Chest Pain Evaluation in Teenagers

Most Common Causes

The American Academy of Pediatrics suggests that costochondritis accounts for the majority of cases when cardiac causes are excluded, characterized by tenderness of costochondral joints on palpation and pain reproducible with chest wall pressure 1, 2
Musculoskeletal pain is typically sharp, localized, affected by breathing, turning, twisting, or bending 2
Point tenderness on examination strongly suggests musculoskeletal origin rather than cardiac pathology 1
Anxiety and panic disorders are common causes of chest pain in young adults, with a suspected psychogenic origin 1

Gastroesophageal reflux disease can mimic cardiac pain, presenting as squeezing or burning sensations, and should be considered if pain occurs after meals or at night, or improves with antacids 1, 2
Pleuritic pain suggests pulmonary involvement 1
Pain described as sharp, fleeting, related to inspiration, positional, or shifting locations suggests a lower likelihood of ischemia 1

Exertional chest pain with radiation to left arm, jaw, or neck requires immediate cardiac evaluation 1, 2
Associated diaphoresis, dyspnea, nausea, or palpitations mandate urgent cardiac workup 1
Family history of premature coronary artery disease, hypertrophic cardiomyopathy, or sudden cardiac death requires immediate evaluation 3
History of Kawasaki disease with coronary involvement necessitates urgent assessment 3

Characterize pain by quality, location, radiation, onset, duration, precipitating factors, and relieving factors 1
Perform focused cardiovascular examination, assess for chest wall tenderness, and evaluate vital signs 1
A 12-lead ECG should be performed and interpreted within 10 minutes if any cardiac concern exists 1, 2
Chest radiography is useful to identify pneumothorax, pneumonia, or mediastinal abnormalities if respiratory cause suspected 1
Cardiac biomarkers (troponin) should only be used if initial evaluation suggests cardiac cause 1

Treat musculoskeletal pain with NSAIDs if indicated 1
Consider referral to cognitive-behavioral therapist if anxiety is suspected with recurrent presentations 1