My Heart Hurts!

Last week I saw yet another teenager with chest pain. He'd been lifting weights, and now his chest hurt, particularly when he moved his arms. Diagnosis: costochondritis, a common condition in kids where the ligaments of their ribcages get sore with strains like breathing hard, coughing, or weight-lifting. The only "red flag" with this teen was he also had pain while playing basketball; chest pain during exercise could mean trouble. Again, it was probably because he was breathing hard while playing, but I called the pediatric cardiologist to be safe. Fortunately, he had an opening that afternoon; talk about service! The cardiologist called me later that evening: "Scott, that boy certainly has costochondritis, but my echocardiogram also showed an anomalous right coronary artery." Holy cats!  For once a kid actually had chest pain from a heart problem! This rare condition, if not treated, can cause heart pain and even heart attacks. We see kids in the Pediatric ER several times per week with chest pain. The majority of these kids have costochondritis. It's easy to diagnose- press where their chest is sore, and they wince and go "ow" as you squeeze on the inflamed ribcage. While some children get costochondritis with chest wall exertion, others can get it out of the blue. The kid could be sitting watching TV, and suddenly get a sharp pain around her breast bone. While this condition is benign, when parents hear "chest pain," they sometimes freak out. After all, adults have been told that if they have chest pain, get seen right away- it could be a heart attack. Sometimes children will even say "my heart hurts," because they know their heart's in there and that's the word they have. Saying that really gets parents' attention!  Fortunately, less than 1% of kids with chest pain have an actual heart problem like my teenage patient. In 1999 I had another patient with chest pain that was actually heart trouble. This 9 year-old girl had been born with a heart defect, had had one corrective surgery, and needed another. Before that second operation, however, the family inexplicably stopped going to the cardiologist. Years later, she showed up in my ER with chest pain. The pain was gone by the time I saw her and she looked fine, but cardiology decided to admit her to the hospital to check out her partially-fixed heart. Time passed while the girl waited for her bed upstairs. Then her mom poked her head out of the room and said, "something's wrong." I went in to find the girl unconscious and grey, in full cardiac arrest! We started CPR, slapped on the monitor leads, and saw a lethal cardiac rhythm on the screen called ventricular fibrillation. The fix: shock with the defibrillator paddles, like on TV. One zap and her heart rhythm normalized. Later the cardiologists found that her heart was beyond surgical repair, too scarred from years of neglect and abnormal function. Instead, she went home with an implanted defibrillator. Like we said above, most pediatric chest pain is benign. Usually in kids it's ribcage soreness, called costochondritis. Occasionally it can be a lung problem, like asthma or pneumonia. Sometimes it's esophagus irritation, a.k.a. "heart burn." Only about 1% of pediatric chest pain is cardiac. Kids' hearts are one of their healthiest organs, young and ready for a lifetime of work. Only when hearts get really old, like in the elderly, do they begin to exceed their warranty and break down. Red flags in pediatric chest pain: pain during exercise, like with our teen boy from above, can occasionally mean heart trouble. Those kids need to see cardiology. But if chest walls hurt when you press on them, rest assured: it's not a heart attack!