Precordial catch syndrome. (Featured CME Topic: Precordial Catch Syndrome).

Abstract: The precordial catch syndrome is frequently mentioned as part of a long differential diagnosis of chest pain in children. It is an extremely common complaint but remains underrecognized. This review describes the distinctive features of the syndrome and points out that this is not a diagnosis of exclusion. Emphasis is placed on the need for taking a careful history to elicit the diagnostic features of the syndrome and performing a thorough physical examination. Diagnostic testing is usually unnecessary. Familiarity with the features of precordial catch syndrome should be helpful to primary care providers caring for children.

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The precordial catch syndrome is an exceedingly common yet underrecognized cause of benign chest pain in children and adolescents. The syndrome has a remarkably consistent, characteristic presentation and is therefore easily diagnosed. Nonetheless, it frequently leads to elaborate testing and/or referral to a pediatric cardiologist and can be a source of considerable anxiety for many patients, their families, and their physicians.

The syndrome was first described and graphically termed precordial catch by Miller and Texidor in 1955. (1) They characterized the condition as presenting with sudden onset, with sharp, stabbing, well-localized precordial pain, and reported its occurrence in 10 patients, 1 of whom was Miller himself. Later authors coined the phrase Texidor's twinge. (2) In 1978, Sparrow and Bird (3) reported 45 healthy patients with the same form of benign chest pain and commented on its underappreciated frequency. Pickering discussed the syndrome in a short article in 1981, (4) and in 1989, Reynolds put together the first report of children with the condition in the United States. (5) To date, these four reports constitute the body of literature identifying precordial catch syndrome as a common complaint. Although the syndrome is mentioned in a number of other publications (2,6-10) it is included only as part of the broad differential diagnosis of chest pain or as a form of idiopathic chest pain. The syndrome is so common, h owever, that it merits wider recognition by the medical community.

Chest pain is a frequent complaint of children and adolescents. During a 9-week period, Driscoll et al (11) prospectively studied 43 pediatric clinic patients with that primary complaint. They identified six diagnostic categories of chest pain and concluded that it was common, usually benign, and rarely of cardiac origin. A number of subsequent studies and reviews drawn from outpatient, (8'9'12) emergency, (2,6,13-15) and cardiology (7,10,16-20) settings have reported similar conclusions. Often, these studies tabulate the causes of the complaint in their series of patients, usually including precordial catch syndrome under a category of idiopathic, functional, or miscellaneous causes. The intent of most of these reports was to outline the differential diagnosis of chest pain and propose an appropriate diagnostic evaluation plan. Precordial catch syndrome is underemphasized relative to the frequency of its occurrence. Recently, Selbst (2,6,13,14) studied and described a large number of pediatric patients with the primary complaint of chest pain. He emphasized the benign and noncardiac etiology of the chest pain (2,6,13,14) and appropriately pointed out that laboratory testing is seldom helpful. (6,3) He mentioned precordial catch syndrome (2,3) among idiopathic causes and stated that it is rarely identified in patients presenting to the emergency department with complaints of chest pain.2 Our experience in Omaha, however, suggests that precordial catch is a frequent cause of referral to a pediatric cardiologist.

Features

The features of precordial catch syndrome (Table 1) are consistent and characteristic. The symptom may occur at any age, but most commonly comes to medical attention in children aged 6 to 12 years. There is no sex predilection. The pain usually (sometimes exclusively) occurs while the patient is at rest, and never occurs during sleep. It has no temporal correlation with meals. The pain is always described as sharp, stabbing, or needlelike. It is well localized, and the patient can point to the painful area with one or two fingers. The most common painful sites are the left sternal border, the right anterior chest, and the flanks. The site of pain may vary from episode to episode.

The pain begins suddenly without provocation. It may be worsened or partially relieved by change of position, but it is characteristically exacerbated when the patient takes a deep breath. The child almost always deliberately breathes shallowly during an episode. The episodes usually last between 30 seconds and 3 minutes but occasionally resolve after a breath or two and rarely may last up to 30 minutes. The pain resolves spontaneously, and typically the child is uncertain of its disappearance until consciously attempting to take a deep breath.

There is a striking paucity of associated symptoms with precordial catch syndrome. When asked to describe the child's appearance during an episode, a parent will report that the child appears to be in pain, but rarely describes pallor, flushing, or other visible signs. Palpitations, syncope, and near-syncope are absent. With prolonged episodes, there may be associated paresthesias or mild light-headedness, both of which are related to the rapid, shallow breathing.

Results of physical examination, during both the painful episode and subsequent evaluation, are usually negative, although it should be mentioned that the presence of cardiac or pulmonary abnormality does not preclude the occurrence of precordial catch syndrome. (7) For example, this common complaint occasionally occurs in patients with atrial septal defect or pulmonary valve stenosis. In such instances, the physical examination will reflect the underlying congenital heart abnormality, but the child's history will nonetheless facilitate the diagnosis of precordial catch syndrome.

