In the last 10 years, several survey studies, review articles, and book sections1'10 have been devoted to the topic of recurrent chest pain in adolescents. This is curious since chest pain as a symptom of major organic disease is almost nonexistent in this age group. Adolescents just do not have heart attacks. Why then this interest in what is a relatively benign symptom? One reason is that chest pain is a frequent presenting complaint of adolescents seen in physicians' offices. Another reason is that adolescence is that stage of life in which individuals become acutely aware of their own mortality. The young or middle adolescent realizes that he or she really can die. Pain emanating from the left side of the chest in such an adolescent certainly will arouse the concern of the teenager's parents if not his or her own.
The typical scenario is that of a 14- or 15-year-old girl whose chief complaint is chest pain. When asked to localize the pain, more often than not she will point to an amorphous area around the lower sternum or she will indicate the area under and medial to her left breast. The pain will have been intermittent, striking at random times unrelated to activity or position. Occasionally, she might have difficulty breathing because of the pain, and she might get light-headed and dizzy. There is a better than even chance that she will have suffered from an upper respiratory infection or had vomiting in the previous 2 months at about the time that the pain started to occur.1 It is equally as likely that she is physically active but does not remember any one particular episode when she hurt her chest. She will have no history of direct chest trauma in the recent past. Other than what is mentioned above, her history will be noncontributory. Physical examination will show a normal heart, lungs, and abdomen. Single digit palpation of one or more of her costal cartilages will reproduce the pain of which she complains.
Certainly this scenario can vary, but in the author's practice, it is the most common scenario.
Chest pain is relatively common as a presenting complaint in adolescents seen in physicians' offices or clinics. One survey found it to be the seventh most common health problem affecting urban, black adolescents.11 It is difficult to get a clear picture of exactly how many teens present to a medical facility with this complaint. Few studies have separated adolescents from children in their design, and the percentage of the total patient population that these patients represent is mentioned infrequently. One study reported that chest pain was the chief or secondary presenting complaint in 0.59% of pediatrie emergency room patients.4 Another study of adolescents with chest pain presenting to a general adolescent clinic found approximately 5% of its patients with this complaint.1 So it seems that chest pain is not quite as common a complaint as are headaches and abdominal pain, but it occurs often enough to attract the attention of physicians caring for adolescents.
Causes of Recurrent Chest Pain in Adolescents
Of those teenagers who do present to clinics or offices with this problem, the majority are girls. In one study, 70% of patients with chest pain were girls. This figure was significantly greater than the percentage of girls in that facility's total clinic population.1 A female preponderance among adolescents with chest pain has been found in other studies as well.2'4 One study reported an equal percentage of each sex.' Racial composition of the affected populations reflects that of the facilities in which the studies were done.1'2
ETIOLOGY AND DIFFERENTIAL DIAGNOSIS
The etiology of chest pain in adolescents is a topic about which a certain amount of controversy exists. The major differences found in the studies of the past decade have been centered on whether most cases are musculoskeletal or psychological in origin. The one point on which all authors agree, however, is that chest pain in adolescents rarely signifies serious organic pathology. Table 1 lists some causes of recurrent chest pain in adolescents.
A study by the author showed that 79% of 100 adolescents with chest pain had costochondritis.1 Pantell and Goodman found musculoskeletal causes in 31% (14% of which were costochondritis) of 100 adolescents.3 Hyperventilation accounted for the pain in 20% of their patients, and 39% of their patients had no readily diagnosable cause.2 In a retrospective chart review of 132 adolescent patients, Selbst found the following major causes: idiopathic (26%), functional (22%), musculoskeletal (15%), costochondritis (12%), and gastrointestinal pathology (8%). ^ In a later prospective study, Selbst et al grouped results from adolescents with those from younger children, but they did note that patients older than 12 years of age were more likely to have psychogenic chest pain.4 Two studies of patients referred to pediatrie cardiology clinics because of chest pain showed that the vast majority of these patients did not have cardiac pathology.12-15 One of these studies showed that 13% of the referred patients were suffering from depression.12 Three studies that examined referred patients showed a significant proportion of them to have an esophageal origin for their chest pain.14'16
Investigation of the cause of chest pain in an adolescent is best performed with a clear idea of the anatomy of the area involved. A systematic approach begins with the internal structures and moves to the outside. Consideration of associated symptoms is essential. Although esophageal dysfunction can cause chest pain without other symptoms, in the primary care setting,14 most patients with chest pain from this cause will have associated heartburn or pain related to eating. Pulmonary causes of pain without other symptoms is decidedly uncommon in this age group. Asthma, pneumonitis, and pleurisy will have associated cough, pain on inspiration, fever, or systemic malaise. Cardiac problems that cause isolated chest pain are rare, as stated previously. One relatively common cardiac condition that must be considered in adolescents is mitral valve prolapse. However, in a recent study of children and young adolescents, chest pain occurred no more frequently in patients with mitral valve prolapse than it did in unaffected patients.17 Another condition that produces pain and usually has associated symptoms and physical findings is pericarditis. Chest pain with exercise is always of concern because it may be a sign of hypertrophie cardiomyopathy (previously called idiopathic hypertrophic subaortic stenosis) or of anomalous coronary arteries. However, these are also rare conditions.
