The Terrible Triad of Pediatric Cardiology: Chest Pain, Syncope, and Palpitations

The Terrible Triad of Pediatric
Cardiology: Chest Pain, Syncope, and
Palpitations
Brendan Kelly, MD
Assistant Professor of Pediatrics
Division of Pediatric Cardiology
Oregon Health Science University
Objectives
• Differentiate benign types of chest pain,
syncope, and palpitations from those
associated with cardiac pathology
• Describe a logical approach to evaluating
chest pain, syncope, and palpitations
• Identify key aspects that should prompt a
referral to pediatric cardiology
Elite runner collapses, dies during
U.S. Olympic trials
Heart Attack Killed French Tennis Player
Following the Trail of Broken Hearts
A congenital cardiovascular abnormality has
become a leading killer of young athletes in
the U.S. So why isn't more being done to save
those who have it?
Soccer Is Haunted by an
Inexplicable Trend
Scope of the Problem
• Sudden cardiac death in pediatrics causes fear and anxiety
– Average risk is low, representing ~2% of all deaths in the age group
• 1.8 deaths/1,000,000 students per year in schools
• 4 deaths/1,000,000 high school and college athletes per year
• Chest pain is a frequent complaint
– ~6/1000 visits to pediatric ED’s and walk-in clinics
– >650,000 visits/yr in PCP’s offices and ED’s in patients 10-21 years old
• Syncope
– Prevalence may be as high as 3% in some ER’s
Important Caveats
• Focus of today’s talk is pediatric patients
without known cardiac disease
– Consult with pediatric cardiologist if the patient
has a known cardiac disorder
• Even with complete history, physical, and
screening tests, we may miss pathology
Key Questions
How bothersome is the problem?
How often does it happen?
What happens with exercise?
Do the symptoms change with respiration, or
are they associated with respiratory
symptoms?
• Are there any other concerning symptoms?
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Causes of Chest Pain
•
Musculoskeletal
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Respiratory
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Trauma/chest wall strain
Costochondritis
Slipping rib syndrome
Tietze syndrome
Cough
Pneumonia
Pleural effusion
Pleurisy
Asthma
Pneumothorax/mediastinum
Psychogenic
– Stress/anxiety
•
Gastrointestinal
– Reflux
– Foreign body
•
Miscellaneous
– Shingles
– Sickle cell crises
– Breast tenderness
•
Idiopathic
– Precordial catch (Texidor twinge)
•
Cardiac
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Anomalous coronaries
Coronary arteritis
Pericarditis
Myocarditis
Hypertrophic cardiomyopathy
Severe pulmonary stenosis
Aortic valve stenosis
Pulmonary hypertension
Aortic dissection
Mitral valve prolapse (?)
Cardiac masses
Pulmonary embolism
Arrhythmia
Chest Pain
• Our fears: Coronary artery anomalies,
pericarditis, myocarditis, cardiomyopathy, LV
outflow tract obstruction, pulmonary
hypertension, arrhythmia, aortic dissection
• The reality: Cardiac causes of chest pain are rare
in children
– Only 4-5% of patients seen for chest pain have cardiac
cause
– Psychogenic pain more likely in teens and those with
family history of chest pain
Chest Pain: History
• Features suggestive of a non-cardiac origin
– Sharp, easily localized pain
– Pain that occurs randomly, even at rest
– Pain that occurs following an injury or is
reproducible with joint motion
– Pain that varies with respiration (*** pericarditis)
– Pain that improves with rubbing the affected area
– Pain that is relieved with antacids or asthma
rescue medication
Chest Pain: Work-up
• History:
– Reassuring: History suggestive of an origin non-cardiac in nature
– Concerning: Pain associated with palpitations or syncope, family history of
sudden death, early myocardial infarction, or genetic disorder
• Physical exam
– Reassuring: Reproducible pain with palpation, lung exam consistent with noncardiac cause
– Concerning: Abnormal or new murmur
• EKG
– Reassuring: Normal EKG
– Concerning: Ventricular hypertrophy, ST segment changes, small voltages
• X-ray
– Reassuring: Pulmonary findings or abdominal findings consistent with noncardiac cause
– Concerning: Cardiomegaly, abnormal pulmonary vascularity, abnormal aortic
contour
Chest Pain: When to Refer
Pain accompanied by syncope or palpitations
Abnormal EKG or chest x-ray
Physical exam concerning for cardiac cause
Family history of sudden death or genetic
disorder
• In consultation with pediatric cardiology
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•
•
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– Echocardiogram
– Holter or Event monitor
– Exercise test with or without pulmonary function
testing to look for ST changes, heart rate, and blood
pressure response
Causes of Syncope
“transient loss of consciousness and postural tone resulting from
an abrupt, transient decrease in cerebral blood flow”
•
Neurologic
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Panic attack
Conversion disorder
Malingering
Hyperventilation
Respiratory
– Hypoxia
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Metabolic
– Hypoglycemia
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Drugs
– Recreational
– Antiarrhythmics
– Diuretics
Cardiac structure
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Psychiatric
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Seizure
Stroke/TIA
Migraines
Tumors
– Vasodilators
– QT-prolonging meds
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Cardiomyopathy
LV outflow obstruction
Pulmonary hypertension
Cardiac tumors
Mitral valve prolapse (?)
