1. Demographics
A total of 7251 children were included in this study, including 4293 boys (59.2%) and 2958 girls (40.8%), aged 3–18 years (mean: 12.1 ± 4.0). Chest pain was more common in school-age children and adolescents. Most patients in the preschool group were girls (55.5%) while most patients in the school-age and adolescent groups were boys (60.6%, 61.3%) (P < 0.05) (Table 1).
Table 1
The sex and causes of chest pain in children with different ages
|
n
|
3yrs ≤ age ≤ 6yrs
|
6yrs < age ≤ 12yrs
|
12yrs < age ≤ 18yrs
|
Total
|
7251
|
784
|
2779
|
3688
|
Age (yrs)
|
12.1 ± 4.0
|
5.1 ± 0.9
|
9.6± 1.7
|
15.5± 1.7
|
Male
|
4293 (59.2%)
|
349 (44.5%)
|
1685 (60.6%)
|
2259 (61.3%)
|
Female
|
2958 (40.8%)
|
435 (55.5%)
|
1094 (39.4%)
|
1429 (38.7%)
|
X2
|
|
|
64.846
|
74.513
|
P
|
|
|
0.000*
|
0.000*
|
Cardiac
|
581 (8.0%)
|
51 (6.5%)
|
171 (6.2%)
|
359 (9.7%)
|
Non-cardiac
|
6670 (92.0%)
|
733 (93.5%)
|
(93.8%)
|
3329 (90.3%)
|
X2
|
|
8.096
|
27.011
|
|
P
|
|
0.004#
|
0.000#
|
|
* stands for P < 0.01 contrast to 3yrs ≤ age ≤ 6yrs group; # stands for P < 0.05 contrast to 12yrs < age ≤ 18yrs group. |
2. Pattern of clinical visits in children with chest pain
The number of children who saw a doctor for chest pain was increasing each year from 2005 to 2019 (Fig. 1). 6312 patients (87.0%) visited a clinic, and 926 patients (12.8%) went to an emergency room. Only 13 patients (0.2%) were admitted to the hospital. At the initial visit, most children saw a pediatric cardiologist (n = 3477, 55.09%).
3. General information
Four patients had a positive family history, including two patients whose fathers had dilated cardiomyopathy, one patient whose sibling had Marfan syndrome, and one patient whose father had died suddenly. Physical examination was positive in 795 children. Among them, 75 patients had pathological heart murmur, including systolic murmur (n = 25), diastolic murmur (n = 32), accentuated P2 (n = 3), splitting of the second heart sound (n = 12), and continuous machine-like murmur (n = 3); 33 had arrhythmia; 62 had a tachycardia; 77 had a bradycardia; 198 patients had fever and bibasilar crackles in both lungs; six had fever and wheezing sounds in both lungs; 327 only had fever; 15 only had wheezing sounds in both lungs; two had hepatomegaly.
Among children with cardiac chest pain (n = 581, 8.0%), the most common concomitant symptom was chest tightness (n = 389, 67.0%). Among patients with noncardiac chest pain (n = 6670, 72.0%), most (n = 4899, 73.4%) had no concomitant symptoms (Table 2).
Table 2
The associated symptoms of chest pain in children
Associated symptoms
|
n (%)
|
Cardiac-related Chest Pain
|
581
|
No Associated symptoms
|
116 (20.0%)
|
Chest oppression
|
389 (67.0%)
|
Palpitation
|
43 (7.4%)
|
Fatigue
|
32 (5.5%)
|
Syncope
|
5 (0.9%)
|
Dizzy
|
4 (0.7%)
|
Headache
|
2 (0.3%)
|
Fever
|
4 (0.7%)
|
Respiratory symptoms
|
11 (1.9%)
|
Gastrointestinal symptoms
|
5 (0.9%)
|
Non-cardiac related chest pain
|
6670
|
No Associated symptoms
|
4899 (73.4%)
|
Chest oppression
|
666 (10.0%)
|
Palpitation
|
102 (1.5%)
|
Fatigue
|
35 (0.5%)
|
Syncope
|
14 (0.2%)
|
Dizzy
|
46 (0.7%)
|
Headache
|
11 (0.2%)
|
Joint pain
|
2 (0.03%)
|
Fever
|
238 (3.6%)
|
Respiratory symptoms
|
562 (8.4%)
|
Gastrointestinal symptoms
|
103 (1.5%)
|
4. Auxiliary exams
All 7251 patients (100%) underwent ECG, 5352 (73.8%) underwent UCG, 128 (1.8%) underwent Holter test, 1037 (14.1%) underwent chest X-ray, and 5408 (74.6%) underwent myocardial enzyme testing.
