Follow-up Survey of Children and Adolescents With Chest Pain.

ABSTRACT

Background. The purposes of this study were to identify the outcome of chest pain in children and to identify the incidence of recurrent chest pain and the need for further medical services.

Methods. A telephone survey was conducted of pediatric patients evaluated in the cardiology clinic for chest pain.

Results. In the majority of patients (53 of 55), chest pain was thought to be noncardiac in origin. Fifteen patients were offered therapy, and all followed the therapy. Most (10 of 15) thought the therapy was helpful. Forty-one (75%) were satisfied with the explanation given to them. Twenty-six had recurrent chest pain, 12 had pain that was severe, 13 thought the pain interfered with daily activities, and 10 sought further medical care. With the secondary evaluation of chest pain, the diagnosis changed in 9 of 10 cases.

Conclusion. Chest pain in children is generally benign. However, chest pain can be recurrent and severe, interfering with activities of daily life.

CHEST PAIN in the pediatric population is commonly benign and generally noncardiac in origin. [1-3] The most common noncardiac causes of chest pain include idiopathic, chest wall or musculoskeletal, psychogenic, respiratory, and gastrointestinal. [4] Most cases are diagnosed as benign after history, physical examination, and laboratory tests rule out primary cardiac disease. In these cases, the family and patient are reassured, and often no further follow-up appointment is made. [5] Therefore, it may be difficult to determine whether a particular diagnosis was missed, the condition was transient, and the cause of the pain was truly benign. As a result, the long-term consequences of chest pain in children and the accuracy of the initial presumed diagnosis may be difficult to demonstrate.

Previously, we retrospectively reviewed the office visits of 103 patients seen for evaluation of chest pain in the pediatric cardiology clinic at the University of Missouri Hospital and Clinics. The evaluation, eventual diagnosis, and therapy were examined. The evaluation included chest radiograph in 5% of the patients, echocardiogram in 67%, electrocardiogram in 85%, Holter monitoring in 4%, and a treadmill stress test in 37%. The results of these tests were largely normal, and 54% of the patients had a diagnosis of benign idiopathic chest pain. Of the remaining cases, the most common causes were gastroesophageal (GE) reflux (12%) and musculoskeletal chest pain (11%). Management consisted of reassurance to the patient and family, treatment for GE reflux, and counseling for psychogenic causes. [6]

This study was done to identify the long-term consequences and outcome of chest pain in the children from our previous study, to determine whether the diagnosis remained unchanged in the years after the clinic visit, and to identify the incidence of recurrent chest pain and the need for further medical services.

METHODS

After approval by the Institutional Review Board of the University of Missouri, all pediatric-aged patients (18 years of age or less) assessed for "chest pain" in the Kiwanis Pediatric Cardiology Clinic at the University of Missouri Hospitals and Clinics over a period of 4 years (1995 to 1999) were identified from the computerized registry. The parents of these patients were contacted by telephone and consented to answer a questionnaire. The parents were asked what they were told about the initial presumed cause of the chest pain, what medications/therapies were recommended, and whether they were satisfied with the explanation. If medications or therapies were suggested, they were asked whether their child received them and whether these therapies improved the child's condition. They were also asked whether they sought further evaluation or second opinions and whether the chest pain recurred. If it recurred, they were asked whether it was severe (ie, interfering with activities), whether they sought medical help, what the diagnosis was, and what medications/therapies were recommended. In addition, each patient's chart was reviewed and the patient's age, weight, sex, and diagnosis at the clinic visit were recorded.

RESULTS

The computerized registry identified 115 patients. Parents of 55 of these responded to the telephone questionnaire, 23 never answered their telephone despite repeated attempts, and 37 were lost to follow-up (no forwarding telephone number could be obtained). The 55 patients whose parents were contacted ranged in age from 6 to 20 years (mean 14.2 [+ or -] 3.8 years) and in weight from 13.8 to 91.5 kg (44.0 [+ or -] 16.6 kg). There were 27 girls and 28 boys. Of the 55 patients whose parents could be contacted to answer the survey, two parents were unable to recall the clinic visit. Both of those patients had been seen 2 1/2 years earlier. One of those patients had been in a recent serious motor vehicle accident, which may have interfered with the parents' memory of any previous medical problems. Both denied any further problems from or therapy sought for the chest pain.

