165: Paediatric Chest Pain in the Emergency Department

Abstract

Chest pain is a frequent chief complaint of paediatric patients presenting to the emergency department (ED). Despite the low risk of a cardiac cause in the paediatric population, chest pain is a worrisome presentation for patients and their families, and sometimes serious underlying pathology can occur. There is no evidence based diagnostic approach, and this results in significant practice variation often with extensive investigations, both in the ED and in follow-up. To establish poor predictive value and over-use of diagnostic testing in pediatric patients presenting with chest pain. After REB approval, a chart review was conducted of all patients presenting to an urban paediatric tertiary care ED with the chief complaint of chest pain over a three year period. Charts were analyzed for sex, age at presentation, associated symptoms, past cardiac history, investigations in the ED, discharge diagnosis, and outpatient echocardiogram and Holter monitor findings. Of the 473 visits, 50 were repeat visits. The mean age at visit was 12.1 years, and mean duration of pain was 53.4 minutes. 16.9% (n=80) of patients reported past cardiac-related medical history. 64.9% (n=307) of patients received chest x-ray, but only 2.9% (n=9) had an abnormal finding. Electrocardiogram was done in 75.7% (n=358) of the patients, and 23.7% (n=85) of the results were abnormal. Troponin was done in 9.5% (n=45) of the cases, with only one abnormal result unrelated to cardiac etiology. 96.0% of patients (n=454) were discharged, and 4% (n=19) were admitted to hospital. Most causes were idiopathic (n=282, 59.6%), followed by musculoskeletal causes (n=145, 30.7%). Within six months following discharge, 75 (15.9%) patients received echocardiogram, 45 (60%) of whom had no reported cardiac history or previous investigations, and 25 had normal ECG in the ED. The echocardiograms yielded only two cases of newly diagnosed mitral valve prolapse, and one case of small patent ductus arteriosus. 50 patients (10.6%) received Holter monitoring within six months following discharge, 20 of whom had no previous cardiac history, and had normal ECGs in the ED, and the arrhythmias found on Holter monitor correlated poorly with the presenting symptoms. This is the largest paediatric review of chest pain in Canada in published literature. Chest pain in the paediatric population are rarely due to cardiac causes, but most patients still receive unnecessary investigations in the ED, and in their follow-up visits. An evidence based diagnostic algorithm would be useful to improve resource utilization in children presenting with chest pain.