Etiology

The painful sensation that constitutes the precordial catch syndrome is neither imaginary nor conversional. There is rarely a significant component of psychologic overlay or secondary gain (as may be seen in other chronic pain syndromes in children). The level of anxiety in the patient or parent may be raised if there has been a recent cardiac event in the family. The syndrome does not occur exclusively or more commonly in children of higher intelligence or socioeconomic status, but it is more readily recognized when the child can articulately describe the pain.

The pathophysiology of the syndrome is unknown. The pain may originate in the parietal pleura, as suggested by Miller and Texidor, (1) but it also resembles that of rib or cartilage injury, and so may stem from the chest wall. The pain is most certainly neither cardiac nor pericardial in origin.

Differential Diagnosis

The differential diagnosis for this complaint (Table 2) must include other causes of cardiac, pulmonary, gastrointestinal, and chest-wall pain, most of which are easily distinguished based on the characteristic history of each. Angina pectoris can occur in children with congenital, inflammatory, or atherosclerotic causes of coronary insufficiency, aortic valve stenosis, and hypertrophic cardiomyopathy. This pain is rarely described as sharp, is not well localized, tends to begin and resolve insidiously, and is provoked by exercise or activity. Mitral valve prolapse occasionally causes so-called atypical chest pain, which may be sharp and well localized; however, this pain is not exacerbated with deep breaths, and is accompanied by the click and murmur characteristic of this condition. The chest pain caused by pericarditis is associated with acute illness and is not transient, intermittent, or well localized. Occasionally, a small child with supraventricular tachycardia will experience chest discomfort and ref er to it as chest pain.

Viral pleuritis or pleurodynia may produce sharp chest pain similar in character to precordial catch syndrome, but it is usually associated with fever and cough, and is generally unrelenting. Pneumonia is often accompanied by chest pain, especially while coughing. The chest tightness associated with reactive airway disease is sometimes described as pain by children. (19) Esophagitis and chronic gastritis can often produce chest symptoms, but the nature of the pain is quite different from that of precordial catch syndrome (7)

Chest wall syndrome (22) and chest trauma, including rib fractures, can produce pain very similar to precordial catch syndrome. A history of trauma and localized tenderness of the chest wall are present. Muscle strains are similarly associated with tenderness. Inflammatory costochondritis is usually a relatively acute illness and, like other chest wall syndromes, is associated with local tenderness on palpation.

Diagnostic Evaluation

The diagnostic evaluation for precordial catch syndrome should consist almost exclusively of a careful history-taking and physical examination. The physician must be especially thorough and attentive to the child's history to identify the diagnostic features of the syndrome, listen for possible indications of an alternative diagnosis, and clearly demonstrate to an anxious patient and family that their concern is being taken seriously. Although the physician will likely strongly suspect the diagnosis of precordial catch syndrome based solely on the patient's history, a thorough physical examination is imperative to exclude other possible causes of chest pain and to ensure credibility.

Ancillary testing, such as electrocardiography, echocardiography, radiography, or barium studies, is rarely indicated. Testing is seldom helpful or necessary in making the diagnosis of precordial catch syndrome, and may lead to increased anxietyt (18,23) and cost for the patient. While ancillary testing is sometimes performed in the interest of completeness, the family may interpret it to mean uncertainty or doubt about the diagnosis, and it may overemphasize the potential seriousness of the child's problem. If the physician has doubt about the diagnosis, then directed testing may be necessary. If pericarditis cannot be excluded on the basis of history and physical examination, for example, echocardiography is indicated. Also, if precordial catch syndrome occurs concomitantly with a separate underlying pathology, such as an atrial septal defect, then ancillary testing may be done as part of that separate evaluation.

Management

Management of precordial catch syndrome, like the diagnostic evaluation, consists largely of careful, attentive conversation with the patient and the family. The objective of the discussion should be to assure the family that the condition is real, but harmless; that the physician understands their concern and has identified the problem with certainty; and that no further evaluation or treatment is necessary.

It is best to begin by explaining that chest pain is a common complaint among children and, unlike in adults, it is seldom cardiac in origin. More specific discussion of the patient's symptoms and the features (eg, sharpness, localization, relation to deep breathing, predominance at rest) that clearly distinguish this condition from cardiac pain is important. Giving the symptoms a name (precordial catch syndrome or Texidor's twinge) emphasizes certainty and familiarity with the diagnosis. It is often helpful to concisely describe the symptoms back to the patient, using slightly different terms or similes that the child will recognize, inspiring confidence that the physician knows exactly what the child is experiencing. This can be especially effective if the physician has personally experienced precordial catch syndrome in the past.

Finally, reassurance must be offered that the pain is completely harmless and that treatment is neither necessary nor helpful. Follow-up visits are unnecessary and can undermine the patient's confidence in the certainty of the diagnosis. A follow-up phone call to the patient or the family may be appropriate. Of course, the physician should always offer to be available for future reevaluation should symptoms change or concerns persist.

