Clinical Practice and
Referral Guidelines

Chest Pain

The following guidelines are intended to assist primary care providers in determining the need for cardiovascular evaluation for pediatric patients (<=18 years of age) presenting with chest pain. They are based on review of the current literature and clinical experience and are intended to provide a consistent, uniform approach to the evaluation of pediatric chest pain in Greater Metropolitan Atlanta, Georgia.

History

Detailed history is paramount in determining the likelihood of cardiovascular etiology for pediatric chest pain. Description of the pain—including nature, onset, timing, alleviating and exacerbating factors, as well as associated symptoms can suggest or eliminate the possibility of a cardiovascular cause. The majority of patients with chest pain can be appropriately diagnosed with a detailed history and physical and need limited further testing. Sibley Heart Center Cardiology has created, and uniformly utilizes, a chest pain questionnaire which assists in history-taking and determining need for possible further evaluation. Grayed areas on the questionnaire represent pain features which can be more concerning for possible, although rare, cardiovascular cause and may indicate a need for formal cardiovascular evaluation. Possible cardiovascular etiology is suggested by pain that is acute in onset, constant, pressure-like in nature, exacerbated by exercise or when lying down, or when it is associated with fever. Patients with a known history of Kawasaki disease should be evaluated by cardiology when they present with new-onset chest pain.

Additionally available is the Pediatric Cardiac Risk Assessment Form which provides further assistance in assessing a pediatric patient’s likelihood for underlying cardiovascular disease.

Specific factors which suggest a possibility of cardiovascular disease include the following:

• Syncope during or after exercise, startle or emotion
• Excessive fatigue or shortness of breath with exercise
• Associated palpitations

Obtaining a detailed cardiovascular family history screens for inherited disease and assists in the determination of risk of cardiac etiology. The family history portion of the Pediatric Cardiac Risk Assessment Form addresses diagnoses within a family which may put a pediatric patient at risk for significant cardiac disease. We recommend utilization of the form in its entirety to evaluate for the presence of any of the following within the family:

• Sudden, unexpected, unexplained death before the age of 50…including SIDS, unexplained car
• accidents, drownings, passing away in their sleep, stillbirth.
• Sudden death from “heart problems” before the age of 50
• Cardiomyopathy
• Unexplained fainting or seizures
• Disability related to heart problems under the age of 50
• A pacemaker or defibrillator
• Congenital deafness
• Long QT syndrome or Brugada syndrome

Physical Exam

A focused and detailed cardiovascular exam can signal the presence of significant cardiac disease. Pertinent positives requiring evaluation on the physical exam include the following:

• Stigmata of Marfan’s Syndrome*
• Pathologic murmur
• Friction rub
• Valve clicks
• Signs of heart failure
• Criteria for Kawasaki
• Xanthomas (may indicate familial hyperlipidemia)

Laboratory Evaluation

Routine laboratory evaluation is generally not helpful in the outpatient evaluation of pediatric chest pain.

Electrocardiogram

Electrocardiograms can be very useful as part of the overall evaluation of pediatric patients presenting with chest pain. Unfortunately, a normal electrocardiogram does not eliminate the possibility of cardiovascular etiology. Knowledge of age-related changes, abnormal findings, and common normal variations is essential for effective interpretation. With a reliable interpretation, a normal ECG significantly diminishes, but does not eliminate, the possibility of cardiovascular cause. The best interpretation of the ECG is done with a full understanding of the history and presentation of the patient.

Echocardiogram

Echocardiograms are used when there is a suspicion for possible cardiovascular etiology. In general, echocardiograms are performed to evaluate for structural or functional heart disease when these are suggested by an abnormal ECG, physical exam, or when the history is suggestive of cardiovascular etiology.

Who may not need evaluation by a cardiologist

Patients with reassuring family history and otherwise normal physical exam may not need furthercardiac evaluation when they present with the following:

• Sedentary chest pain which is reproducible on exam
• Chest pain attributable to reflux which resolves with reflux treatment
• Chest pain attributable to reactive airway disease which resolves with asthma treatment

Pediatric chest pain is a common presenting complaint to both general pediatric and pediatric

cardiology offices. It very rarely has a cardiovascular cause. Cautious, detailed, history-taking with attention to risk factors for cardiovascular disease and close attention to salient physical exam features can help direct those patients who are at risk for cardiovascular etiology to further, more intensive evaluation by a pediatric cardiologist. Please feel free to utilize our questionnaires to help with screening of your patients.

If you have questions, visit www.choa.org/cardiology, call 1-800-542-2233, or email information@kidsheart.com .

*Non-cardiac stigmata of Marfan Syndrome include the following: Armspan greater than height, exceptionally tall, thin body habitus, pectus excavatum, kyphosis, scoliosis, pes planus, joint hypermobility, arachnodactyly, high arched palate, myopia, lens dislocation, retinal detachment, spontaneous pneumothorax, unexplained stretch marks.

Acknowledgement

This Guideline was created by Sibley Heart Center in conjunction with the Atlanta based Quality Assurance Council (QAC). The QAC is composed of pediatric physicians representing Emory Children’s Center, Georgia Pediatric Subspecialists, Hughes Spalding, Kids Health First Pediatric Alliance, The Children’s Healthcare Network, and WellStar. The recommendations in the above guideline do not indicate an exclusive course of treatment. The guideline’s intent is to build a consensus of care in the pediatric market and provide a framework for clinical decision-making.