In children, there can be many causes of chest pain. The most common are musculoskeletal (pain in the muscles or chest wall), pulmonary causes (asthma or pneumonia), and idiopathic causes (no abnormalities found). Chest pain due to cardiac disease is relatively uncommon.
Two cardiac causes of chest pain in children are due to inflammation around the heart “pericarditis” and coronary artery type chest pain or angina pectoris. The latter is usually the biggest concern of parents and patients alike though rarely occurs in children and adolescents.
Angina pectoris is a sensation of tightness or squeezing in the chest, accompanied by anxiety. It happens when the heart does not get enough oxygenated blood. There may or may not also be pain in the chest, arms, or back. Angina is brought on by exercise such as walking, especially uphill or after a meal, and disappears with rest. Cold weather and emotional upsets may bring it on. Some people are awakened at night with angina.
The pain is caused by an imbalance of the heart’s need for oxygenated blood and the ability of the coronary arteries to deliver it. This pain is a warning that a heart attack may occur.
There are several congenital coronary artery abnormalities that may cause an imbalance between the delivery of oxygenated blood and the needs of the heart. In some defects, the oxygen needs of the heart may be increased due to thickening of the heart as seen with certain muscle diseases of the heart known as cardiomyopathy. In other defects, there is obstruction of blood flow from the heart causing thickening of the heart muscle as well. Coronary abnormalities causing the inability of the heart to get enough oxygenated blood include abnormal course or origin of the coronary arteries as well as a few other rare congenital abnormalities. Narrowing or blockage of the coronary artery similar to that in adults is rare but can occur after certain diseases involving the coronary arteries such as Kawasaki disease or due to a genetic elevation of cholesterol levels. In adults, the narrowing is mainly due to plaque, known as atherosclerosis or “hardening of the arteries.”
The discomfort and pain are usually in the front of the chest but may radiate to the left arm or to the jaw. It is often described as a weight on the chest. Breathing may be heavy, although taking a breath does not make the pain worse. The pain of angina is typically dull and aching and not knife-like or shooting pain. It usually lasts no longer than three to five minutes, depending on what triggers the attack. If it occurs while walking, prompt rest causes it to subside. Some people with angina can carry on and "walk through" the attack with no further symptoms. Others note a discomfort that persists, but they continue on and are able to tolerate the pain. In most cases, however, the pain worsens until relieved by rest or medication.
Most chest pain in children and adolescents is not due to angina. Concerns should be brought to the attention of your child’s primary care doctor. If the pain has the characteristics of angina described above, notify your child’s doctor immediately.
In most patients, several simple tests help to confirm the diagnosis. Sometimes a resting electrocardiogram (ECG) may show changes of ischemia (when the heart is deprived of oxygenated blood). An ultrasound or echocardiogram may do the same at rest. The more typical test is a stress test with either an ECG, echocardiogram or radionuclide scan (radioactive material injected into the blood stream showing areas of the heart which do or do not receive blood flow) to show the typical changes when the heart muscle is deprived of oxygen. An exercise stress test may be performed on a treadmill, bicycle or by injecting medicines that cause the heart to pump harder (as if the child is exercising).
One treatment is aimed at either reducing the heart's need for oxygen or increasing its blood flow. Decreasing physical activity is an effective, though limited, way of improving the condition. Nitroglycerin is the time-honored drug used to increase blood flow to the heart. It reduces the workload on the heart by dilating the coronary blood vessels and lowering blood pressure slightly. Also effective are drugs called beta-blockers, calcium channel blockers, and ACE inhibitors.
At times, so little blood is passing through the coronary arteries that more complicated treatments, such as coronary angioplasty or coronary bypass surgery, may be necessary. In children with congenital coronary artery abnormalities, this is almost always the case. These procedures allow more blood to flow through the coronary arteries. If angina is present and due to atherosclerosis, rare in children, a strict diet to control cholesterol and fat and cholesterol may be recommended as may cholesterol- and fat-lowering drugs.