Cardiac rhythm
– Channelopathies
– Bradycardia
•
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AV block
Sick sinus syndrome
– Tachycardia
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Ventricular tachycardia
Supraventricular tachycardia
Syncope
• Our fears: Hypertrophic cardiomyopathy, LV
outflow obstruction, pulmonary hypertension,
tachyarrhythmia, bradycardia
• The reality: Rarely, syncope is the first sign of a
serious condition
– Unlike in adults, most cases in children are benign
• Vasovagal, orthostatic, hyperventilation, breath holding
Syncope: History
• Features suggestive of a vasovagal origin
– Prodrome of warmth then cold, nausea,
diaphoresis, pallor, dizziness/lightheadedness
– Associated with prolonged or abrupt standing,
fasting, hot and humid conditions, dehydration
– Preceded by pain or fright, hair grooming,
swallowing, hot AM shower, defecation, or
micturation (reflex syncope)
– Loss of consciousness <1-2min, tired afterward,
but with rapid recovery of awareness
Syncope: Work-up
• History
– Reassuring: Story consistent with vasovagal syncope or
seizure
– Concerning: Absence of a prodrome, abnormal family
history, chest pain preceding syncope, syncope during
exercise
• Physical exam
– Reassuring: Normal exam
– Concerning: Abnormal or new murmur
• EKG
– Reassuring: Normal EKG
– Concerning: Prolonged QTc, pre-excitation, bradycardia, AV
block, ventricular ectopy
Syncope: When to Refer
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Story not consistent with vasovagal syncope
Syncope during exercise
Chest pain preceding syncope
Syncope in driving age patient
Recurrent syncope or syncope that results in injury
Abnormal EKG findings
Physical exam concerning for cardiac abnormality
Family history of sudden death or genetic disease
In consultation with pediatric cardiology
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Holter or Event monitor
Echocardiogram
Tilt table test
Evaluation by Neurology
Glucose testing
Vasovagal (Neurocardiogenic) Syncope
• Almost always resolves within several months to years
• Treatment
– Increased salt and fluid intake (2L/day minimum)
– Avoid caffeine
– Pre-emptive maneuvers
• Slow position changes, sit or lie down w/ prodrome, leg-pumping,
hand grip maneuvers
– Drug therapy (2nd line)
• Fludrocortisone: increased salt and water retention
• Midodrine: alpha agonist that causes vasoconstriction
– Other treatments:
• Beta-blockers, disopyramide, anticholinergic, SSRI’s, pacemaker
Postural Orthostatic Tachycardia
Syndrome (POTS)
• Variation of neurocardiogenic syncope
– Rapid palpitations with symptoms of low blood
pressure (dizziness/lightheadedness)
– Unusual to have true syncope
• Treatment:
– Avoid venous pooling and dehydration
– Increased salt and water intake
– Compression stockings
– Avoid B-blockers
Palpitations
• Our fears: Undiagnosed arrhythmia
• The reality: Occasional skipped beats are
normal, as is a sensation of an increased heart
rate with exercise and anxiety.
Causes of Palpitations
(strong, rapid, or irregular heart beats)
• Sinus tachycardia
– Anxiety
– Exercise
– Atrial flutter/fibrillation
– Re-entrant tachycardia
– Ectopic atrial
tachycardia
• Sinus arrhythmia
• Ventricular rhythm
• Supraventricular
abnormalities
rhythm abnormalities
– Premature atrial
contraction (PAC)
– Blocked premature
atrial contractions
– Premature ventricular
contractions (PVC)
– Ventricular tachycardia
Palpitations: History
• Features suggestive of a benign abnormality
– Isolated and rare skipped beats
– Palpitations without other symptoms
– Fast heart rate is expected in the situation
– Irregular beats that disappear with activity
Palpitations: Work-up
•
History
– Reassuring: Benign features
– Concerning: Occur at rest or out of proportion to activity/anxiety level, more frequent with
activity, associated with syncope or chest pain, family history of sudden death or significant
arrhythmia
•
Physical exam
– Reassuring: Normal exam
– Concerning: Abnormal or new murmur
•
EKG
– Reassuring: Normal EKG, sinus arrhythmia, occasional PAC’s, occasional uniform PVC’s, PVC’s
that disappear with exercise
– Concerning: Prolonged QTc, pre-excitation, multiform PVC’s, atrial flutter/fibrillation, SVT, VT
(3 or more PVC’s in a row with a HR of 120-200bpm)
•
X-ray
– Reassuring: Normal CXR
– Concerning: Cardiomegaly, abnormal pulmonary vascularity
Palpations: When to Refer
• Palpitations preceding chest pain or syncope
• Sudden onset of fast heart rate at rest out of
proportion to the situation
• Family history of sudden death or significant
arrhythmia
• Irregular heart beat
• Abnormal EKG or CXR with cardiac abnormalities
• In consultation with pediatric cardiology
– Holter or Event monitor
– Echocardiogram
– Exercise test
Asthma Has A Special Place in Our
Hearts
• Weins et al. Pediatrics, 1992
• 88 patients with chest pain
– No history of asthma or heart disease
– Normal physical exams, EKGs, echos, and CXRs.