According to responses on the remaining 53 questionnaires, the presumed causes of the chest pain were idiopathic (30%), musculoskeletal (32%), GE reflux (15%), supraventricular tachycardia (8%), anxiety (4%), aortic stenosis (2%), asthma (2%), mitral valve prolapse (2%), GE reflux with anxiety (2%), GE reflux and musculoskeletal (2%), and GE reflux and hyperventilation (2%). Thirty-eight patients (72%) were not given any medications. Interventions were offered to 15 of the patients. Seven were given oral medications (nonsteroidal anti-inflammatory agents, [H.sub.2-] antagonists, or amitriptyline), 3 were given inhaled medications (bronchodilators), 1 was advised to receive antibiotic prophylaxis for dental procedures, 1 was advised to receive counseling, 1 was told to "relax," and 2 could not recall what was recommended. All of those who were given recommendations reportedly followed them. Medications were taken between 3 days and 1 to 3 years. The patient for whom counseling was recommended received it for 1 year. The inhaler was used between 1 week and 5 years. Ten of 15 parents believed that the therapy that they followed was beneficial. One parent thought that it helped occasionally; in this case, the patient was being treated with an antacid for presumed GE reflux.

Of the 53 responding to the questionnaire, 40 were satisfied with the explanation, 8 were undecided, and 5 were not satisfied. Four of the five dissatisfied respondents believed they had not received an explanation. Forty-three respondents did not obtain further evaluation and 10 did.

Twenty-seven patients (51%) did not have a recurrence of the chest pain, and 26 (49%) did have a recurrence, but 12 of these patients had pain only occasionally. Twelve had pain that was considered to be severe, and 14 did not have severe pain. Of the 26 patients with recurrent pain, 13 thought the pain interfered with daily activities, and 13 did not think it interfered; 10 of the 26 sought medical care, and 16 did not. Of the 10 who sought further medical care, 5 saw another cardiologist, 3 a primary care physician (family practitioner, pediatrician, internist), and 2 a gastroenterologist. With the secondary evaluation of chest pain, the presumed diagnosis was different in 9 of 10 cases (Table).

DISCUSSION

Information is limited in the literature concerning the long-term follow-up and outcome of children with chest pain. This is probably due to the benign and often transitory nature of the pain. Selbst et a1 [5] reported a 2-year follow-up study of children seen in the emergency department (ED) for the evaluation of chest pain. The authors reexamined these patients in clinic 2 years after their visit to the ED and found that 43% of them had recurrent chest pain. After reevaluation, a change in the diagnosis was suggested in 34%. They concluded that life-threatening disease is unlikely to be present and recommended a need for follow-up services for psychogenic problems and dysfunction from pain.

Rowland et a1 [7] reported the results of a mail and telephone follow-up of children with chest pain evaluated in a cardiology clinic. The follow-up period ranged from 1.2 to 9.5 years. They found that although 45% of patients continued to have chest pain, most had less severe and less frequent pain than when they were first evaluated. Eighty-one percent of their patients were symptom-free within 3 years after the initial assessment, and none of their patients later had heart disease diagnosed.

Driscoll et a1 [8] conducted a telephone follow-up 4 to 8 weeks after the clinic visit. In most of the patients with recurrent chest pain, the pain had been classified as idiopathic or of unknown cause. In patients with idiopathic causes, the pain did not interfere with activity. The concluded that children in whom no cause is found are more likely to complain of recurrent pain. The authors also concluded that an organic cause is unlikely if the pain lasts for more than 6 months.

Fyfe and Moodie [9] did a telephone evaluation 13 months after clinic assessment of chest pain. They found that the majority of patients (29 of 34) were either asymptomatic or had reduced symptoms. In their experience, idiopathic chest pain resolved or diminished within 1 year in most cases. Chest pain was infrequently due to primary cardiac disease. Additionally, the authors believed that reassurance when no cardiac disease is present enabled symptomatic patients to tolerate their problem better.

The results of our current telephone survey are consistent with those of previous studies. Although we were able to reach only a limited number of our patients (55 of 115), such problems are commonplace in follow-up surveys of mobile populations such as those that we care for in rural Missouri. As noted in previous studies, we found no life-threatening cardiac disease in children with chest pain. We could find no patient with any type of morbidity or mortality related to cardiac causes despite a follow-up period of 1 to 5 years. In the total of 55 patients that we contacted, the total follow-up time would account for a total of 147 patient years.

As in the study of Selbst et al, [5] a significant number of our patients (49%) continued to have chest pain, and almost half of the patients stated that they had severe pain. Despite the recurrence of pain, most of these patients did not seek medical care. This could be due to an understanding of the cause and knowledge of the treatment, as in the case of GE reflux. Additionally, reassurance from the clinic that the pain was not cardiac in nature may also explain why few of these patients sought medical care. This emphasizes the importance of a thorough evaluation followed by an explanation and reassurance. According to Anzai and Merkin, [3] chest pain in adolescents rarely indicates serious disease. However, they state that it should not be casually dismissed because adolescent chest pain is often chronic and needs support and adequate follow-up by primary care physicians.

