Chest pain is a frequent symptom and complaint in the teenage population. There are many common, benign causes of chest pain. However, it can create tremendous anxiety in the mind of the patient and family members and sometimes it can be perplexing even for the primary providers especially if there is associated family history of premature coronary artery disease. This article focuses on the evaluation of chest pain and how to differentiate between noncardiac and cardiac causes of chest pain in teenagers.
Key points
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Chest pain in teens is most commonly noncardiac and musculoskeletal in nature.
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Chest pain from a cardiac cause is rare in teenagers.
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A thorough history and physical examination are typically the only evaluation required for assessment of chest pain.
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Patients with a history of repaired congenital heart disease, Kawasaki disease with coronary artery aneurysms, certain connective tissue disorders, symptoms of exertional chest pain, or association with syncope should be referred to a pediatric cardiologist for further evaluation.
Introduction: nature of chest pain
Chest pain is a commonly encountered symptom in the outpatient setting as well as the emergency room. The onset of chest pain in adults usually necessitates prompt cardiac evaluation because coronary vascular disease, while potentially life-threatening, can be managed and treated successfully if detected in a timely fashion. When this symptom is seen in the teenage population, teenagers and their parents are typically concerned about cardiac causes for the pain. Fortunately, chest pain in the teenage population is most commonly benign. Media coverage of rare and unfortunate events of sudden cardiac death only contributes to teen and parental anxiety about chest pain complaints. Chest pain has been associated with higher health care utilization in children with noncardiac chest pain particularly if the parent or child has increased psychological stress. These factors all add to the challenge for the medical professional who is evaluating the teenage patient with chest pain.
Chest pain has previously been reported to account for 0.29% of patient chief complaints to the emergency room in a prospective trial by Driscoll and colleagues. In more recent studies, chest pain accounted for 5.2% of all cardiology consultations and 15% of all outpatient visits at a large, tertiary center pediatric cardiology practice. However, less than 5% of chest pain complaints are associated with a cardiac condition. Although media attention to these episodes in the community gives the sense that these episodes occur on a more frequent basis, several studies have shown that the incidence of sudden cardiac death in teens is fortunately rare. Most recently, Roberts and Stovitz reported an incidence of sudden cardiac death in adolescents as 0.24 per 100,000 athlete-years over the last 19 years in Minnesota. Chest pain in teens is most commonly divided into noncardiac and cardiac causes.
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Chest pain is a common complaint seen in primary care office, emergency room, and pediatric cardiology practice
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Chest pain in adolescents is most commonly benign
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Chest pain in this age group is perceived as cardiac by parents and patients and associated with tremendous anxiety
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Less than 5% of the chest pain is cardiac in origin
Introduction: nature of chest pain
Chest pain is a commonly encountered symptom in the outpatient setting as well as the emergency room. The onset of chest pain in adults usually necessitates prompt cardiac evaluation because coronary vascular disease, while potentially life-threatening, can be managed and treated successfully if detected in a timely fashion. When this symptom is seen in the teenage population, teenagers and their parents are typically concerned about cardiac causes for the pain. Fortunately, chest pain in the teenage population is most commonly benign. Media coverage of rare and unfortunate events of sudden cardiac death only contributes to teen and parental anxiety about chest pain complaints. Chest pain has been associated with higher health care utilization in children with noncardiac chest pain particularly if the parent or child has increased psychological stress. These factors all add to the challenge for the medical professional who is evaluating the teenage patient with chest pain.
Chest pain has previously been reported to account for 0.29% of patient chief complaints to the emergency room in a prospective trial by Driscoll and colleagues. In more recent studies, chest pain accounted for 5.2% of all cardiology consultations and 15% of all outpatient visits at a large, tertiary center pediatric cardiology practice. However, less than 5% of chest pain complaints are associated with a cardiac condition. Although media attention to these episodes in the community gives the sense that these episodes occur on a more frequent basis, several studies have shown that the incidence of sudden cardiac death in teens is fortunately rare. Most recently, Roberts and Stovitz reported an incidence of sudden cardiac death in adolescents as 0.24 per 100,000 athlete-years over the last 19 years in Minnesota. Chest pain in teens is most commonly divided into noncardiac and cardiac causes.
- •
Chest pain is a common complaint seen in primary care office, emergency room, and pediatric cardiology practice
- •
Chest pain in adolescents is most commonly benign
- •
Chest pain in this age group is perceived as cardiac by parents and patients and associated with tremendous anxiety
- •
Less than 5% of the chest pain is cardiac in origin
Noncardiac chest pain
Musculoskeletal chest pain is a very common type of noncardiac chest pain with reported prevalence anywhere from 15% to 31%. Several types of musculoskeletal chest pain are seen in teenagers ( Box 1 ).
