While the most common reasons for chest pain in the young aren’t related to the heart, providers need to be certain before they can reassure worried parents. In this presentation for the PCP, pediatric cardiologist Walter Li, MD, breaks down cardiac and noncardiac causes and describes symptom and history details that point to a need for cardiac studies. Included are keys to the physical exam, such as localizing the pain, and tips on appropriate use of specific tests.
So, I'm gonna talk about chest pain in children today. Um, seems to be a pretty appropriate topic for Valentine's Day and any kind of heartbreaks that may or may not occur today. Um, uh, um, please feel free to, uh, put questions into the Q&A section and, uh, towards the end of the, uh, talk, I'll, I'll do my best to address them as best as possible. I So first things first, I have no disclosures. Um, I, I, I'll take applications, of course, but I have no uh disclosures except to say thank you for um giving me a portion of your day uh during your um lunch, uh, probably, um, lunch hour to, um, to speak. So the objectives of this talk are to view what are the causes of the chest pain in, in kids and get a sense of what is the relative prevalence both in terms of generally how, how often is it due to cardiovascular conditions and how often is it due to something else. Um, hopefully, I'll be able to give some key, um, questions and historical perspectives that will give everyone, uh, the ability to quickly, um, determine if this is a very concerning uh chest pain from a child versus Um, something that is, um, um, uh, that we can provide reassurance rather quickly. Um, we'll also, uh, talk about certainly in pediatrics, what are the age-limiting factors and what kind of makes our jobs all much more challenging than necessarily, um, adults, and, um, lastly, I do want to go over the appropriate or at least my perception was appropriate use in terms of testing that can be done or should be done in the assessments of children with chest pain. So in terms of non-cardiac etiologies, that is By far the most common reasons for chest pain among individuals under 20 years of age. Most commonly costochondritis, musculoskeletal ideologists, so costochondritis, so specifically that cartilage that attaches one of the ribs to the sternum. There's also prechordial catch syndrome which is very typical towards the apex of the heart and it's pleuritic, it's short, it's stabbing, it's a very prototypical sign of prechordial catch syndrome. Um, certainly any kind of muscular trauma, um, particularly among, um, uh, uh, younger athletes who would be having repetitive motion kind of issues with their shoulders and, um, very common among particularly, um, adolescents who are perhaps doing some bench pressing and things like that for to have that kind of muscular trauma and strain there. And there is an etiology of hypersensitive xiphoid syndrome, which is where literally the xiphoid process just underneath the bottom part of the sternum is very sensitive for a very small percentage of the population and certainly one needs to be cognizant of the possibility of sickle cell disease causing a chest pain. And then moving on from musculoskeletal etiologies, pulmon pulmonary causes certainly can result in chest pain, whether it's long-standing known um history of asthma or whether it's an acute illness of some sort of pneumonia or some sort of upper respiratory infection, um, and then pneumothorax is certainly something we need to be cognizant of because that could be potentially um um uh very, very dangerous. And then pulmonary embolism is probably the one I, I would like to um um have as a point of emphasis for everyone to have on the radar in terms of the assessments. So in terms of cardiac etiologies, and this is probably the reason why it is of such a concern for a lot of our patients whom and their families whom we take care of, these are the things that we need to be assessing to and hopefully be able to provide reassurance to our patient population to say, look, these are the things we need to kind of worry about and this is A, B, C, D, and E, why I don't think we need to be worried about it. So the etiology is to be concerned about pericarditis or inflammation of the pericardium, myocarditis, which is the inflammation of the heart muscle itself. Aortic dissection, uh, in certain patient populations should make us, um, pause and really, really make sure that we get the correct assessment quickly. Perhaps the most um well described one is Marfan syndrome for which we have the most robust amount of data in terms of that risk, although one can certainly extend this to connective tissue tissue disorders such as Lowy Dietz syndromes and potentially uh things like Ella Danzlos. Aside from that, tachycardic arrhythmias is something we should be cognizant about and particularly scenarios in which we have this episodic chest pain here and there and uh hopefully we have patients who are able to tell us that they're feeling like their heartbeat is unusual during these scenarios, these times. And then finally, perhaps most rarely in terms of cardiac etiology chest pains, although certainly from most of our families and patients, what they're most concerned about