Key Points for Management of Chest Pain in Adolescents
Pain emanating from the chest wall is much more common than intrathoracic causes of chest pain. Consideration of the chest wall must take into account the various structures present including the bones (ribs, sternum, and scapulae), their associated cartilages, and the muscles. Pain from the chest wall can result from direct trauma, from overuse, from recurrent coughing, from recurrent vomiting, and from viral or nonspecific cartilage inflammation. With these condition, history and physical examination are paramount in making the diagnosis. The importance of obtaining a good history cannot be overemphasized. Particular attention should be paid to everyday activities that an adolescent would not consider worth mentioning unless specifically asked. These activities include lifting weights, doing calisthenics and other exercise, doing house cleaning chores, and lifting infant siblings. Physical examination of the chest wall should include maneuvers calculated to stress various muscle groups. For example, having the patient press his or her palms against a wall forcefully will stress the pectoral muscles and will elicit pain if they are strained.
After the patient goes through several such maneuvers, the examiner should palpate the ribs and compress the thoracic cage anteriorly/posteriorly and laterally. If this elicits pain, then the individual ribs and intercostal spaces should be palpated firmly. Finally, the sternocostal, costocostal, and intrasternal cartilages should be palpated individually with a single digit. If pain is elicited and it is the same or very similar to the pain of which the patient is complaining, and the rest of the history and physical examination is unproductive, then the diagnosis of ostochondritis can be made.
There is no question that a thorough psychosocial history should be obtained if there is no evident organic cause of the chest pain. A history of dizziness or light- head edness combined with a report of perioral paresthesia and tingling in the hands or feet combined with shortness of breath or a history of rapid breathing should suggest the diagnosis of hyperventilation syndrome. Sometimes parents can be very helpful with this diagnosis because they may have witnessed their child while he or she was hyperventilating or they may have had the same problem themselves. While hyperventilation can cause chest pain itself due to respiratory alkalosis, it is most commonly found to be an accompanying finding of costochondritis because the chest pain causes anxiety about death. This also may be why the author found a predominance of left-sided or bilateral chest pain in patients diagnosed with costochondritis.1 Pain on the right side only is probably not interpreted by a teenager as being of cardiac origin, so the patient does not develop enough anxiety to instigate a visit to a physician.
As can be seen from the preceding discussion, chest pain in an adolescent rarely demands immediate action to stave off life-threatening consequences. Even when significant organic pathology is suspected, a prudent, well thought-out approach is possible. Because the history and physical examination indicate the diagnosis in almost every case, referral to consultants or for laboratory or imaging evaluations is usually unnecessary. What is necessary is an understanding of adolescent cognitive development and sufficient time to explain and to reassure the patient and his or her parents that no serious condition exists. Table 2 lists the key points for managing chest pain in adolescents.
Adolescence is the period for transition from concrete thinking to formal operational or conceptual thought that should be characteristic of adults. Adolescents begin to be able to think abstractly at about 12 years of age, but are not able to use abstract concepts well until after the age of 1 5. When teenagers are under stress, such as when they are worried about dying or being ill, they tend to think concretely, even if they normally can think abstractly. Therefore, it is incumbent on the physician to explain what's wrong to the patient in concrete terms to help ensure that what is said is understood and, if necessary, acted on properly. For example, an adult who presents to a doctor with the complaint of chest pain and who is found to be free of significant pathology can be told that he or she is normal. The adult can infer from that statement that no abnormalities have been found, that no significant cardiac problem exists, and that death will not result from the cause of the pain. The physician cannot expect the same understanding from an adolescent.
First, the physician must explain what various parts are involved in the production of the pain. For instance, if the cause of the pain is costochondritis, then the patient (and the parents) must be told how the ribs are connected to the sternum and to each other by cartilage (drawing a picture of the rib cage and then touching the relevant points on the adolescent's chest is a good technique). He or she must then be told what cartilage is. A good way to demonstrate that is to have the patient feel his or her nose or ear. The physician then has to explain that the patients heart is normal and, ". . . you're not having a heart attack, and you're not going to die from this pain." Until those words are specifically stated, the patient may still harbor doubts as to the benign nature of the problem. Finally, the patient has to be told that the condition, in the case of costochondritis, may last for several weeks and can recur. Otherwise, the patient will be right back in the office with similar complaints in the near future. Moderately potent analgesics, such as nonsteroidal anti- inflammatory drugs, usually are sufficient to control the pain until it disappears. If the pain is due to gastroesophageal reflux, then a similar approach is needed to make the patient understand what the esophagus is, how it is connected to the stomach, what a sphincter is, and how acid can reflux and cause the pain.
The physician also must attend to the implications that chest pain may have for the adolescent. Has this pain become severe enough to warrant a physician's attention just because the adolescent thinks it may be a symptom of heart trouble, or has a close relative recently died of a heart attack? Is there a family member who has angina, and has the adolescent "adopted" this symptom because of undue stress in school or at home? Does this chest pain come from the use of cocaine18·19 and is it an opening that can be used to investigate the patient's possible drug problem? All these, and similar issues, may be the real reason that an adolescent comes to see a physician because of chest pain.
Chest pain in an adolescent is rarely a symptom of significant pathology. In the opinion of this author, it usually has an organic cause, albeit one that frequently is accentuated by psychosocial factors. An understanding of adolescent cognitive development and an awareness of the possible stresses in an adolescents life is necessary to adequately address the problem and bring it to a satisfactory conclusion. Diagnosis and management of this condition allow the physician to use both the science and the art of medicine to good advantage.
The author thanks William Hritsko, BSIM, for his assistance in preparing this manuscript.
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Causes of Recurrent Chest Pain in Adolescents
Key Points for Management of Chest Pain in Adolescents