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? • • • • Causes of Chest Pain • Musculoskeletal – – – – • Respiratory – – – – – – • 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 – – – – – – – – – – – – – 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 • • • • – 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 – – – – • Panic attack Conversion disorder Malingering Hyperventilation Respiratory – Hypoxia • Metabolic – Hypoglycemia • • Drugs – Recreational – Antiarrhythmics – Diuretics Cardiac structure – – – – – Psychiatric – – – – • Seizure Stroke/TIA Migraines Tumors – Vasodilators – QT-prolonging meds • Cardiomyopathy LV outflow obstruction Pulmonary hypertension Cardiac tumors Mitral valve prolapse (?) Cardiac rhythm – Channelopathies – Bradycardia • • AV block Sick sinus syndrome – Tachycardia • • 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 • • • • • • • • • 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 – – – – – 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 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