What is the approach to evaluating chest pain in a pediatric patient with a history of asthma and a family history of cardiac conditions?

Evaluation of Chest Pain in Children with Asthma and Family History of Cardiac Disease

In a pediatric patient with chest pain, asthma history, and family cardiac history, begin with targeted history focusing on exertional symptoms, syncope, and palpitations, perform a focused cardiac examination, and obtain an ECG—but recognize that cardiac causes remain rare (1-8% of cases) and most chest pain in children is benign, even with these risk factors. 1, 2, 3

Initial Risk Stratification Through History

The history should immediately identify high-risk features that warrant urgent cardiac evaluation:

Red Flag Symptoms Requiring Immediate Attention

• Exertional chest pain occurring during physical activity or emotional stress suggests possible cardiac ischemia and requires immediate ECG and cardiology evaluation 1, 4
• Syncope or presyncope accompanying chest pain warrants immediate concern and further cardiac workup 1, 4
• Palpitations or sensation of irregular heartbeat requires rhythm evaluation 1, 4
• Sudden onset "ripping" pain radiating to the back suggests aortic dissection, though extremely rare in pediatrics 4

Family History Assessment

• Identify family history of sudden death, aborted sudden death, hyperlipidemia, or pulmonary hypertension as these increase cardiac risk 1
• Document any family history of premature coronary artery disease, cardiomyopathy, or inherited arrhythmia syndromes 1

Asthma-Related Considerations

• Bronchospasm and persistent coughing can lead to excess use of chest wall muscles causing musculoskeletal chest pain 5
• Distinguish between chest pain from muscle overuse versus true cardiac symptoms 5
• Pleuritic pain that is sharp and worsens with breathing suggests respiratory etiology 4

Reassuring Features Suggesting Benign Etiology

These characteristics make cardiac causes unlikely but do not completely exclude them:

• Fleeting pain lasting only seconds is unlikely to be cardiac 4
• Sharp, localized pain that can be pointed to with one finger suggests musculoskeletal origin 4
• Positional pain that changes with body position is typically non-cardiac 4
• Reproducible pain with chest wall palpation suggests costochondritis, though 7% of patients with reproducible tenderness may still have acute coronary syndrome 4, 6

Physical Examination Priorities

Cardiac-Focused Examination

• Assess for murmurs, abnormal heart sounds, and irregular rhythm 4
• Measure vital signs including heart rate, respiratory rate, blood pressure, and temperature 4
• Evaluate for signs of cardiac compromise including diaphoresis, tachycardia, or hypotension 7

Musculoskeletal Assessment

• Palpate for chest wall tenderness and reproducible pain at costochondral joints 4
• Note that costochondritis is characterized by tenderness on palpation but does not exclude cardiac disease 4, 6

Respiratory Evaluation

• Assess for abnormal breath sounds, decreased breath sounds, wheezing, or friction rub 4
• Evaluate for signs of respiratory distress, especially given asthma history 4

Diagnostic Testing Algorithm

Mandatory Initial Testing

• ECG should be obtained in ALL patients with chest pain and family cardiac history, even if musculoskeletal pain is suspected 4
• The ECG should be obtained within 10 minutes if any concern for cardiac etiology exists 4, 7
• Look for long QT interval, conduction abnormalities, or ischemic changes 1

Selective Additional Testing Based on Risk Stratification

High-Risk Features Present (exertional pain, syncope, palpitations, abnormal ECG, or significant family history):

• Echocardiography to evaluate cardiac structure and function 1
• Cardiac troponin measurement if acute coronary syndrome is genuinely suspected 4, 7
• Ambulatory ECG monitoring (Holter/event monitor) for palpitations with suspected arrhythmia 1, 4
• Exercise stress testing if exertional symptoms are present and baseline evaluation is inconclusive 1

Low-Risk Features (non-exertional, reproducible, no syncope, normal ECG):

• Chest radiograph if respiratory symptoms suggest pneumonia, pneumothorax, or asthma exacerbation 4, 5
• No routine echocardiography or stress testing needed 2
• Consider reassurance and observation as primary management 1, 4

Common Pitfalls to Avoid

• Do not assume young age excludes cardiac disease, especially with positive family history 7
• Do not rely on nitroglycerin response as a diagnostic criterion—esophageal spasm and other conditions may also respond 4, 6
• Do not assume reproducible chest wall tenderness excludes cardiac disease—7% of patients with palpable tenderness have acute coronary syndrome 4, 6
• Do not order extensive cardiac testing without clear indications—this leads to unnecessary resource use and anxiety 4, 2
• Do not delay emergency evaluation if high-risk features are present 7

Management Based on Etiology

If Cardiac Cause Identified (1-8% of cases)

• Pericarditis or myocarditis: Anti-inflammatory medications and cardiology consultation 6, 5
• Arrhythmias: Electrophysiology referral 1, 2
• Structural heart disease: Cardiology follow-up and activity restrictions as indicated 1

If Non-Cardiac Cause Identified (92-99% of cases)

• Musculoskeletal/costochondritis (most common, 76%): Anti-inflammatory medications, reassurance 8, 2
• Asthma-related: Optimize asthma control, bronchodilators as needed 5, 8
• Gastrointestinal causes: Trial of acid suppression if reflux suspected 1, 8
• Psychogenic causes: Consider referral to cognitive-behavioral therapy if cardiac workup negative and pain persists 1, 4

Communication and Reassurance

• Provide thorough explanation to patient and family, taking symptoms seriously while explaining the benign nature when organic causes are excluded 1, 4
• Explain the rationale for any proposed testing and why extensive cardiac workup may not be necessary 1
• Discuss implications of family cardiac history but emphasize that most pediatric chest pain remains benign 1, 3
• Address anxiety as 81% of children with unexplained chest pain meet criteria for anxiety disorders 4

Cost-Effective Approach

Applying a standardized algorithm can lead to:

• ~20% reduction in echocardiogram use 2
• Elimination of exercise stress testing in most cases 2
• Reduction in outpatient rhythm monitoring by 20% 2
• Significant reduction in myocardial enzyme testing while still capturing all cardiac diagnoses 3

This targeted approach maintains diagnostic accuracy while reducing unnecessary testing, anxiety, and healthcare costs 2, 3