Effectiveness of Screening for Life-Threatening Chest Pain in Children
The Study: Effectiveness of Screening for Life-Threatening Chest Pain in Children
Pediatrics June, 2011
Pediatric chest pain is a high volume chief complaint that is rarely caused by significant pathology. The workup is often quite variable among physicians and many times results in a high amount of referrals and utilization of pediatric cardiologists. These prolonged and often unfinished workups result in missed school/sports, anxiety, and fear of exercise. Studies like this are helpful for developing guidelines for assessment and management pathways that will help us more efficiently take care of patients and utilize resources.
What is the incidence of sudden cardiac death among patients discharged from the cardiology clinic with presumed noncardiac chest pain?
This was a retrospective review of children who presented to Boston Children’s Hospital cardiology clinics with a complaint of chest pain. All patients received EKGs and workup was dictated at the discretion of the cardiologist.
Results: The etiology was determined to be of cardiac origin in just 1% of the 3700 patients. Cardiac diagnoses included pericarditis, myocarditis, anomalous RCA, cardiomyopathy, SVT, non-sustained VTach and cardiac syncope. Most of the cases were determined to be of unknown and MSK etiologies followed by pulm, GI, and others including psych and illicit substances. There were three deaths accounted for in the study; none of which were cardiac in origin. Two deaths were from suicide and one from a spontaneous retroperitoneal hemorrhage.
The Take-Away: This study confirms much of what we already know regarding which kids with chest pain that need further workup. There is a four part screening approach that will help us identify the kids with worrisome chest pain: 1. exertional symptoms 2. worrisome PMH/HPI/FHx 3. abnml exam findings 4. abnml EKG
-No patients discharged from the cardiology clinic died of a cardiac cause but significant cardiac disease was effectively caught using the screening history, exam, and EKG approach highlighted in this study.
-This study does provide us with good data supporting the practice of PCP follow up instead of cardiology follow up in kids that present with low risk chest pain. In this study population, 43% of the patients needed further workup leaving 57% of patients to be discharged with PCP follow up. This is a divergence from the all too common negative workup that still gets discharged with generic “no strenuous activity until cleared by cardiology” instructions.
Of note, the two patients that died from suicide had been seen by a cardiologist for chest pain in this study. This is an important reminder that kids with life threatening psychiatric disease may present with somatic complaints.