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Noncardiac causes
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Musculoskeletal
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Costochondritis
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Idiopathic
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Tietze syndrome
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Trauma and muscle strain
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Slipping rib syndrome
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Scoliosis
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Chronic cough
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Asthma
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Pneumonia
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Pneumothorax/pneumomediastinum
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Pulmonary embolism
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Gastroesophageal reflux disease
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Gastritis
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Esophagitis
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Psychogenic
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Breast disease, gynecomastia
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Herpes zoster
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Sickle cell disease (acute chest syndrome or vaso-occlusive crisis)
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Cardiac causes
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Arrhythmia—supraventricular tachycardia, ventricular tachycardia
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Pericarditis—infectious, noninfectious or autoimmune, postpericardiotomy syndrome
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Left ventricular outflow tract obstruction—aortic stenosis, subaortic stenosis, supravalvar aortic stenosis
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Anomalous origin of the coronary artery
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Kawasaki disease
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Coronary artery vasospasm
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Hyperlipidemia or family history of early coronary artery disease
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Cocaine use
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Other—cardiac device or stent complications, aortic dissection, ruptured aortic aneurysm, pulmonary hypertension
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Costochondritis or costosternal syndrome
Costochondritis or costosternal syndrome typically presents as a sharp, stabbing pain along 2 or more contiguous costochondral joints. Deep breathing usually exacerbates the pain and this pain usually lasts just a few seconds to a few minutes. Signs of joint inflammation are absent, but palpation of the chest over the area reproduces the pain.
Tietze syndrome
Tietze syndrome is most often seen in teens and adults. There is frequently a history of recent upper respiratory infection. Excessive coughing is thought to be a possible mechanism. There is localized inflammation of a single costochondral joint with the second and third ribs most often involved. Signs of inflammation, such as warmth, swelling, and tenderness, are found at the specific costochondral, costosternal, or sternoclavicular joint involved. Signs of inflammation are what helps differentiate this from costochondritis.
Trauma and muscle strain
Trauma and muscle strain are particularly common in teenagers who are active in sports and are prone to chest wall trauma or muscle strain. Skeletal trauma in one series was the cause of chest pain in 2% of teenagers and children. If trauma is the underlying cause, there may be inflammation or signs of injury at the site of pain. In cases where the history of trauma is significant, signs or symptoms of hemopericardium and myocardial contusion should be evaluated. Weight training or history of heavy lifting is often underreported unless specifically asked in cases where muscle strain is suspected to be the source of the chest pain.
Idiopathic chest-wall pain
Idiopathic chest pain typically is located over the midsternum or inframammary area and is sharp, lasting only a few seconds to minutes, and is exacerbated by deep inspiration. Palpation over the sternum or rib cage may elicit pain.
Slipping rib syndrome is seen infrequently and involves intense pain in the lower chest or upper abdominal area. The 8th, 9th, and 10th ribs are attached to each other and not directly to the sternum. Trauma or dislocation in this area can lead to this condition and can be diagnosed by a positive “hooking maneuver” whereby the examiner pulls on the inferior rib margin, which pulls the lower rib cage out.
Pulmonary
A pulmonary cause is also a common cause of chest pain. Asthma represents the most common pulmonary cause of chest pain. Seventy-three percent of children with chest pain were found to have evidence of asthma in a study by Weins and colleagues. Infections of the bronchial tree or lungs, such as pneumonia, bronchitis, empyema, pleural effusion, or pleurisy, can cause acute chest pain. Pulmonary embolism can also be associated with chest pain and may be suspected in teens presenting with hypoxia and a predisposition to thrombosis.
Gastrointestinal
Gastrointestinal causes can also account for a certain percentage of teenagers with chest pain. Evangelista and colleagues reported a prevalence of gastrointestinal causes for chest pain as high as 8%. Gastroesophageal reflux disease, peptic ulcer disease, esophagitis, gastritis, and cholecystitis may present as chest pain. More rarely, ingestion of caustic substances, foreign body, or an esophageal stricture may present as chest pain.
Psychogenic
Psychogenic chest pain is typically caused by anxiety or a history of a recent stressful event. Often, psychogenic chest pain is associated with other somatic complaints such as abdominal pain or headache. Psychosocial factors have been attributed to the development and maintenance of chest pain as defined by Gilleland and colleagues. Psychogenic chest pain has also been demonstrated in other somatic complaints such as abdominal pain and headache.
Miscellaneous
There are various other causes of chest pain that can be placed in this category. Chest pain from breast-related causes can be seen in postmenarche teen girls in association with mastitis, fibrocystic disease, or pregnancy. In teen boys, gynecomastia may occasionally cause unilateral or bilateral chest pain. Herpes zoster infection may initially present with pain or paresthesia in a dermatomal pattern, be extremely painful and uncomfortable, and precede the rash by several days. Scoliosis or other deformities can cause chest pain because of nerve compression or abnormal posture and positioning or stretching of the chest wall.
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Musculoskeletal chest pain is extremely common in this age group
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Associated symptoms may suggest a pulmonary, gastrointestinal cause for the chest pain
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Psychogenic chest pain is a diagnosis of exclusion and may be seen with other somatic symptoms such as headaches and abdominal pain
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