Summary

Precordial catch syndrome is a frequently encountered complaint in children. It is a condition that is underrecognized and commonly mistaken for other causes of pain. It consists of a set of characteristic, nearly invariable features, and is not a diagnosis of exclusion. Evaluation and management are performed in the office setting without ancillary testing, but can require considerable time and patience. When undertaken thoroughly, conscientiously, and knowledgeably, this evaluation and management process can achieve a definitive diagnosis with resolution of considerable patient and family anxiety.

Table 1

Characteristics of precordial catch syndrome

Sudden onset
Occurs most frequently at rest
Very well localized
Sharp, stabbing, needlelike pain
Exacerbated by deep breathing
Each episode lasts for 30 seconds to 3 minutes
Sudden, complete resolution
No associated symptoms
No abnormal physical findings

Table 2

Differential diagnosis of chest pain

Cardiac causes
 Angina pectoris
 Pericarditis
 Mitral valve prolapse
 Supraventricular tachycardia
Pulmonary causes
 Pneumonia
 Asthma
 Pleurodynia
 Pneumothorax
Gastrointestinal causes
 Gastritis
 Esophagitis
Chest wall causes
 Trauma
 Muscle strain
 Inflammatory costochondritis
 Chest wall syndrome
 Slipping rib syndrom (a)
Other causes
 Sickle cell disease
 Substance abuse (cocaine)

(a) For a description of slipping rib syndrome, see Porter GE. Slipping
rib syndrome: An infrequently recognized entity in children--A report of
three cases and review of the literature. Pediatrics 1985;76:810-813
(21).

Accepted September 15, 2001.

References

(1.) Miller AJ, Texidor TA. "Precordial catch," a neglected syndrome of precordial pain. JAMA 1955;159: 1364-1365.

(2.) Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: A prospective study. Pediatrics 1988;82:319-323.

(3.) Sparrow MJ, Bird EL. "Precordial catch": A benign syndrome of chest pain in young persons. N Z Med J 1978;88:325-326.

(4.) Pickering D. Precordial catch syndrome. Arch Dis Child 1981;56:40l-403.

(5.) Reynolds JL. Precordial catch syndrome in children. South Med J 1989; 82:1228-1230.

(6.) Selbst SM. Chest pain in children. Am Fam Physician 1990;41:179-186.

(7.) Fyfe DA, Moodic DS. Chest pain in pediatric patients presenting to a cardiac clinic. Clin Pediatr 1984;23:32l-324.

(8.) Leung AK, Robson WL, Cho H. Chest pain in children. Can Fam Physician 1996;42:l156-1164.

(9.) Feinstein RA, Daniel WA: Chronic chest pain in children and adolescents, Pediatr Ann 1986;15:685-686, 691-694.

(10.) Dichl AM. Chest pain in children: Tip-offs to cause. Postgrad Med 1983;73:335-342.

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

(12.) Pantell RH, Goodman BW. Adolescent chest pain: A prospective study. Pediatrics 1983;71:881-887.

(13.) Selbst SM. Chest pain in children. Pediatrics 1985;75:1068-l070.

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

(15.) Zavaras-Angelidou KA, Weinhouse E, Nelson DB. Review of 180 episodes of chest pain in 134 children. Pediatr Emerg Care 1992;8:189-193.

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

(17.) Woolf PK, Gewitz MH, Berezin S, et al. Noncardiac chest pain in adolescents and children with mitral valve prolapse. J Adolesc Health 1991;12:247-250.

(18.) Goodman Kaden G, Shenker IR, Gootman N. Chest pain in adolescents. J Adolesc Health 1991;12:251-255.

(19.) Wiens L, Sabath R, Ewing L, et al. Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma. Pediatrics 1992;90:350-353.

(20.) Tunaoglu FS, Olgunturk R, Akeabay S, et al. Chest pain in children referred to a cardiology clinic. Pediatr Cardiol 1995;16:69-72.

(21.) Porter GE. Slipping rib syndrome: An infrequently recognized entity in children--A report of three cases and review of the literature. Pediatrics 1985;76:810-813.

(22.) Epstein SE, Gerger LH, Borer JS. Chest wall syndrome: A common cause of unexplained cardiac pain. JAMA 1979;241:2794-2797.

(23.) Milov DE, Kantor RJ. Chest pain in teenagers: When is it significant? Postgrad Med 1990;88:145-154.

RELATED ARTICLE: Key Points

* Precordial catch syndrome has a remarkably characteristic and consistent presentation and therefore is easily diagnosed.

* The pain is always described as sharp, stabbing, or needlelike; it is well localized, and the patient can point to the painful area with one or two fingers.

* The diagnostic evaluation for precordial catch syndrome should consist almost exclusively of careful history-taking and physical examination.

* Precordial catch syndrome is not a diagnosis of exclusion.

From the Division of Pediatric Cardiology, Children's Hospital, University of Nebraska Medical Center, Omaha, NE.

Reprint requests to Carl H. Gumbiner, MD, Division of Pediatric Cardiology, Children's Hospital, 8200 Dodge Street, Omaha, NE 68114. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association

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