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Children's chest pain rarely signals heart problem

By Amy Norton

NEW YORK (Reuters Health) - Children and teenagers who complain of chest pain only rarely have a heart problem causing it, a study published Monday suggests.

What's more, researchers say, relatively simple steps -- including a physical exam, taking a family history and doing an electrocardiogram -- could pinpoint those kids who need more extensive, and expensive, testing for heart problems.

The study, reported in the journal Pediatrics, looked at records for 3,700 children older than six who came to Children's Hospital Boston to have their chest pain evaluated.

Just one percent turned out to have an underlying heart condition. The most common were inflammation of the heart muscle or its surrounding sac, which is often the result of an infection; and supraventricular tachycardia, a rapid heartbeat that is rarely life-threatening.

No child died of a cardiac cause during the 10-year study period.

"This study should be reassuring," said lead researcher Dr. Susan F. Saleeb, a pediatric cardiologist at the Boston hospital.

"Chest pain in children is very common," she told Reuters Health, "but the chance of a cardiac cause is very low."

CARDIAC ARREST DEATHS RARE

It's known that sudden death from cardiac arrest is quite rare in children and teenagers. In the U.S., estimates range from less than 1 to about 6 such deaths per 100,000 -- about one-quarter of which happen during sports.

Despite the rarity, those deaths are tragic and -- in the case of young athletes, in particular -- often garner media attention. So parents may become unduly alarmed by their children's chest pain, and kids may end up getting tests they don't need, according to Saleeb's team.

Often, chest pain in kids comes from something much milder than a heart condition -- like a muscular cause, respiratory conditions like asthma or a gastrointestinal problem like acid reflux.

In many cases, though, the precise cause cannot be pinpointed. That was true of 52 percent of kids in this study. Of the remaining patients, musculoskeletal causes were most common, followed by respiratory and gastrointestinal conditions, and, in one percent of all cases, anxiety.

There are no universal guidelines on how to check out children's chest pain.

Children in the current study were seen between 2000 and 2009, when the hospital had no standardized method for assessing chest pain. All of the children had their family history taken, underwent a physical exam and had an electrocardiogram (ECG); many had other tests, like an echocardiogram or exercise stress test.

'SCAMP' PROVES USEFUL

Since then, doctors there have started using guidelines known as chest pain SCAMP.

Children are first screened based on their symptoms, family history, a physical exam and an ECG (also known as an EKG). If there are concerns, they go on for further testing -- usually with an echocardiogram, which uses sound waves to produce images of the heart.

Of the children in this study who were ultimately diagnosed with a heart problem, the "vast majority" had concerning findings on their history, physical exam or ECG, according to Saleeb's team.

So the SCAMP screening, they say, could help get echocardiograms and other more extensive tests to the children who need them -- while avoiding unnecessary tests in other kids.

Having pediatricians and other primary care doctors perform that screening would be ideal, since it would avoid referrals to a cardiologist. And Saleeb said the researchers are looking at ways to adapt their screening method for primary care.

A primary care doctor might, for example, be able to perform an ECG and have it read by a cardiologist -- avoiding having a child actually visit the specialist.

Saleeb's team estimates that, in theory, more than half of the kids in the current study might not have needed to see a cardiologist if they'd had "effective screening" by a primary care doctor.

In the meantime, Saleeb said that while parents should bring up any chest pain problem to their child's doctor, they should also feel reassured that it's unlikely to signal a heart condition.

"Chest pain in children does not represent the same disease as chest pain in adults does," Saleeb said.

She did, though, point to some "red flags" that could suggest an underlying heart problem in kids -- including chest pain that arises specifically during exercise, or pain accompanied by other symptoms like irregular heartbeat or fainting.

SOURCE: http://bit.ly/pxRdOX Pediatrics, online October 10, 2011.

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