is, is whether or not this is a heart attack, myocardial ischemia, and the patient populations for whom we need to be most concerned about in terms of predisposing factors are patients who have had Kawasaki disease which did have coronary involvement from the onset of the illness. Williams syndrome for which um some patients may have um uh narrowings of their coronary arteries. And then finally and perhaps most controversial is the possibility of anomalous coronary arteries with an intra-arterial course. So going from a historical vantage point for decades and decades now, we've had the Gestalt the sense that chest pain in younger patients is rarely or very, very rarely due to a primary heart condition, and this is a paper from the 1980s that is showing in this author's um in their data set, how often or what types of chest pain or what were the ideology of chest pain back in their data set in 1980s. And you can see from here, the vast majority of them percentage wise. Non-cardiac etiologies. Looking at it from the 90s on an updated um uh data set of different authors, different patient populations, we see fairly similar distributions in terms of, well, how often is a cardiac, very small percentage of time and how often are these other general broad categories. In fact, when they wrote the textbook, Early mid to late 2000s. This is the congenital cardiac um textbook that pretty much every pediatric cardiologist reads during our training. The frequency of chest pain in those editors experience and to which they decided to devote 7 out of 1000, nearly 1400 page textbook, they decided to devote seven pages in terms of talking about chest pain in pediatric patients because it is in terms of cardiac causes, it's that rare. Well, we have even more data at this point in which that, uh, in which to refer to and that is, in my opinion, very reassuring for ourselves and for our patients. So this is what we term the SCAM study. So this was conducted at the Children's Hospital in Boston in the 2000s and it looked at patients who came into pediatric cardiologist's office for an assessment of chest pain. And I refer to this, this study pretty much universally whenever I see patients for chest pain in the office. And I try to convey the information as plainly as possible to all the patients. I'll tell them over 3000 patients were assessed in, in this case, and yes, small percentage time there are cardiac issues. What I found interesting from this study, and if you look at the etiologies listed here from the authors. Is that, yes, some of these things are pretty dangerous. But a number of them. And I would in in even totaling the numbers here total. The majority of them don't primarily cause chest pain, and they may have chest pain in addition to feeling palpitations, feeling tired, but in terms of what potentially could just primarily cause chest pain. It's actually a minority even among that 1% of the time. And I should also add that this is a patient population that was specifically were patients referred to pediatric cardiologist's office. So you can imagine that um that this is 1% of patients coming to the pediatric cardiologist's office and then you can probably derive from your own experience from uh in clinical. How often are there other patients for whom it's clearly musculoskeletal, so they don't even come to see the pediatric cardiologist. So the possibility the incidence of cardiac causes of chest pain are thankfully very, very small. Well, if we do look at the patients who do have cardiac positive chest pain, well, what are the relative incidences of it? And the by far and large. And it, and um what I hope uh everyone can kind of take from this is that it's primarily 4 different things and I wouldn't even say primarily 3 different things. So myocarditis, pericarditis, and pulmonary embolism. And to that end it's very advantageous because it will show us and inform us in terms of what types of testing will be very helpful in terms of high yield and what is the uh appropriate use in terms of these assessments. I'll come back to this in a little bit. This is another study which I found to be quite, quite fascinating. So this was a study conducted again in the 2000s uh out of an emergency department in Turkey. And it was quite an intense study, so 380 children, all of whom coming to an emergency department. Um, all had these four core studies. And then depending upon the specifics of the history, Uh, additional testing was done. And what I find to be quite, quite, quite interesting is that in an emergency room-based patient population, they're all pediatric patients, so this is very severe, very concerning chest pain. In terms of cardiac causes of chest pain, things that are potentially dangerous, out of 380 patients, 1. 