Should I clear a 14‑year‑old adolescent who reports chest pain at rest for an upcoming surgical procedure?

Do Not Clear This Patient for Surgery Until Cardiac Evaluation Is Complete

A 14-year-old with chest pain at rest requires immediate cardiac exclusion before any surgical clearance can be considered. Although cardiac disease is rare in adolescents, the complaint of chest pain at rest mandates a focused evaluation to rule out life-threatening conditions before proceeding with elective surgery.

Immediate Diagnostic Steps Required Before Clearance

Mandatory Initial Workup

• Obtain a 12-lead ECG immediately to exclude congenital heart disease, cardiomyopathy, arrhythmias, or other structural abnormalities that could pose perioperative risk. 1, 2
• Measure high-sensitivity cardiac troponin if there is any concern for myocarditis, pericarditis, or other inflammatory cardiac conditions. 1, 2
• Perform a focused cardiovascular examination assessing for murmurs (aortic stenosis, hypertrophic cardiomyopathy), pericardial friction rub, S3 gallop, or signs of heart failure. 1, 2

Critical History Elements to Elicit

• Characterize the chest pain precisely: quality (sharp vs. pressure), location, radiation to arm/jaw/neck, duration, and relationship to exertion versus rest. 1, 2
• Ask about exertional symptoms: syncope, presyncope, palpitations, or dyspnea with exercise are red flags for structural heart disease or arrhythmias. 1
• Screen for cardiac risk factors: family history of sudden cardiac death before age 50, known congenital heart disease, Marfan syndrome or other connective tissue disorders, prior Kawasaki disease, or rheumatic fever. 1
• Assess associated symptoms: diaphoresis, nausea, lightheadedness, or syncope increase concern for cardiac etiology even in adolescents. 1, 2

High-Risk Cardiac Conditions That Preclude Surgical Clearance

Structural Heart Disease

• Hypertrophic cardiomyopathy can present with chest pain and carries significant risk of sudden cardiac death, particularly with anesthesia and surgery; a systolic murmur that increases with Valsalva is characteristic. 1, 2
• Aortic stenosis in adolescents (typically congenital bicuspid valve) may cause angina, syncope, or dyspnea; a systolic murmur with delayed carotid upstroke is the key finding. 1, 2
• Anomalous coronary arteries can cause exertional chest pain or syncope and require identification before surgery. 1

Inflammatory Cardiac Conditions

• Myocarditis presents with chest pain, fever, and signs of heart failure (S3 gallop); troponin elevation confirms myocardial injury. 2
• Pericarditis causes sharp, pleuritic chest pain that worsens supine and improves leaning forward, often with a friction rub and fever. 1, 2

Arrhythmias

• Long QT syndrome, Brugada syndrome, or other channelopathies may present with chest pain, palpitations, or syncope and carry perioperative arrhythmia risk; ECG is diagnostic. 1

When Cardiac Clearance Is Appropriate

Low-Risk Features Suggesting Benign Etiology

• Musculoskeletal chest pain (costochondritis) is the most common cause in adolescents, accounting for approximately 43% of cases after cardiac causes are excluded; pain is sharp, localized, reproducible with palpation, and worsens with movement or breathing. 2, 3, 4
• Absence of exertional symptoms, syncope, palpitations, or family history of sudden death substantially lowers cardiac risk. 3, 4
• Normal ECG, normal cardiac examination, and pain reproducible with chest wall palpation make cardiac disease unlikely. 3, 4

Appropriate Testing Algorithm

• If history, examination, and ECG are completely normal, no further cardiac testing is needed and surgical clearance can be provided. 3, 4
• If exertional chest pain is present, exercise stress testing or cardiology referral is required before clearance. 1, 4
• If ECG is abnormal or examination reveals a murmur, echocardiography and cardiology consultation are mandatory before surgery. 1, 4

Critical Pitfalls to Avoid

• Do not dismiss chest pain in adolescents as "just anxiety" or "growing pains" without objective cardiac exclusion; although rare, cardiac disease in this age group carries high morbidity and mortality if missed. 3, 5, 6
• Do not assume a normal physical examination excludes cardiac disease; many serious cardiac conditions (including early myocardial infarction, arrhythmias, and some structural lesions) can present with entirely normal exams. 1, 2, 5
• Do not rely on the patient's age alone to exclude cardiac pathology; congenital heart disease, cardiomyopathy, myocarditis, and arrhythmias all occur in adolescents. 1, 3, 4
• Do not provide surgical clearance if the chest pain occurs at rest without a clear benign explanation; rest pain is atypical for musculoskeletal causes and warrants thorough evaluation. 1, 2

Recommended Management Pathway

1. Obtain detailed history focusing on pain characteristics, exertional symptoms, syncope, palpitations, and family history of sudden cardiac death. 1, 2
2. Perform focused cardiovascular examination including auscultation for murmurs, rubs, and gallops; assess chest wall for reproducible tenderness. 1, 2
3. Order 12-lead ECG and interpret for conduction abnormalities, hypertrophy, repolarization changes, or arrhythmias. 1, 2
4. If any abnormality is found (abnormal ECG, murmur, exertional symptoms, syncope, or concerning family history), refer to pediatric cardiology before surgical clearance. 1, 4
5. If all findings are normal and pain is clearly musculoskeletal (reproducible with palpation, no exertional component), surgical clearance can be provided with reassurance. 3, 4
6. If diagnosis remains uncertain, defer surgical clearance until cardiology evaluation is complete. 5, 4, 7