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.

Labs/Imaging Normal complete metabolic panel WBC 9.1, Plt 309 Urine toxicology screen: Negative D-dimer: 0.29 (normal) ESR/CRP: Normal CK: 892  1129 CKMB: 72.6  85.5 Troponin: 0.21  EKG: Inverted T-waves in leads V2-V5

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

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

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.

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.

Epidemiology of Chest Pain in Adolescents

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

Signs and Symptoms of Adolescent Myocardial Infarction CardiacPulmonaryNeurological Chest painDyspneaMental confusion OrthostasisTachypneaWeakness PalpitationsNasal flaringPre-syncope Tachy/bradycardiaGruntingSyncope Dysrhythmias (i.e. ventricular fibrillation) RetractionsIrritability S3/S4RalesLethargy Murmurs of mitral/tricuspid insufficiency RhonchiUnconsciousness

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

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.

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

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.

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.

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.