Majority of children with chest pain do not have an underlying cardiac cause

Article Outline

• Question
• Design
• Setting
• Participants
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Friedman KG, Kane DA, Rathod RH, Renaud A, Farias M, Geggel R, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics 2011;128:239-45.

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Question 

For children presenting with chest pain, what is the most cost-effective strategy for evaluation?

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Design 

Retrospective chart review.

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Setting 

Children's Hospital, Boston, Massachusetts.

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Participants 

406 patients, aged 7 to 21 years, presenting for evaluation of chest pain to an outpatient pediatric cardiology clinic over a one year period.

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Outcomes 

Demographics, clinical characteristics, patient outcomes, and resource use were analyzed.

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Main Results 

Testing included electrocardiography (ECG) in all 406 patients, echocardiography in 175 (43%), exercise stress testing in 114 (28%), event monitoring in 40 (10%), and Holter monitoring in 30 (7%). A total of 44 (11%) patients had a clinically significant medical or family history, an abnormal cardiac examination, and/or an abnormal ECG. Exertional chest pain was present in 150 (37%) patients. In the entire cohort, a cardiac etiology for chest pain was found in only 5 of 406 (1.2%) patients. Two patients had pericarditits and 3 had arrhythmias. The authors developed an algorithm using pertinent history, physical examination, and ECG findings to suggest when additional testing is indicated. Applying the algorithm to this cohort could lead to a reduction of around 20% in echocardiogram and outpatient rhythm monitor use and elimination of exercise stress testing, while still capturing all cardiac diagnoses.

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Conclusions 

Evaluation of pediatric chest pain is often extensive and rarely yields a cardiac etiology. Targeted testing can reduce resource use and lead to more cost-effective care.

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Commentary 

Although chest pain is a common complaint in children, it is rarely indicative of significant cardiac pathology. Because chest pain is often a signal of serious cardiac pathology in adults, it often results in significant concern in patients and their families. The authors of this study propose an algorithm for the evaluation of children with chest discomfort in the outpatient setting. One of the most interesting and important findings of this study is the lack of utility of exercise testing for evaluation of chest discomfort. The primary limitation of this study is the potential for missed cardiac diagnoses in patients who only underwent limited testing (history, physical, and electrocardiogram). Because it was assumed that patients with a benign history and normal ECG did not have significant disease, the potential for a missed diagnosis remains. Additionally, patients were identified using the ICD-9 code for chest pain. A patient found to have a significant diagnosis would likely have been coded with that particular diagnosis rather than the more general chest pain diagnosis. This limitation was mitigated by validation of the algorithm against a previously reported cohort of patients presenting with chest pain who were found to have a cardiac etiology. Although validation of this algorithm at additional centers is required prior to its use with other populations, it provides a helpful framework for the evaluation of children with chest pain.