Cardiologic perspectives of chest pain in childhood: A referral problem? To whom?

Chest pain in children and adolescents is responsible for an increasing number of primary physician visits and specialty consultations. As a presenting symptom it must engender a great deal of concern and frustration in the primary care physician. Concern exists because of the multitude of organic factors that must be addressed to uncover a potentially life-threatening etiology, to prevent disability, and ultimately to insure proper medical therapy. Frustration permeates the diagnostic process because of the realization that in the absence of an acute onset of chest pain with associated symptoms of illness, the longer the symptoms exist, the less likely that an organic abnormality will be defined. Apprehension and uncertainty must also exist in children and adolescents presenting with chest pain, many of whom believe that they are experiencing a heart attack. Pantell attributed this belief to the adolescent's lack of understanding and knowledge of the risks and probabilities of heart disease in his own age group. This lack of sophistication exists despite the organized health education of efforts in junior and senior high schools and the community-based efforts of local heart associations. Anxiety can also be augmented by the initial medical contact where, because of uncertainty or lack of familiarity with this symptom complex in children, the physician offers an incomplete or overly dramatic assessment of the patient's symptoms, or performs standard laboratory tests to exclude heart disease, all the while reinforcing the association of chest pain and cardiac dysfunction. Over-dependence on screening laboratory tests (ECG, chest x-ray, echocardiogram) is not likely to provide the desired result for the physician or the patient. Noninvasive cardiac evaluation is not more useful in discriminating between the presence or absence of disease than a careful physical examination by a qualified examiner. However, for the less confident physician, equating negative test results with the absence of heart disease, or conversely, equating positive test results with the presence of heart disease will lead to a high proportion of erroneous diagnoses. Noninvasive tests are helpful only when appropriately applied. Additionally, the occurrence of heart disease in older children and adolescents is relatively rare, findings reinforced by the three surveys reported herein. Reliance on subspecialty referral may be appropriate when specific concerns have been defined. The pediatric cardiologist should be able to resolve the issues of the presence or absence of heart disease by history and physical examination. If structural or functional heart disease is present, its severity can be assessed noninvasively. Anginal symptoms or exercise-induced syncope should initiate a detailed and aggressive evaluation. Where there is little evidence to suggest cardiac disease and a thorough history indicates recent life-stress, then longitudinal follow-up by the primary care physician should provide the medical surveillance necessary while permitting time for further assessment of psychosocial issues and appropriate reassurance. Persistence of chest pain occurring unabated for weeks to months is likely to indicate a psychogenic disorder; management may require the addition of a behavioral pediatrician or psychologist. The object of medical care remains the reduction of morbidity associated with symptoms of chest pain and elimination of the unlikely risk of mortality.