ECG was abnormal in 574 of 7251 children (7.9%). The most common abnormality was pathological ST-segment or T-wave changes (n = 537, 93.6%), followed by frequent premature ventricular contractions (n = 7, 1.2%), pre-excitation syndrome (n = 10, 1.8%), supraventricular tachycardia (n = 7, 1.2%), deviation of the electrical axis (n = 6, 1.0%), pathological Q wave (n = 6, 1.0%), and left atrial enlargement (n = 1, 0.2%).
UCG was abnormal in 331 of 5352 children (6.2%). The abnormality was unrelated to chest pain in 221 of these patients (66.8%) (Table 3) and was related to chest pain in 110 of them (33.2%), including aortic sinus enlargement with aortic sinus aneurysm (n = 3, 2.7%), coronary artery dilation (n = 3, 2.7%), generalized cardiomegaly with reduced left ventricular systolic function (n = 4, 3.6%), pericardial effusion (n = 2, 1.8%), large ventricular septal defect (n = 2, 1.8%), severe pulmonary valve stenosis with pulmonary valve regurgitation (n = 1, 0.9%), quadricuspid aortic valve with aortic sinus aneurysm (n = 1, 0.9%), aortic valve stenosis (n = 3, 2.7%), coronary-pulmonary arterial fistula (n = 4, 3.6%), anomalous origin of the left coronary artery from the pulmonary artery (n = 6, 5.5%), anomalous origin of the right coronary artery from the left sinus (n = 3, 2.7%), pulmonary arterial hypertension (n = 6, 5.6%), and left ventricular enlargement with normal left ventricular systolic function (n = 72, 65.5%).
Table 3
Incidental Echocardiographic Findings
|
n
|
Mild tricuspid regurgitation
|
69
|
Patent foramen ovale
|
62
|
Atrial septal defect
|
23
|
Mild mitral regurgitation
|
14
|
Patent ductus arteriosus
|
10
|
Mild aortic regurgitation
|
9
|
LV hypertrabeculation/noncompaction*
|
9
|
Small ventricular septal defect
|
5
|
Bicuspid aortic valve
|
5
|
Mitral valve prolapse
|
3
|
Mild dilated aortic sinus
|
2
|
Mild LV hypertrophy
|
2
|
Mild pulmonary stenosis
|
2
|
Subaortic septum
|
1
|
Mild pulmonary regurgitation
|
1
|
Small ventricular septal defect with double-chambered RV
|
1
|
Tetralogy of Fallot
|
1
|
Tetralogy of Fallot with atrial septal defect and patent ductus arteriosus
|
1
|
Partial anomalous pulmonary venous connection with atrial septal defect
|
1
|
LV indicates left ventricular. |
RV indicates right ventricular. |
* Normal LV function. |
The Holter test was abnormal in only 6 of 128 children (4.7%), all of whom had frequent premature ventricular contractions. Chest X-ray was abnormal in 643 of 1037 children (62.0%). Myocardial enzyme tests were abnormal in 453 of 5408 children (8.4%).
5. Diagnosis
Based on medical history, physical examination, and auxiliary exams, 581 patients (8.0%) were diagnosed with cardiac chest pain, and 6670 patients (92.0%) were diagnosed with noncardiac chest pain. (Fig. 2). The incidence of noncardiac chest pain was significantly higher in the preschool group and the school-age group than in the adolescent group (93.5% vs 93.8% vs 90.3%, P < 0.05) (Table 1).
Among the 581 cases of cardiac chest pain, the most common cause was suspected myocarditis (n = 431, 74.2%) (Fig. 3).
Among the 660 cases of chest pain due to respiratory diseases, the most common cause was bronchitis (n = 357, 54.1%) (Fig. 4).
Among the 44 cases of chest pain due to gastrointestinal diseases, the most common cause was gastritis (n = 28, 63.6%) (Fig. 5). Among the 12 cases of chest pain due to mental diseases, the causes included anxiety (n = 5), depression (n = 4), and hysteria-like attacks (n = 3). Among the three cases of chest pain due to other disorders, the causes included breast mass (n = 1), dysmenorrhea (n = 1), and poor wound healing (n = 1).
6. Suggestion for targeted myocardial enzyme testing for chest pain in children
For children with chest pain, clinicians should collect detailed information about the history of the present illness, past medical history, and family history and perform a comprehensive physical examination. Patients with potential cardiac chest pain should be referred to a pediatric cardiologist and undergo ECG or ECG plus UCG if they have a pathological heart murmur or hypoxemia, respectively. Based on the ECG or UCG results, targeted myocardial enzyme testing merely should be conducted for children with chest pain probably be induced by myocarditis or suspected myocarditis.