Chest pain in adolescents: distinguishing cardiac from noncardiac causes

Abstract

Chest pain, a common problem motivating adults to seek medical care, occurs frequently in adolescents. Physicians may embark on a sequence of nonproductive investigations that can be costly and anxietyprovoking for the adolescent and parent. This review attempts to simplify the medical evaluation and management of the young patient with chest pain. Idiopathic chest pain is the most common diagnosis for childhood and adolescent chest pain, accounting for about 40% of cases. Of those cases for which a cause is found, musculoskeletal causes are most common, accounting for at least 20% of chest pain. Hyperventilation or panic disorders account for 10 to 20% of diagnoses. Noncardiac chest pain typically occurs at rest, which is helpful in distinguishing it from cardiac pain. In those with exercise-induced chest pain asthma must be carefully sought. Congenital coronary artery anomalies leading to angina must also be considered in those with exertional chest pain. Although exertional chest pain should raise a red flag, not all exertional chest pain is worrisome; it may simply reflect poor conditioning or an anxious athlete. In these cases a normal cardiac evaluation including a normal treadmill exercise test with or without reproducible chest pain may help provide the reassurance the anxious athlete needs. After eliminating the possibility of a medical illness, the psychiatrist is in a unique position to provide reassurance and counseling because knowledge about recent life events and the adolescent's beliefs about the symptoms may be necessary prerequisites for successful treatment.