– Underwent exercise test w/ PFT’s
• Results:
– 72% had FEV1 or PEFR fall of ≥ 15%
– Most patients with spirometry changes had chest pain,
SOB, or chest tightness without wheezing
• Many patients may benefit from increased asthma
treatment prior to extensive cardiac work-up
Chest Pain
Syncope
Palpitations
Suggesting non-cardiac origin
•Sharp, easily localized pain
•Pain occurs randomly, even at rest
•Pain following an injury or is
reproducible with joint motion
•Pain varies with respiration (***
pericarditis)
•Pain improves with rubbing the
affected area
•Pain relieved with antacids or
asthma rescue medication
Suggesting a vasovagal origin
•Prodrome of warmth then cold,
nausea, diaphoresis, pallor,
dizziness/lightheadedness
•Associated with prolonged or
abrupt standing, fasting, hot and
humid conditions, dehydration
•Preceded by pain or fright, hair
grooming, swallowing, hot AM
shower, defecation, or micturation
•Loss of consciousness <1-2min,
tired afterward, but with rapid
recovery of awareness
Suggesting a benign problem
•Isolated and rare skipped beats
•Palpitations without other
symptoms
•Fast heart rate is expected in the
situation
•Irregular beats that disappear with
activity
Red Flags
•Pain accompanied by syncope or
palpitations
•Abnormal EKG or chest x-ray
•Physical exam concerning for
cardiac cause
•Family history of sudden death or
genetic disorder
•Syncope during exercise
•Chest pain preceding syncope
•Syncope in driving age patient
•Recurrent syncope or syncope that
results in injury
•Abnormal EKG findings
•Physical exam concerning for
cardiac abnormality
•Family history of sudden death or
genetic disease
•Palpitations preceding chest pain
or syncope
•Sudden onset of fast heart rate at
rest out of proportion to the
situation
•Family history of sudden death or
significant arrhythmia
•Irregular heart beat
•Abnormal EKG or CXR with cardiac
abnormalities
Thank You
References
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Batra, A. S., & Hohn, A. R. (2003). Consultation with the specialist: Palpitations, syncope, and sudden
cardiac death in children: Who's at risk? Pediatrics in Review / American Academy of Pediatrics, 24(8),
269-275.
Dick, M., & University of Michigan. Mott Children's Hospital. Division of Pediatric Cardiology. (2006).
Clinical cardiac electrophysiology in the young. New York: Springer Science+Business Media.
Kapoor, W. N. (1992). Evaluation and management of the patient with syncope. JAMA : The Journal of
the American Medical Association, 268(18), 2553-2560.
Koester, M. C. (2001). A review of sudden cardiac death in young athletes and strategies for
preparticipation cardiovascular screening. Journal of Athletic Training, 36(2), 197-204.
Leung, A. K., Robson, W. L., & Cho, H. (1996). Chest pain in children. Canadian Family Physician Medecin
De Famille Canadien, 42, 1156-60, 1163-4.
Park, M. K. (2002). Pediatric cardiology for practitioners (4th ed.). St. Louis Mo.: Mosby.
Reddy, S. R., & Singh, H. R. (2010). Chest pain in children and adolescents. Pediatrics in Review /
American Academy of Pediatrics, 31(1), e1-9.
Selbst, S. M. (1997). Consultation with the specialist. chest pain in children. Pediatrics in Review /
American Academy of Pediatrics, 18(5), 169-173.
Selbst, S. M., Ruddy, R. M., Clark, B. J., Henretig, F. M., & Santulli, T.,Jr. (1988). Pediatric chest pain: A
prospective study. Pediatrics, 82(3), 319-323.
Wiens, L., Sabath, R., Ewing, L., Gowdamarajan, R., Portnoy, J., & Scagliotti, D. (1992). Chest pain in
otherwise healthy children and adolescents is frequently caused by exercise-induced asthma. Pediatrics,
90(3), 350-353.
Wren, C. (2009). Screening for potentially fatal heart disease in children and teenagers. Heart (British
Cardiac Society), 95(24), 2040-2046.
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