Ten patients with recurrent pain did seek further medical attention, and all 10 of these patients were seen by other physicians. We did not specifically inquire regarding why the parents chose to seek the opinion of another physician rather than return to our clinic. Additionally, since we did not have access to these records, we have no information regarding how the new diagnosis was reached or its accuracy. Aside from these patients, the majority of patients (75%) who were evaluated in our cardiology clinic were satisfied with the explanation offered. Of our 55 respondents, 53 remembered the explanation offered to them and the presumed diagnosis. All 15 of the patients for whom therapy was suggested carried out the physicians' orders, and in 10 of 15 patients, this therapy was thought to be beneficial.

The study of Selbst et al [5] and our current survey are also in agreement in that a significant proportion of patients who are reevaluated are given another diagnosis. Although several possibilities exist to explain this phenomenon, it may be that the primary diagnosis to explain chest pain in many cases is based solely on the physical examination and history rather than definitive diagnostic testing. Therefore, such diagnoses may be more subjective. Given that most of the patients who sought medical care had a different diagnosis, follow-up in cases of recurrent chest pain is important because of the possibility of a missed diagnosis or the development of a different problem. Although the diagnosis may have changed, the new diagnosis did not involve significant cardiac disease. This finding is similar to that found in other studies. [5,7-9]

This study is limited by its reliance on parental report. However, it may offer valuable insight into what our patients understand and learn from our explanations and their perceptions of the healthcare providers' response to their child's problem. As noted earlier, two of the parents could not remember visiting the cardiology clinic or that their child ever had chest pain. Also, some parents had difficulty remembering the clinic visit, particularly if it had been 5 years earlier. With any follow-up survey such as this, there may also be inaccuracy from parents who do not understand medical terminology or who do not receive an adequate explanation.

In summary, our follow-up study further supports the notion that chest pain in children is generally a benign condition related to noncardiac causes. However, in some patients, chest pain can be recurrent and severe. It can interfere with activities of daily life and may last for years. Reassurance and support are essential in patients with recurrent pain. When indicated clinically, follow-up and reevaluation may be necessary to ensure that an accurate diagnosis is obtained and, when available, appropriate therapy offered.

From the Division of Pediatric Anesthesiology/Pediatric critical Care, University of Missouri, Columbia.

References

(1.) Kocis KC: Chest pain in pediatrics. Pediatr Cardiol 1999; 46:189-201

(2.) Selbst SM: chest pain in children. Pediatr Rev 1997; 18:169-173

(3.) Anzai AK, Merkin TE: Adolescent chest pain. Am Fam Physician 1996; 53:1682-1688

(4.) Horne BS: Chest pain in children. J SC Med Assoc 1999;95:379-381

(5.) Selbst SM, Ruddy R, Clark BJ: Chest pain in children. follow-up of patients previously reported. Clin Pediatr 1990; 29:374-377

(6.) Lam J, Lababidi Z: Chest pain in children: a retrospective review of 103 patients. Am J Pain Manage 2000 (in press)

(7.) Rowland TW, Richards MM: The natural history of idiopathic chest pain in children. a follow-up study. Clin Pediatr 1986; 25:612-614

(8.) Driscoll DJ, Glicklich LB, Gallen WJ: Chest pain in children: a prospective study. Pediatrics 1976; 57:648-651

(9.) Fyfe DA, Moodie DS: Chest pain in pediatric patients presenting to a cardiac clinic. Clin Pediatr 1984; 23:321-324

TABLE

Secondary Diagnosis in Patients With Recurrent Chest Pain


Initial Diagnosis                 Second Diagnosis

Vasovagal syncope, GERD, anxiety  Allergy/asthma, MVP
Musculoskeletal (chest wall)      Hiatal hernia
Mild MVP, GERD                    Anxiety
Chest wall                        Anxiety, panic
GERD                              Idiopathic
Pectus excavatum, PAC             Valve problem
Musculoskeletal (chest wall)      SVT
GERD                              GERD
Benign, idiopathic                Heart murmur,? MVP



GERD = Gastroesophageal reflux disease, MVP = mitral valve prolapse,
SVT = supraventricular tachycardia, PAC = premature atrial contraction.

KEY POINTS

* Chest pain in children is generally benign and of noncardiac origin.

* Despite its benign nature, chest pain in adolescents may be recurrent and does interfere with activities of daily life.

* During reevaluation of persistent or recurrent chest pain, a new etiology is frequently offered.