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Comparative Study
. 2011 Aug;128(2):239-45.
doi: 10.1542/peds.2011-0141. Epub 2011 Jul 11.

Management of pediatric chest pain using a standardized assessment and management plan

Kevin G Friedman  1 , David A Kane, Rahul H Rathod, Ashley Renaud, Michael Farias, Robert Geggel, David R Fulton, James E Lock, Susan F Saleeb
Affiliations
Comparative Study

Management of pediatric chest pain using a standardized assessment and management plan

Kevin G Friedman et al. Pediatrics. 2011 Aug.

Abstract

Objectives: Chest pain is a common reason for referral to pediatric cardiologists and often leads to an extensive cardiac evaluation. The objective of this study is to describe current management practices in the assessment of pediatric chest pain and to determine whether a standardized care approach could reduce unnecessary testing.

Patients and methods: We reviewed all patients, aged 7 to 21 years, presenting to our outpatient pediatric cardiology division in 2009 for evaluation of chest pain. Demographics, clinical characteristics, patient outcomes, and resource use were analyzed.

Results: Testing included electrocardiography (ECG) in all 406 patients, echocardiography in 175 (43%), exercise stress testing in 114 (28%), event monitoring in 40 (10%), and Holter monitoring in 30 (7%). A total of 44 (11%) patients had a clinically significant medical or family history, an abnormal cardiac examination, and/or an abnormal ECG. Exertional chest pain was present in 150 (37%) patients. In the entire cohort, a cardiac etiology for chest pain was found in only 5 of 406 (1.2%) patients. Two patients had pericarditits, and 3 had arrhythmias. We developed an algorithm using pertinent history, physical examination, and ECG findings to suggest when additional testing is indicated. Applying the algorithm to this cohort could lead to an ∼20% reduction in echocardiogram and outpatient rhythm monitor use and elimination of exercise stress testing while still capturing all cardiac diagnoses.

Conclusions: Evaluation of pediatric chest pain is often extensive and rarely yields a cardiac etiology. Practice variation and unnecessary resource use remain concerns. Targeted testing can reduce resource use and lead to more cost-effective care.

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Conflict of interest statement

FINANCIAL DISCLOSURE: The authors have indicated they have no personal financial relationships relevant to this article to disclose.

Figures

FIGURE 1. SCAMP algorithm to guide testing in patients with chest pain. a Diagnoses that lead to increased risk of cardiac chest pain (ie, inflammatory disorders, malignancy, thrombophilia). b Family history was considered positive if any of the following were present in a first-degree relative: sudden or unexplained death; aborted sudden death; cardiomyopathy; or pulmonary hypertension. Six patients had an abnormal ECG result and an abnormal past medical history, family history, or physical examination. Patients with more than 1 abnormality (ie, ECG, past medical history, family history, and/or physical examination) were counted in only 1 category in this figure. CP indicates chest pain; PMHx, past medical history; echo, echocardiogram.
FIGURE 1
SCAMP algorithm to guide testing in patients with chest pain. a Diagnoses that lead to increased risk of cardiac chest pain (ie, inflammatory disorders, malignancy, thrombophilia). b Family history was considered positive if any of the following were present in a first-degree relative: sudden or unexplained death; aborted sudden death; cardiomyopathy; or pulmonary hypertension. Six patients had an abnormal ECG result and an abnormal past medical history, family history, or physical examination. Patients with more than 1 abnormality (ie, ECG, past medical history, family history, and/or physical examination) were counted in only 1 category in this figure. CP indicates chest pain; PMHx, past medical history; echo, echocardiogram.
FIGURE 2. Cardiac testing according to provider experience.
FIGURE 2
Cardiac testing according to provider experience.
FIGURE 3. Cardiac testing according to clinical volume.
FIGURE 3
Cardiac testing according to clinical volume.
See this image and copyright information in PMC

Comment in

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