Residency · Residency · Medicine Pediatrics

Chest Pain Evaluation: The Pediatric vs. Adult Approach

Overview

Chest pain is a common chief complaint in both children and adults, but the diagnostic approach differs dramatically. In children, chest pain is overwhelmingly benign (musculoskeletal, functional, or idiopathic), while in adults, acute coronary syndrome must be rapidly excluded. The Med-Peds physician must know when to apply which framework, particularly in the challenging adolescent and young adult age range.

Epidemiology

Pediatric Chest Pain

Accounts for 0.3-0.6% of pediatric ED visits; Peak age: 12-14 years; Etiology is benign in >95% of cases; Cardiac causes account for <1-5% of pediatric chest pain presentations; Despite benign etiology, parental and patient anxiety drives significant healthcare utilization.

Adult Chest Pain

Accounts for 5-8% of adult ED visits (6-8 million visits annually in the US) ACS is diagnosed in approximately 5-13% of adults presenting with chest pain. Other serious diagnoses: PE, aortic dissection, tension pneumothorax, pericardial tamponade, esophageal rupture. Rapid triage and rule-out protocols are essential.

Differential Diagnosis by Age

Pediatric Causes (Approximate Frequency)

Musculoskeletal (30-40%): costochondritis, muscle strain, precordial catch syndrome (Texidor twinge), slipping rib syndrome. Idiopathic (20-40%): no identifiable cause despite evaluation. Pulmonary (5-15%): asthma (exercise-induced bronchospasm), pneumonia, pneumothorax, pleuritis. GI (5-10%): GERD, esophagitis, esophageal spasm, foreign body. Psychogenic (5-15%): anxiety, panic attacks, depression, school avoidance; increases with age. Cardiac (<1-5%): Structural: HCM, anomalous coronary arteries, severe aortic stenosis, mitral valve prolapse. Inflammatory: myocarditis, pericarditis. Arrhythmic: SVT, WPW, long QT syndrome, ventricular tachycardia. Vascular: Kawasaki disease (coronary aneurysms), aortic dissection (Marfan, Ehlers-Danlos) Other: pulmonary hypertension, cocaine/stimulant use in adolescents.

Adult Causes

Acute coronary syndrome: STEMI, NSTEMI, unstable angina. Other cardiac: stable angina, pericarditis, myocarditis, aortic stenosis, aortic dissection, Takotsubo cardiomyopathy. Pulmonary: PE, pneumonia, pneumothorax, pleuritis, COPD exacerbation. GI: GERD (most common non-cardiac cause), esophageal spasm, PUD, biliary disease, pancreatitis. Musculoskeletal: costochondritis, chest wall strain. Psychogenic: panic disorder, anxiety.

Evaluation

Pediatric Approach

History (Key Questions)

Character: sharp, stabbing, brief pain suggests musculoskeletal; exertional pain with syncope is a red flag. Location: reproducible point tenderness suggests MSK; substernal may be GI or cardiac. Duration: brief (<30 seconds) and sharp favors benign cause; prolonged exertional pain is concerning. Exertional component: pain only with exercise raises concern for cardiac cause. Associated symptoms: syncope, palpitations, or exertional dyspnea are red flags. Family history: sudden cardiac death <50, HCM, long QT, Marfan syndrome, premature CAD. Substance use in adolescents: cocaine, stimulants, vaping, energy drinks.

Physical Examination

Vital signs: tachycardia, hypertension, hypoxia. Chest wall tenderness reproduction: strongly suggests MSK cause (but does not exclude cardiac disease) Cardiac exam: murmurs (ejection murmur of HCM increases with Valsalva), clicks, rubs, gallops. Marfanoid habitus: tall stature, arm span > height, pectus excavatum, joint hypermobility. Lung exam: wheezing (asthma), decreased breath sounds (pneumothorax)

Diagnostic Testing

ECG: should be obtained in most children with chest pain; look for ST changes, prolonged QTc, WPW (delta wave), ventricular hypertrophy, arrhythmia. Chest X-ray: if fever, respiratory symptoms, or suspected pneumothorax. Echocardiogram: ONLY if clinical concern for structural heart disease (murmur, exertional symptoms + syncope, family history of cardiomyopathy/sudden death, Marfanoid features) Exercise stress testing: exertional chest pain with cardiac concern. Holter monitor: palpitations or arrhythmia suspected. NOT routinely indicated: troponin, CT angiography, cardiac catheterization (unless specific clinical indications)

Adult Approach

History (Key Elements)

Character: pressure, squeezing, heaviness suggest ACS; sharp pleuritic pain suggests pericarditis or PE. Radiation: jaw, left arm, back (ACS); interscapular tearing (dissection) Duration: >20 minutes concerning for MI. Risk factors: age, hypertension, diabetes, smoking, hyperlipidemia, family history of premature CAD. Exacerbating/relieving factors: exertional (angina), positional (pericarditis), food-related (GERD)

Risk Stratification Tools

HEART Score: History, ECG, Age, Risk factors, Troponin (0-10 scale) 0-3: low risk (1.7% MACE at 30 days); consider early discharge. 4-6: moderate risk (12% MACE); observe, serial troponin, possible stress testing. 7-10: high risk (65% MACE); cardiology consultation, early invasive strategy. TIMI Score: for known ACS risk stratification. Wells Score / PERC Rule: PE evaluation. ADvISE / Stanford Type A Criteria: aortic dissection.