1 out of 380 had chest pain that was primarily cardiac um in etiology. So, hopefully none of, uh, none of us as a cardiologists are um having uh this disposition when we're answering the question about chest pain from our perspective. And oftentimes, yes, I do acknowledge, uh, I do have uh I have seen this situation where we say it's not the heart. However, I would amend that to say, OK, let's say it's not the heart, but Well, if we're saying that, make sure we don't say it's not, you know, we don't miss myocarditis, myocardial ischemia, or pulmonary embolism. So what's helpful in terms of the assessment? Well, I think history, so knowing the past medical history will give us a sense of whether this is a vulnerable patient to whom we should be diverting more resources to the assessment. And to me the scenarios in which it's more concerning are patients who may have Um, a potential risk to the coronary arteries from past illness or past or underlying illnesses such Kawasaki, uh, disease or Williams syndrome, but the other patient population I would be very concerned about would be Marfin in terms of the risk of aortic dissection. So hopefully this is something we can um help um uh uh determine uh at um very early on whether this is something, this is a, a patient we need to triage quickly to emergency services or have a more expedited um assessment. The context in which the chest pain has been experienced, I think it's very, very informative. I worry a great more, a great deal more about patients who are having exertional chest pain because to me that is concerning for the possibility, not inevitability, but possibility of coronary ischemia. Um, if it happens with respiration, specifically a deep breath causes the pain to be worse, oftentimes that points to a, uh, pulmonary, uh, underlying process or a musculoskeletal process because we're having stretch, stretches of the, the different intercostal muscles and the muscle groups overlying the chest wall. Sometimes we have very um insightful patients who will give us the answer already and they'll say, yeah, I've been having the chest pain and if I keep pushing on this one spot here, it hurts, in which case makes our job much, much, much easier to say, yeah, that's probably very likely musculoskeletal. Other social symptoms may be helpful in terms of, of um helping us in terms of um determining uh how concerning or what the underlying etiologies are. Palpitations sometimes are helpful, particularly palpitations occurring before the onset of chest pain may point us to the possibility of a, of a tachycardia arrhythmia. Uh, the shortness of breath, perhaps the patient themselves can't initially articulate that, oh yeah, I feel the pain a lot more when I take a deep breath, but then when you prompt, you know, when they say, oh you know I have some shortness of breath and it can prompt us to say, well, are you having shortness of breath because when you take a deep breath, it hurts a little more and sometimes that kind of helps uh trigger the memory a little bit in terms of Um, what, what the possibilities are. Review of symptoms can be helpful. So if you have symptoms of an upper respiratory infection or, uh, uh, uh, or a past history of COVID or a pneumonia, that can potentially be helpful and reassuring in terms of nothing imminently dangerous, uh, family history, um, oftentimes in these scenarios we get a family history of Grandfather Uncle parent who's had symptoms of myocardial ischemia which helps us kind of understand like OK, what are some of the other issues that are going on here? Perhaps that is feeding into a uh a pediatric patient who has a type A personality who now says, oh gosh, that's gonna be me, that's that's gonna be me, in which case then we're starting to get more sense like, you know, maybe there's a little bit of uh stress here, a little bit of anxiety kind of going on here, but we understand that because of the family history. Um Other times we, we, we are, we, if we understand that, hey, this is an elite athlete. Who wants to exercise all the time, they're having some chest pain here that may put that um um frame that patient's concern a little bit more so and help um help us kind of guide us in terms of figuring out, hey, what's the best way that we can provide reassurance for these different patients. So I think particularly in this, you know, chest pain in children, I think that physical exam can be extremely, extremely informative and particularly reassuring. And one of the reasons is that On a physical exam, sometimes we can localize that, that pain to the point where we can be so, so, so specific that we can help persuade families and patients say, you know, this is very clearly chest wall pain. This is very clearly musculoskeletal etiology or oftentimes this is clearly costochondritis and the way and as with most things in life, the devil is always in the details. Exactly how do we go about that? And for me, It's not just a matter of just generally hey where the area is, it's finding that out from the onset from the patient, but then going point by point and for me what I do is I actually go fingertip point by point. Until I get closer and closer and closer to that one spot. In about, yeah, probably about 70-80% of the time, we can locate like, yep, that's that one spot, that's the spot that, that, that bothers me, that's causing me the pain. It may radiate to other places, but instigating that and explaining to the families and to the patient like, look, this is chest wall, there's no way I can affect your heart by pushing just with my fingertips here, so we're in a good spot. We're OK. It also gives us the opportunity on physical exam to take a listen. So it wouldn't be unheard of to