Serious causes of pediatric chest pain and key findings

Cause	History	Physical exam findings	ECG findings
Hypertrophic cardiomyopathy	Positive family history Exercise intolerance Exertional chest pain Syncope and/or arrhythmia	Dynamic systolic murmur	Left ventricular hypertrophy or left axis deviation ST segment or T wave changes Q waves Arrhythmias, ventricular premature beats Ventricular pre-excitation (Wolff-Parkinson-White)
Dilated cardiomyopathy	Family history Decreased exercise tolerance, syncope Heart failure symptoms	Gallop Mitral regurgitation murmur	Intraventricular conduction delay High or low QRS voltages Arrhythmia, premature beats
Anomalous coronary artery origin	Exertional chest pain Exertional syncope	Usually normal	Usually normal
Coronary ischemia	Predisposing conditions: History of Kawasaki disease Cardiac surgery or heart transplant Systemic arteriopathy (Williams syndrome) Severe familial hypercholesterolemia Drug use: Cocaine, sympathomimetics Anginal chest pain	Tachycardia Tachypnea New murmur or gallop	ST segment depressions or elevation T wave changes Q waves
Severe left ventricular outflow tract obstruction	Exertional symptoms Exertional syncope	Loud systolic murmur	Left ventricular hypertrophy Left ventricular strain pattern
Arrhythmia	Palpitations Syncope Positive family history	Irregular rhythm	Atrial arrhythmia Ventricular arrhythmia Premature contractions Ventricular pre-excitation (Wolff-Parkinson-White)
Pericarditis	Positional chest pain Predisposing factors: Rheumatologic conditions Malignancy Mediastinal radiation Infection (HIV, tuberculosis, viral) Renal failure Recent cardiac surgery	Cardiac rub Tachycardia/tachypnea Distant heart sounds, JVD	Diffuse ST segment changes T wave inversions
Myocarditis	Fever Viral prodrome Short duration of symptoms New onset heart failure symptoms	Tachycardia Tachypnea With or without gallop rhythm, ventricular ectopy Cardiovascular collapse	Diffuse ST segment changes T wave inversions PR depression Ventricular ectopy Low QRS voltages
Aortic dissection	Personal or family history of bicuspid aortic valve or connective tissue disorders (Marfan, Loey-Dietz, Ehlers-Danlos type IV, others) Acute onset sharp or tearing type of pain	Marfanoid body habitus	See coronary ischemia above
Pulmonary embolus	Pain description: Acute onset, pleuritic, associated dyspnea Personal or family risk factors (inherited thrombophilia, hypercoagulable states, immobilization, medications)	Right ventricular heave (elevated right ventricular pressure) Loud and/or unsplit S₂ (if right ventricular pressure elevated)	Right ventricular hypertrophy Right ventricular strain pattern

ECG: electrocardiogram; JVD: jugular venous distension; S₂: second heart sound.

Reproduced from: Friedman KG, Alexander ME. Chest pain and syncope in children: A practical approach to the diagnosis of cardiac disease. J Pediatr 2013; 163: 896. Table used with the permission of Elsevier Inc. All rights reserved.

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Serious causes of pediatric chest pain and key findings