Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain

Drossner, David M.; Hirsh, Daniel A.; Sturm, Jesse J.; Mahle, William T.; Goo, David J.; Massey, Robert; Simon, Harold K.

doi:10.1016/j.ajem.2010.01.011

« Previous Next »American Journal of Emergency Medicine
Volume 29, Issue 6 , Pages 632-638, July 2011

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain☆

David M. Drossner, MD
- Department of Pediatrics, Emory University and Sibley Heart Center at Children's Healthcare of Atlanta, GA 30322, USA
- Corresponding author.
Daniel A. Hirsh, MD
- Departments of Pediatrics and Emergency Medicine, Emory University and Children's Healthcare of Atlanta, GA 30322, USA
Jesse J. Sturm, MD, MPH
- Departments of Pediatrics and Emergency Medicine, Emory University and Children's Healthcare of Atlanta, GA 30322, USA
William T. Mahle, MD
- Department of Pediatrics, Emory University and Sibley Heart Center at Children's Healthcare of Atlanta, GA 30322, USA
David J. Goo, MD
- Departments of Pediatrics and Emergency Medicine, Emory University and Children's Healthcare of Atlanta, GA 30322, USA
Robert Massey
- IS&T, Children's Healthcare of Atlanta, GA 30322, USA
Harold K. Simon, MD, MBA
- Departments of Pediatrics and Emergency Medicine, Emory University and Children's Healthcare of Atlanta, GA 30322, USA

Received 20 December 2009; received in revised form 7 January 2010; accepted 7 January 2010. published online 14 July 2010.

Abstract

Background

Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts.

Objectives

The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain.

Methods

Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori.

Results

Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia.

Conclusion

Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.