basically hear diminished breath sounds like, oh gosh, maybe this is uh, maybe this is a pneumothorax and I need a little bit of help here. Sometimes we hear very diminished heart sounds and we begin to, you know, begin to be concerned about um pneumonia and things. Uh, certainly chest wall deformities uh can be helpful. So it's not necessarily a patient who has Marfan syndrome who have may have, uh, um. Uh, uh, uh, uh, uh, a pectus, uh, abnormality for which that can be painful, in which case that is, we know where that patient will get the, uh, more, most optimal or most direct care in terms of perhaps potentially a, a surgeon in terms of assessing that. Um, the possibility of facial dysmorphism may give us, uh, some insight, some clue that perhaps this is a patient who has Williams syndrome and perhaps we need to be assessing for those possibilities of different arterial narrowings. Certainly vital signs will help us triage and help determine like hm. How much do I need to be worried about myocarditis in this patient or pulmonary, uh, pulmonary embolisms. So all those different basic routine vital signs that we're always kind of getting these patients could be extremely, extremely helpful. So with that, well, one of the things we have to kind of watch out, what are the specific um details and symptoms that point us to the possibility of myocarditis? Well, Interesting thing, it's not, it's as with most things in, in our fields, it's never usually just one thing, it's usually multiple things and that's what I like from this kind of this first table here is usually not any one thing, usually there are multiple things kind of going on that kind of clue us in and it's not always just the fact that I have chest pain for patients with myocarditis and it makes sense if you think about well, what is the meaning of myocarditis is, well, the heart muscle is inflamed. Typically it doesn't work super duper well, in which case the ability of the heart to receive blood, push blood, gets impaired, and then blood typically backs up. So typically these are patients who have both chest pain, they also will have tachypnea. They'll have you struggling a little bit to breathe, particularly when we get to a very dangerous spot. Hopefully we're not at a point where we're seeing hyperperfusion, but usually it's a combination of things in terms of symptoms in terms of pediatric myocarditis. And these are the other uh different factors that we um see in terms of physical exam findings. So it's usually a number of these different things, not any one particular, not chest pain in isolation. The other one I think is really important for us to always assess for and, and, and, and um look out for is pulmonembolism. Yes, chest pain is definitely one of those symptoms. But typically we're seeing a number of other symptoms with, with that, and we're seeing other vital signs to tachycardia, tachypnea, low oxygen saturations for these patients here. However, one thing I do want to kind of uh put as a point of emphasis. It's not super duper, it's not the majority of patients without any underlying issues for whom pulmonary embolism is commonly seen. In fact, there are a number of underlying conditions for which should prompt us to say, hm, I really need to think about pulmonary embolism. Now, yes, patients who are overweight and yes, that's a Increasing problem and an issue that we, we all see is uh the recent um controversy from the American Academy of Pediatrics in terms of barrier surgery and such, um, I think informs us about. But in terms of things we, we'll know ahead of time. Yeah. Maybe someone had an indwelling catheter as part of their uh congenital heart surgery, or maybe it's someone who's followed with nephrology from for nephrotic syndrome, or perhaps they've previously had a pulmono, and these are the scenarios in which we need to be much more cognizant of the possibility of pulmonary embolism. And usually, it's not just one thing, it's multiple things. So this is an emergency uh um department-based study in terms of, hey, what are the different factors we're kind of seeing here. So usually it's multiple different things that we're seeing. So differentiating symptoms. So this is, uh, and this is more adult-based cause um it's not thankfully with the, in a pediatric patient population, we don't see Myocard's skin and pericarditis in pulmonary as much. But these are some of the differentiating factors here. So with With in terms of the character of the pain. The less traumatic the pain is, the more concerned I am about the possibility of, of a heart, you know, issue. So marker ischemia, they tend to be pressure like heavy squeeze, not just dramatic. Oh my goodness, it's one spot, it's how that really kind of really, really hurts. But you contrast that to things like pericarditis and pulmonary embolism, it's very different. Positional changes point us more towards the possibility of pericarditis. Um, the EKG to me this is a particularly helpful differentiating factor here because they, it will look very different. So if that rare occasion where we're seeing myocardial ischemia causing chest pain, it's going to be localized to the segments of the myocardium that are being affected. You contrast that to