What are the possible causes and treatments of chest pain in teenagers without other signs and symptoms?

Chest Pain in Teenagers Without Other Signs and Symptoms

Chest pain in teenagers without accompanying symptoms is most commonly musculoskeletal (particularly costochondritis) or idiopathic in origin, and rarely represents serious cardiac disease. 1, 2

Most Common Causes

Musculoskeletal Pain (Primary Consideration)

• Costochondritis accounts for the majority of cases when cardiac causes are excluded, characterized by tenderness of costochondral joints on palpation and pain reproducible with chest wall pressure 1, 3
• Pain is typically sharp, localized, affected by breathing, turning, twisting, or bending 3
• Point tenderness on examination strongly suggests musculoskeletal origin rather than cardiac pathology 1

Idiopathic Chest Pain

• Idiopathic causes represent approximately 73.6% of adolescent chest pain presentations 2
• These cases typically resolve without specific therapy and have no identifiable organic cause 4
• The absence of exertional symptoms, radiation of pain, and associated symptoms (diaphoresis, dyspnea, nausea, syncope) makes acute coronary syndrome extremely unlikely 1

Psychogenic/Anxiety-Related Pain

• Anxiety and panic disorders are common causes of chest pain in young adults 1
• Onset with emotionally stressful situations may indicate psychogenic origin 4
• The sensation of "feeling hot" without other symptoms like diaphoresis, dyspnea, or syncope makes acute coronary syndrome less likely 1

Less Common But Important Causes

Gastrointestinal Causes

• Gastroesophageal reflux disease can mimic cardiac pain, presenting as squeezing or burning sensations 1, 3
• Consider if pain occurs after meals or at night, or improves with antacids 1

Respiratory Causes

• Respiratory causes account for approximately 9.3% of cases 2
• Abrupt, continuous chest pain of short duration (1-2 days) in older adolescents is characteristic of air-leak syndrome (pneumothorax or pneumomediastinum) 2
• Pleuritic pain suggests pulmonary involvement 1

Cardiac Causes (Rare but Critical)

• Cardiac causes represent only 3.8% of adolescent chest pain cases 2
• When cardiac, arrhythmias are most common (65%), followed by congenital heart disease (30%) 2
• Pain described as sharp, fleeting, related to inspiration, positional, or shifting locations suggests a lower likelihood of ischemia 1

Critical Red Flags Requiring Immediate Evaluation

The following features mandate urgent cardiac workup:

• Syncope combined with chest pain requires immediate cardiac evaluation, as this combination can indicate serious arrhythmias like atrial flutter 2
• Exertional chest pain with radiation to left arm, jaw, or neck 1, 3
• Associated diaphoresis, dyspnea, nausea, or palpitations 1
• Family history of premature coronary artery disease, hypertrophic cardiomyopathy, or sudden cardiac death 5
• History of Kawasaki disease with coronary involvement 5, 2

Recommended Evaluation Approach

Initial Assessment

• Characterize pain by quality, location, radiation, onset, duration, precipitating factors, and relieving factors 1
• Perform focused cardiovascular examination, assess for chest wall tenderness, and evaluate vital signs 1
• A 12-lead ECG should be performed and interpreted within 10 minutes if any cardiac concern exists 1, 3

When to Pursue Further Testing

• Chest radiography is useful to identify pneumothorax, pneumonia, or mediastinal abnormalities if respiratory cause suspected 1
• Cardiac biomarkers (troponin) only if initial evaluation suggests cardiac cause 1
• For recurrent symptoms with negative cardiac workup, consider trial of acid suppression therapy for suspected gastrointestinal causes 1

Common Pitfalls to Avoid

• Routine testing generally does not help establish diagnosis and may reinforce unspoken fears of serious illness 4
• Do not use nitroglycerin response as a diagnostic criterion, as esophageal spasm also responds to nitroglycerin 3
• In patients with pneumomediastinum, radiological diagnosis can be difficult without careful examination 2
• Most teenagers with chest pain have no serious illness, and symptoms usually resolve without therapy 4, 6

Management Strategy

For isolated chest pain without red flags:

• Provide reassurance after appropriate evaluation 4
• Treat musculoskeletal pain with NSAIDs if indicated 1
• Consider referral to cognitive-behavioral therapist if anxiety is suspected with recurrent presentations 1
• Avoid unnecessary cardiac testing that may increase anxiety 6