At a recent Johns Hopkins Children's Center Grand Rounds, Nina Guo asked fellow pediatric residents to imagine assessing a young patient’s chest pain on their very first shift in the pediatric ED.
“Here you are, fresh from medical school where you were exposed to adults having heart attacks, and you’re facing a child with chest pain,” said Guo. “Are you worried? How concerned are you that it’s a true cardiac cause?”
Guo noted that she was greatly relieved when one dose of Maalox relieved her first pediatric ED patient’s chest pain, but continued to wonder about the frequency of cardiac-related chest pain in children and how to manage it. Are there criteria for tests, a standardized protocol for pediatric patients with chest pain?
“We work these patients up, rule out everything scary and dangerous, and then focus on what we think is going on,” Guo said. “Sometimes there’s not a good answer. Sometimes we discharge them and wonder whether we missed anything.”
Looking into the literature, Guo found that while chest pain is a frequent complaint in the pediatric ED, the incidence of cardiac causes is very small. Prior to 2009, studies estimated cardiac causes in 1-to-5 percent of pediatric ED cases. A more recent study of over 4,000 patients with chest pain at two tertiary care pediatric EDs found only .06 percent had chest pain of cardiac origin (American Journal of Emergency Medicine 2011;29:632-638). Of the non-cardiac etiologies in this cohort of patients, 56 percent were related to musculoskeletal causes and inflammatory disorders like costochondritis and Tietze syndrome. Asthma and wheezing represented 12 percent of chest pain causes, infections 8 percent, and gastrointestinal disorders like esophagitis 6 percent. Of the cardiac causes of chest pain, dysrhythmia was the most common cause, followed by pericardial disease, myocarditis, acute myocardial infarction, and pulmonary embolism.
In the workup of these patients, chest x-ray was ordered in 50 percent of the cases, electrocardiogram (ECG) in 92 percent, echocardiogram in 58 percent, and labs in 79 percent. The study found that ECG and echo were used significantly less often in patients found to have non-cardiac chest pain.
“The study suggests providers already had a low index of suspicion of heart disease after their initial evaluation,” Guo said. “But there was no significant difference in chest x-ray use in cardiac related patients with chest pain.”
Guo noted that another study found that certain criteria—including the presence of comorbidities, history of trauma, shortness of breath, and palpitations—would have identified patients with positive results on chest x-ray (Pediatric Emergency Care 2012;28:451-454). Such findings are important, she added, in lowering radiation exposure, length of stay and related costs. Also, while some hospitals have started implementing a standardized approach in evaluating chest pain complaints in the outpatient setting to reduce practice variation (Journal of the American Heart Association 2012;1:jah3-e000349), pediatric EDs generally have not followed suit.
“The ED has such fast turnover that you really need to be more sure and precise—there’s not that much time to waver,” said Guo. “We need to develop criteria to aid in smarter and more efficient resource utilization in the evaluation of emergent pediatric chest pain.”