pericarditis, it's the entire heart, it's the lining of the hearts everywhere, so that will cause widespread changes everywhere and I'll show you some examples of this in the, in the ensuing slides. And then you contrast the pulmonary embolism. Well, from a physiological standpoint, when it's really, really bad, pulmonary embolism will cause strain onto the heart and we'll see those changes limited to the EKG leads that are Affected by the right ventricle function. So what is helpful, you can probably already tell that uh I, I think very strongly that an EKG is helpful in this case and this is one of the EKG and one of the uh data points that um it's, you know, informs my kind of decision-making process. And a chest X-ray can be uh helpful, but I think the EKG is perhaps a little bit more informative. And troponin? Yeah, maybe. Um, although you oftentimes find some other things, so chest pain not otherwise specified. Um, and if you're waiting for the troponent to kind of tell you someone's septic, then you kind of have some issues, but it could be helpful, but it's more of a Uh, affirming things like I already think this patient has myocarditis. I already think this patient has perimyocarditis. OK, let's see what the one is like, you know, it's also, it's elevated. OK, yeah, this, this makes me more, more convinced that my, um, my presumptive diagnosis is, is accurate. So on EKGs, so a quick reminder from that prior slide, so myocarditis, we're going to see diffuse low voltage amplitudes, sometimes, particularly if the, if the ventricles are really, really strained, we'll see T wave abnormalities. Contrast to pericarditis, typically the voltages, unless there's a massive pericardial effusion, but typically the voltages will all be OK, we'll just see diffuse SE segment elevations everywhere. Uh, the EKG is helpful in terms of, uh, assessing actively for the possibility to tachyardia arrhythmia and certainly mild cardio ischemia, but these are localized changes, so we only see them in very specific distributions on the EKG. So as an example, myocarditis. So this is, I think we can all generally agree the voltage amplitudes. Here of the R waves are all drastically drastically decreased. In fact, the only ones we see anything remotely kind of normal is the right heart distribution here. Sometimes what we're seeing is not so much a very um profound and um decrease in the R wave um amplitudes, but we're seeing diffuse T wave inversions what oftentimes is referred to as a wide uh QRS T wave angle. In other words, the T wave doesn't fall along with the QRS complex axis in pretty much all the leads. This is an example, real life example of someone who um was known to have um lupus and then for um Reasons um that the patient didn't want, did not want to um share decided just to stop taking all the medications and it was Um One of the worst heart functions I've actually seen is someone who is um awake and alert. Contrast anticipation with an example of pericarditis, so we see diffuse ST segment elevations in pretty much just about all the leads here. Another example of this is uh shown here. So we see perceived PR depressions and the ST elevations pretty much in. Every lead Another example, uh this is a patient who actually came to the emergency department saying they have chest pain and lo and behold, EKG was done. This patient had um a diffuse ST elevations everywhere. Contrast that to a patient who is tachycardia and we look in to see if they have um a normal rhythm and in this case, this patient has SVT supraventricular tachycardia, and you see narrow complex tachycardia at a very, very elevated heart rate. Sometimes the patient may not be actively having a um Pachyarrhythmia, but we'll see uh an underlying substrate for SVT in Wolf Parks and White, so that's due to an accessory pathway, extra nerve from the atrium down to the ventricle resulting in a short PR interval and a Uh, slurring or quote unquote delta wave. And this was, thankfully, it's really rare that we see my uh we see myocardial infarction with um with, with children. Uh, this is an example of a patient who underwent an electrophysiology study and was having a catheter ablation, not my patient by the way, um. Um, whom had a coronary injury from their ablation. And you can see localized. ST elevations with reciprocating ST depressions. I mentioned in one of the earlier slides that the possibility of an abnormal coronary. Unfortunately, resting EEG is probably not going to inform us very much because, well, they're resting. There's no active increased myocardial demand, increased need for coronary perfusion at that point. So typically, Their EKG is normal, particularly early in terms of the potential of their symptoms. However, let's say this is a patient who tells us, yeah, I have chest pain anytime I exercise or most of the time when I exercise. Well, oftentimes we may ask them to do exercise in a mantra setting. In which case We'll often see this So we'll see T wave inversions. ST elevations? Induced by increased work on an exercise test. So this is the same patient, by the way, between their baseline EKG here. In their exercise test here. So very marked, marked abnormalities. So If I may I'm, I'm advocating for the use of um mostly