What causes chest pain and syncope in children and adolescents, and how can pediatricians recognize and eliminate the causes that may lead to significant morbidity or even death?
Barbara J Deal, MD, Getz professor of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, addressed these questions in a presentation titled “Chest pain and syncope: functional or fatal” at the American Academy of Pediatrics National Conference and Exhibition in Chicago, Illinois, on September 17.
As suggested by the title, a key goal of Deal’s session was to help pediatricians recognize life-threatening causes of chest pain that should prompt concern and be addressed urgently from common nonthreatening causes. Her talk centered on nontraumatic chest pain related to cardiac concerns in the absence of heart disease.
Deal focused her discussion on what to look for to recognize potentially life-threatening causes of nontraumatic chest pain that include congenital or acquired cardiac conditions and arrhythmias and chest pain associated with common medications such as antidepressants and stimulants. For example, children presenting with acute life-threatening myocarditis may show exercise intolerance, fatigue, poor weight gain, vomiting, or change in appetite.
Deal also provided information on syncope in childhood and how to distinguish syncope caused by cardiovascular problems, and especially when an episode of syncope in a child is cause for concern.
Of primary importance is for pediatricians to know when to refer children with suspected life-threatening chest pain and syncope to a cardiology specialist, and to understand the urgency of such a referral. She provided an algorithm for guidance.
Among the clinical presentations that Deal underscored as needing urgent referral to a cardiologist is in a child with chest pain or syncope that occurs during exertion. “These children require urgent evaluation and an [electrocardiogram (ECG)],” she emphasized. “Patients with known underlying cardiac disease should be presumed to have a cardiac and potentially life-threatening etiology until proven otherwise.”
Deal also discussed the more common causes of chest pain that are not life threatening and therefore do not require urgent referral, including postural orthostatic tachycardia syndrome (POTS), an increasingly common condition among adolescents.
She focused primarily on providing pediatricians with information on POTS given its diffuse symptomatology that can make diagnosis difficult. Even though the palpitations, chest pain, and fatigue associated with POTS are common complaints among adolescents, she emphasized that adolescents can go through multiple and unnecessary evaluations prior to an accurate diagnosis, and such a delay in diagnosis and subsequent treatment can prolong time to recovery. If a diagnosis is uncertain, she encouraged pediatricians to refer to a specialist and to avoid extensive testing and prescribing drug therapy.
Deal emphasized that once correctly diagnosed, POTS may be effectively managed with lifestyle changes.