Standard Workup

ECG (within 10 minutes of presentation); Serial high-sensitivity troponin (0 and 1-3 hours; rapid rule-out protocols); Chest X-ray; Basic labs: CBC, BMP, BNP if dyspnea; CT angiography: if PE, dissection, or triple rule-out indicated; Echocardiography: wall motion abnormalities, pericardial effusion, aortic root dilation. Coronary angiography: STEMI (emergent), high-risk NSTEMI.

The Adolescent and Young Adult Challenge

Bridging the Frameworks

Adolescents (13-21) fall in a diagnostic gray zone; Most chest pain in this group remains benign and MSK; However, must consider:; HCM (leading cause of sudden cardiac death in young athletes); Anomalous coronary arteries; Myocarditis (including post-COVID and post-vaccination myocarditis); Long QT syndrome and other channelopathies; Drug-related (cocaine, stimulants, vaping-related lung injury); ACS is exceedingly rare <30 years without risk factors (Kawasaki history, familial hypercholesterolemia, cocaine use, hypercoagulable state).

When to Apply the Adult Framework

Age >25-30 with traditional cardiovascular risk factors; Known CAD risk factors (diabetes, smoking, familial hypercholesterolemia); History of Kawasaki disease with coronary involvement; Cocaine or stimulant use; Hypercoagulable conditions.

Precordial Catch Syndrome (Texidor Twinge)

Extremely common, benign cause of chest pain in older children and young adults; Sharp, stabbing, left-sided pain lasting seconds to minutes; Worse with deep inspiration; resolves spontaneously; No associated symptoms; normal exam and ECG; Diagnosis is clinical; NO further workup needed; Reassurance is the treatment.

<image>A split-screen diagnostic approach diagram for chest pain evaluation. The left panel shows the pediatric approach: a pyramid with "Musculoskeletal/Idiopathic" as the broad base (most common), "Pulmonary/GI/Psychogenic" in the middle, and "Cardiac" at the narrow apex (less than 5%). Red flag symbols mark concerning features (exertional syncope, family history of sudden death, Marfanoid habitus). The right panel shows the adult approach: an inverted pyramid emphasizing the need to rule out ACS first, with the HEART score algorithm prominently displayed and a clock icon showing the 10-minute ECG and 0/1-hour troponin protocol. A central bridge connects the two panels at the adolescent/young adult zone with considerations for both frameworks.</image>

<image>An ECG interpretation guide for chest pain evaluation across ages, showing six example ECG strips: normal sinus rhythm, ST elevation (STEMI pattern), delta wave (WPW syndrome), prolonged QTc (long QT syndrome), left ventricular hypertrophy with strain pattern (HCM), and diffuse ST elevation with PR depression (pericarditis). Each strip is annotated with the diagnosis, the age group most commonly affected, and the immediate clinical action required.</image>

<image>A Venn diagram showing the overlap and differences in chest pain etiologies between pediatric and adult populations. The pediatric-only circle includes precordial catch syndrome, congenital coronary anomalies, Kawasaki-related chest pain, and exercise-induced bronchospasm. The adult-only circle includes ACS/MI, aortic dissection from atherosclerosis, and COPD exacerbation. The overlapping center includes pericarditis, myocarditis, pneumothorax, PE (rare in children), GERD, costochondritis, and anxiety/panic.</image>

Clinical Pearls

In children, chest pain is benign in >95% of cases -- the most important diagnostic tool is a thorough history and physical exam, not an echocardiogram. Reproducible chest wall tenderness is the hallmark of musculoskeletal chest pain in children and is reassuring (though does not absolutely exclude cardiac disease) An ECG should be obtained in most children with chest pain -- it is inexpensive and can screen for WPW, long QT, and HCM. Echocardiography should NOT be routinely ordered for pediatric chest pain without specific clinical indications (murmur, exertional syncope, family history of cardiomyopathy) The HEART score is the most widely validated risk stratification tool for adult chest pain in the ED. High-sensitivity troponin with a 0/1-hour protocol can rapidly rule out MI in adults. Precordial catch syndrome is the most underdiagnosed and over-investigated benign cause of chest pain in adolescents -- learn to recognize it clinically. Always ask about substance use in adolescents and young adults with chest pain -- cocaine and stimulants can cause coronary vasospasm and MI at any age. Post-COVID and post-mRNA vaccine myocarditis typically presents in young males with chest pain, troponin elevation, and ST changes -- cardiac MRI is diagnostic.

References

• Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr. 2013;163(3):896-901.
• Mahle WT, Campbell RM, Favaloro-Sabatier J. Myocardial infarction in adolescents. J Pediatr. 2007;151(2):150-154.
• Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction. Circulation. 2018;138(20):e618-e651.
• Poldervaart JM, Langedijk M, Backus BE, et al. Comparison of the HEART score and TIMI score in chest pain patients at the emergency department. Crit Pathw Cardiol. 2017;16(2):35-40.
• Saleeb SF, Li WY, Warren SZ, et al. Effectiveness of screening for life-threatening chest pain in children. Pediatrics. 2011;128(5):e1062-e1068.

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