EKGs. Although most of the times we're often asked to say, to, to see if an echocardiogram is helpful in terms of the patient's assessment. So this was Um, again, the SCAM study, the, the study, uh, conducted in, in Boston, and they had some pretty In my opinion, persuasive data about uh how uh useful the echocardiogram is um for um chest pain assessments. And this, these are the criteria in which they set uh for their study protocols like for which patients are we going to be doing, um, are we going to be doing echocardiogram. So you can see their very delineated EKG findings, historical findings that, that inform that, that decision-making process. And in terms of historically just over the phone, you know, just patient telling us, these are the things I found particularly uh uh informative and the things that in terms of the underlying ideology, these are the things that scare me or potentially would scare me. So even in that context, the test is recommended, but they also compared when a test is not recommended and I, I don't recall why they still went with the echocardiogram, um, even if it wasn't recommended, but probably it's good reasons, um. That that didn't fall into the the the the study's parameters. The interesting thing is, Even in a case where the test is recommended, so basically the patient had chest pain with exercise. Or some other kind of concerning things. Out of over 400 patients, only 2. had an underlying cardiovascular abnormality that would explain their pain. In their series. Patients were far, far more likely to have an incidental abnormality, not associated with the chest pain than they were to have a finding on echocardiogram that explained their chest pain. Add into that uh a publication from uh in the um uh I, I believe this was uh American College of Cardiology and this was a, a pediatric cardiology work, echocardiography work group and they were saying, OK, what are the times we should be doing echocardiograms for these patients? And they had a section about chest pain here. They reported very, very similar findings. So, in their case, it wind up being uh rounding up to 1%, but still. Extremely, extremely small percentage of patients, even in the context, this is number 30 here that the numbers are coming from here, even in the case of exertional chest pain, the possibility of finding an echocardiogram in and of itself. Of uh underlying explanation for a chest pain. Very, very small, even in the classic case. The other thing I thought was very, very informative, helpful from that study from Boston. And I referred to this um all the time when I talk to patients. Is that They checked in on all the patients. Like 5 to 10 years after the initial cardiology visit, including the patients who had a heart condition. In their series. In 5 to 10 years is a pretty good length of time in terms of uh follow-up. No patients were had died from the cardiovascular conditions and in fact in, in the text of the um of, of the paper they even report about any um uh they, they say there weren't any uh significant sequelae even among the patients who had cardiovascular condition even if they survived well. Even though they, even among the patients, they all survived, none of them even had something horribly um go on and had any significant morbidity from their underlying cardiovascular condition. So OK, hopefully I've given you some, some information that's uh reassuring to say, OK, well, maybe the echocardiogram maybe not be too terribly helpful. What's, what are other things that could be helpful? Well, I think in the case of, of, of exertional chest pain, I, I think an exercise test could be potentially helpful for all for one, if you do have someone who has very significant um abnormal coronary, you'll pick up on it. Um, but I think the other reason why it can be um pretty helpful is Helps build reassurance to say, hey, we have you monitored the whole time. Someone is assessing your chest pain. We're looking at your EKG the entire time. We're checking the blood pressure the whole time. We're seeing how you're doing. Sometimes we're even doing what we term a full cardiopulmonary exercise test where we even measuring the oxygen consumption and the CO2 production the whole time. Um, this is potentially helpful. Uh, this is, uh, pictures from our, our, um, prior exercise, uh, uh, lab in, um, in the Parnassus campus, but we have multiple places where we do these types of testing. Um, it's potentially very, very helpful. And one of the reasons I think we need to be cognizant of like what is helpful. It's because medicine is getting really, really expensive over time and I like to think that we're all good stewards in terms of, hey, I want to, let's take care of you, let's take care of you in the most efficient and economically responsible way possible. And for me, now this is Old data and it's about 10 years old, uh, so I don't have it updated for inflation and things like that, but to me it's still impressive from 10 years ago. This is how much things cost. So an EKG, relatively speaking, it's one of the cheapest things we do, uh, in all of medicine, to be quite honest. Some of these other things that we do an echocardiogram, I mean, it's, it doesn't hurt anything, but it's still