growing pains (common in this age group, often nocturnal) 3
• Anxiety or panic disorder (can present with chest pain and early morning awakening) 3, 5

Immediate Next Steps

Discontinue aspirin ("ATT") unless there is a specific non-cardiac indication not mentioned in this case. 3 Aspirin in children carries risk of Reye syndrome and is not indicated for non-cardiac chest pain. 3

Continue vitamin D and calcium supplementation as these are appropriate for general pediatric health and may help if there is a musculoskeletal component. 3, 6 Hypocalcemia can cause chest discomfort and has been reported to mimic cardiac conditions, though the normal ECG makes this less likely. 6

Diagnostic Workup

Detailed pain characterization:

• Ask if pain changes with position, breathing, or palpation of the chest wall (suggests musculoskeletal origin) 3
• Assess for relationship to meals or lying down (suggests GERD) 3, 2
• Evaluate for associated symptoms: nausea, regurgitation, sour taste (GERD), or anxiety symptoms 3

Physical examination focus:

• Palpate the chest wall, costochondral junctions, and sternum for reproducible tenderness (costochondritis is common in this age) 3
• Assess for joint hypermobility if there are other systemic features (though unlikely given normal cardiac workup) 3
• Evaluate posture and thoracic spine alignment 3

Consider trial of:

• Proton pump inhibitor (omeprazole 10-20 mg daily) for 2-4 weeks if GERD suspected 3, 2
• NSAIDs (ibuprofen) for musculoskeletal pain if aspirin is discontinued 3

What NOT to Do

Do not pursue further cardiac testing. The triad of normal ECG, normal echo, and normal CT thorax has already excluded structural heart disease, coronary anomalies, and pericardial disease. 3, 1 Additional cardiac workup would be low-yield and potentially harmful through unnecessary radiation or sedation. 1, 5

Do not continue aspirin without a clear cardiac indication. This child does not meet criteria for acute coronary syndrome, which requires either ST-segment changes, elevated troponin, or high-risk features like hemodynamic instability—none of which are present. 3

Follow-Up Plan

Reassess in 2-4 weeks after implementing the above changes. 3, 5 If pain persists despite addressing GERD and musculoskeletal causes, consider:

• Pediatric gastroenterology referral for endoscopy if GERD treatment fails 2
• Pediatric psychology evaluation for anxiety-related chest pain 3, 5
• Sleep study if there are features suggesting sleep-disordered breathing 3

Red flags requiring immediate re-evaluation (though unlikely given current workup):

• Syncope or presyncope 3, 2
• Chest pain with exertion that stops with rest 3
• New ECG changes 1, 2
• Hemodynamic instability 3, 2