Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical...

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Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital

Transcript of Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical...

Page 1: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Chief Complaint: Chest Pain

Jamie R. Macklin, M.D.The Ohio State University Medical Center/Nationwide Children’s Hospital

Page 2: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Case Presentation• 17 year-old Caucasian female with history of well-

controlled mild intermittent asthma• Eight hours prior to presentation, she developed left-

sided chest and arm pain while pumping gasoline.• She denied shortness of breath, dizziness, or wheezing.• She had started a triphasic birth control pill two days

prior to presentation.• On presentation, she had a normal pulse, equal and

appropriate blood pressures in both arms, and a normal oxygen saturation on room air.

• While uncomfortable, she did have normal cardiac and pulmonary exams.

Page 3: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Labs/Imaging

• Normal complete metabolic panel• WBC 9.1, Plt 309 • Urine toxicology screen: Negative• D-dimer: 0.29 (normal)• ESR/CRP: Normal• CK: 8921129• CKMB: 72.685.5• Troponin: 0.2146.64• EKG: Inverted T-waves in leads V2-V5

Page 4: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Management

• Started on aspirin, a beta-blocker, and continuous heparin/GP IIb/IIIa IV medications

• Taken for cardiac catheterization, where she was found to have a mural thrombus in her left anterior descending artery

• Tolerated thrombectomy well• Was later found to be a heterozygote for

Factor V Leiden

Page 5: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Learning Objectives

• Review etiologies of chest pain in adolescents• Review the clinical signs/symptoms and

diagnostic workup for adolescent myocardial infarction

• Recognize that adolescent myocardial infarction can be caused by many varied anatomic and pathologic abnormalities

Page 6: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Case Discussion• Chest pain is a common complaint of adolescents

seeking medical evaluation.• While uncommon, acute myocardial infarction

should always be considered in an adolescent with chest pain.

• The long differential diagnosis of adolescent chest pain can make promptly diagnosing a myocardial infarction challenging.

• Early recognition and intervention in adolescents with coronary pathologies leading to infarction is essential to the prevention of significant morbidity and mortality in this age group.

Page 7: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Chest Pain in Adolescents

• Though often benign, it is a common cause of worry in adolescents

• Over 650,000 adolescents seek medical care for chest pain every year.

• It is one of the top ten common reasons to visit a pediatrician.

• Most of the concern is due to the idea that chest pain can be a symptom of serious illness in the adult population.

Page 8: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Epidemiology of Chest Pain in Adolescents

Page 9: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

How Common is Adolescent Myocardial Infarction?

• Incidence is ~157 cases per year.• The mortality rate from adolescent myocardial

infarction is 0.2 deaths/100,000 population in age 15-24 years.

• Adolescent males are significantly more likely to have a myocardial infarction than females (80%).

Page 10: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Signs and Symptoms of Adolescent Myocardial Infarction

Cardiac Pulmonary Neurological

Chest pain Dyspnea Mental confusion

Orthostasis Tachypnea Weakness

Palpitations Nasal flaring Pre-syncope

Tachy/bradycardia Grunting Syncope

Dysrhythmias (i.e. ventricular fibrillation)

Retractions Irritability

S3/S4 Rales Lethargy

Murmurs of mitral/tricuspid

insufficiency

Rhonchi Unconsciousness

Page 11: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Differential Diagnosis of Adolescent Myocardial Infarction

• Coronary artery abnormalities– i.e. anomalous origin of the L coronary artery from the

right sinus of Valsalva• Kawasaki’s disease• Coronary artery thrombi• Myocarditis/Pericarditis• Coronary artery vasospasm• Atherosclerosis/Familial Homozygous Hyperlipidemia• Drug or medication use (cocaine, sumatriptan)• Sickle cell disease• Trauma

Page 12: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Diagnosis and Management of Adolescent Myocardial Infarction• Cardiac bioenzymes– CK/CK-MB and Troponin levels

• ECG findings– ST or T-wave changes, widened Q-waves

• Transthoracic echocardiography• Treatment is aimed at removing/ameliorating the

underlying condition– Cardiac catheterization, medications, surgery, drug abstinence, etc.

Page 13: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

References• Koestenberger M et al. Myocardial infarction in an

adolescent: anomalous origin of the left main coronary artery from the right coronary sinus in association with combined prothrombotic defects. Pediatrics, Vol. 120, No. 2, 424-427.

• Lane, J et al. Myocardial infarction in healthy adolescents. Pediatrics, Vol. 120, No. 4, 938-943.

• Massin, M et al. Chest Pain in Pediatric Patients Presenting to an Emergency Department or to a Cardiac Clinic. Clinical Pediatrics, Vol. 43, No. 3, 231-238.

• www.disastercenter.com/cdc/aacutcar.html• www.teengrowth.com

Page 14: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Question

• A 16 year-old male comes to your office for a sports physical. Once alone, he nervously confides to you that for the past six months, he has had sharp, substernal chest pain twice monthly. The pain is not radiating and is not associated with eating, breathing problems, or dizziness/syncope. The pain dissipates on its own after several minutes.

Page 15: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Question

After listening to his concerns, you tell him that:A. The pain is likely related to cardiac causes, and you will be

referring him to a cardiologist immediately.B. The pain is “all in his head” and that he should ignore it.C. Based on statistics, the pain is likely related to

musculoskeletal causes. He should try ibuprofen for relief.D. Chest pain is an uncommon complaint in his age group and

usually signals serious illness.

Page 16: Chief Complaint: Chest Pain Jamie R. Macklin, M.D. The Ohio State University Medical Center/Nationwide Children’s Hospital.

Answer - C

• Chest pain in adolescents, while a common presenting problem in the office, rarely is due to cardiovascular disease in a well adolescent.

• The history and physical exam are important to determine which organ system is involved in chest pain.

• Pain that is constant, dull, pressure-like, radiates to the back, shoulders, or left arm, or is associated with exercise is more likely to be due to cardiac causes.

• Musculoskeletal causes are the most common etiology for adolescent chest pain.