pretty costly. Uh, monitors. This is what, how much they, they cost in terms of doing heart rhythm monitoring. In terms of a chest X-ray, that's uh, aside from the radiation exposure, that's, uh, that's, it's uh not that cheap. An exercise test? Well, it oftentimes depends on where we're doing the exercise test. So, in a hospital-based testing, it's, it can be pretty, pretty darn expensive. Um, these are kind of add-ons. So if we do a pulmonary function test and we do, um, uh, nuclear myocardial perfusion, it's additive, not total, it's additive, $2000 to $3000. Um, and then certainly an MRI, uh, it can be quite, quite costly, so. I think it's really important for us to use these resources in as responsible a manner as possible. So Overall, by far and large, most patients, pediatric patients who have chest pain, most of the time what is needed is reassurance. And to me that reassurance um starts with the history and, and physical. Um I think Sharing data, sharing our understanding of the medical literature, I think is very helpful to the patients saying like, look, this is not just my opinion. These are multiple people's opinions. This is the data, this is the research that is available, that is widely available that we all kind of look at. So this is Has been investigated. So these, these, these are the pieces of information that's helping me draw this conclusion. So you're, it kind of helps build that confidence for, for those families like no, we, you know, we, we, we have the right screenings, we know what are things to kind of look out for. I would advocate for the use of the EKG in these situations, but I will fully, fully acknowledge that I have a little bit of a bias because I do think that universal EKG screenings are helpful for the population in general, although I do admit that it's a very, very, uh, controversial topic. Sometimes, particularly for these episodic chest pain, and we have the and then we have the concern for a palpitation, the possibility of a tachycardiagramia, that ambulatory cardiac rhythm monitoring could be helpful, not universally, could be helpful in select cases. Exercise testing, again, depending upon the circumstance can be helpful. Perhaps that uh patient who is an athlete, who is the quote unquote high school quarterback who's convinced that he's gonna be um leading the Kansas City um Chiefs to the Super Bowl. Yeah, maybe that patient we, you know, needs a little bit more reassurance kind of going forward or this is the this is the person who's classic says every time I exercise, it hurts. And I, I will certainly get to questions at the end. I'm almost done. And then lastly, I'm not saying never. I think imaging should be one of those issues that we rarely consider. Uh, mostly because I think the physiology is there and the physiology we have other means to assess for and can provide those types of reassurance. For the most part, knowing what the underlying etiologies are, that is most times they're musculoskeletal cause chest pain. Non-steroidal anti-inflammatory medications can be helpful. Quite commonly will suggest, um, and depends on size, uh, uh, a week's worth of uh ibuprofen, uh, or whichever uh non-steroidal anti-inflammatory one is comfortable with. I usually recommend that for about a week and to see if it does help, I fully tell the patients this may be helpful, it may not totally extinguish, but it's reasonable to try. And really what we're trying to do is, as Homer is trying to tell us here is own your OKness. We're trying to empower patients to say, OK, this is why we know you are OK. So conclusions Chest pain? Very anxiety provoking. Yeah, and probably rightfully so because we hear a lot of scary things that happen to adults with, with chest pain. Fully acknowledging, we don't always, always have the answer, although I always kind of like to refer to situations. We are all fallible. We may not know exactly what the right answer is, but I think what our duty is to patients say, look, I'm assessing for the really scary things, the things that we need to treat now, the things that are potentially dangerous, and oftentimes that's helpful, and then we can say, what are the things that make us really, really worried? Well, they're cardiac causes. Well, thankfully they're really rare and they usually don't present with chest pain. The other thing that can be really helpful in terms of counseling patients and say mortality, uh, saying has not been reported, you know, referring to this scam study, maybe a little bit extreme. I mean there's, I, I think I would mean that to say it's extremely, extremely rarely, you know, every so often people hear of these different anecdotes that perhaps overly, overly persuade us one way or another in terms of uh doing assessments. In my opinion, I think the chest, uh, the pediatric chest pain, chest pain in children often results in excessive amounts of testing. Whereas I think what standardly is helpful. History, basically old school things. Things have been around for decades, you know, hundreds of years. History, physical exam, EKG. I, I think these are always appropriate. Not saying additional tests is not helpful, but I think it depends on the context, depends upon what specifically we're looking for.
