title: Management of pediatric chest pain using a standardized assessment and management plan.
abstract: OBJECTIVE
  Chest pain is a common reason for referral to pediatric cardiologists and often leads to an extensive cardiac evaluation. The objective of this study is to describe current management practices in the assessment of pediatric chest pain and to determine whether a standardized care approach could reduce unnecessary testing.
  
  
  METHODS
  We reviewed all patients, aged 7 to 21 years, presenting to our outpatient pediatric cardiology division in 2009 for evaluation of chest pain. Demographics, clinical characteristics, patient outcomes, and resource use were analyzed.
  
  
  RESULTS
  Testing included electrocardiography (ECG) in all 406 patients, echocardiography in 175 (43%), exercise stress testing in 114 (28%), event monitoring in 40 (10%), and Holter monitoring in 30 (7%). A total of 44 (11%) patients had a clinically significant medical or family history, an abnormal cardiac examination, and/or an abnormal ECG. Exertional chest pain was present in 150 (37%) patients. In the entire cohort, a cardiac etiology for chest pain was found in only 5 of 406 (1.2%) patients. Two patients had pericarditits, and 3 had arrhythmias. We developed an algorithm using pertinent history, physical examination, and ECG findings to suggest when additional testing is indicated. Applying the algorithm to this cohort could lead to an ∼20% reduction in echocardiogram and outpatient rhythm monitor use and elimination of exercise stress testing while still capturing all cardiac diagnoses.
  
  
  CONCLUSIONS
  Evaluation of pediatric chest pain is often extensive and rarely yields a cardiac etiology. Practice variation and unnecessary resource use remain concerns. Targeted testing can reduce resource use and lead to more cost-effective care.
authors: Department of Cardiology, Children's Hospital Boston, Boston, MA 02115, USA. kevin.friedman@cardio.chboston.org
authors: Kevin G
authors: KG
authors: Friedman
authors: David A
authors: DA
authors: Kane
authors: Rahul H
authors: RH
authors: Rathod
authors: Ashley
authors: A
authors: Renaud
authors: Michael
authors: M
authors: Farias
authors: Robert
authors: R
authors: Geggel
authors: David R
authors: DR
authors: Fulton
authors: James E
authors: JE
authors: Lock
authors: Susan F
authors: SF
authors: Saleeb
mesh_terms: D000293:Adolescent; D002637:Chest Pain / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D002648:Child; D019468:Disease Management; D004562:Electrocardiography / Q000379:methods / Q000592:standards; D005080:Exercise Test / Q000379:methods / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods / Q000592:standards; D008297:Male; D010372:Pediatrics / Q000379:methods / Q000592:standards*; D012189:Retrospective Studies