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Chest Pain

Hearing your child complain of chest pain is undoubtedly frightening! Fortunately, the majority of causes of chest pain in children and young adults is rarely due to the heart. Many people think that when a child is complaining of chest pain, that he or she may be having a heart attack. Although this is one of the first things we think of when an adult has chest pain, this fortunately rarely happens with kids. The following is a list of potential heart and non-heart related causes of chest pain in children and young adults:

Non Heart Related Causes

The body experiences "pain" when it receives appropriate signals from nerves throughout the body. There are different types of pain signals, which is beyond the scope of this current discussion. However, the nerves that send such signals are sometimes shared by different parts of the body. Therefore, it can sometimes be difficult for the brain to distinguish the exact source. For example, when someone reports chest pain, it may be difficult for the brain to know if the pain is coming from the heart, the lungs, the muscles/ribs that makeup the chest. 

 

Costochondritis

This type of pain most often involves two or more connected ribs, at the junction where each rib meets the breast-bone. The pain typically involves only one side of the breast-bone, but may involve both. This type of pain is usually described as "sharp" and lasting several seconds to several minutes. It may be worsened when you take a deep breath. Also, sometimes pressing on the joints that are involved may reproduce the pain.  

 

Musculoskeletal injury

The chest wall is made-up of several different types of muscle, some of which are able to withstand strenuous activities, whereas others are not. For example, the pectorals major muscles can help us support our chest when lifting heavy objects, but they are still not as powerful as our biceps or quadriceps. In addition, the small muscles between our ribs ("intercostal muscles") are not designed to withstand heavy loads at all. In fact, these muscles are only used when we exhale forcefully (i.e., exercising). So, these muscle groups (and the supporting bones, tendons, etc) can become injured fairly easily, resulting in inflammation, and thus, pain. This injury may also result from direct trauma to the area. 

 

Asthma

Asthma is described as reactive airway obstruction. The mechanics of our respiratory tract are quite complex, and beyond the scope of this site. Basically, the airway is made-up of a series of specialized tubes or passageways that become progressively smaller from the larynx (our "voicebox") until the tiny little air pockets known as alveoli. This is analogous to our American highway systems ... you drive on a huge, multi-lane highway and progressively travel on more narrow roadways until you reach the small side-streets and finally reach your garage. The passageways that direct air into our lungs are covered by very thin sheets of muscle that allow them to respond appropriately (i.e., allow more or less air through). With asthma, these muscles often get inflamed and result in narrowing of the passageways. Whatever air has already traveled through will have difficulty in getting back out; hence, the "obstruction". So, if you're having difficulty removing the air from your lungs, your body will then try to use it's intercostal muscles to force the air out. This may cause inflammation of those muscles, resulting in pain.  

 

Bronchitis/Pneumonia

Infections of the lungs, or lining of the lungs may cause pain through several different mechanisms. Inflammation that results from the infection may directly cause pain, but these signals are sent through nerve fibers that are shared by other parts of the chest. So, the brian may not be able to distinguish this from other sources of pain. Infections of the lung are often associated with significant coughing, which may cause strain to the intercostal muscles that work to forcefully expel air from the lungs. 

 

Pneumothorax

This refers to a small "air bubble" that sometimes develops then bursts in the lung. Not uncommonly, this is found to happen in completely healthy young adults. This most often is completely benign, but at times, may lead to significant shortness of breath and severe chest pain if a significant amount of air leaks out of the "bubble". This diagnosis is made with careful physical examination, assessment of the patient's vital signs, and a chest X-ray.

 

Gastroesophageal Reflux

Also commonly known as "heartburn". Gastroesophageal Reflux refers to the passage of liquid contents from the stomach ("gastro-") back into the esophagus, or food-pipe ("esophageal"). We all have a band of muscle that separates the stomach from the esophagus to prevent the regurgitation, or backward flow of stomach contents. However, sometimes this muscle is a little more relaxed, allowing stomach contents (ie, stomach acid) to reflux back into the esophagus. The lining of the stomach is designed to withstand a very acidic environment; the lining of the esophagus, however, is not. So, acid that refluxes back into the esophagus may cause inflammation, irritation, and therefore, pain. The pain is usually located in the middle of the chest (anywhere along the food-pipe), although sometimes is located just underneath the ribs.  

 

 

Heart Related Causes

Cardiac causes of chest pain result from either inflammation of the heart muscle (i.e., from infection or another underlying medical condition) or from inadequate blood (and therefore oxygen) supply to the heart muscle (the heart's blood supply is inadequate to meet its demand for nutrients/energy sources). Many of these causes can be evaluated by performing an echocardiogram to assess the structure and function of the heart.

 

Myocarditis/Pericarditis

Some viruses or infectious agents have a predisposition to attack different parts of the heart, for reasons currently unknown. They may attack the heart muscle (myocardium), heart valves (endocardium), or lining of the heart (pericardium). This may cause a variety of signs and symptoms, including fever, chest pain, shortness of breath, rapid heart beat, nausea, abdominal pain, etc.  This pain may either result from inflammation of the heart, or moreso from the heart's inability to pump enough blood to it's own muscle and to the rest of the body. This" myocardial dysfucntion" may result in other parts of the body receiving inadequate supplies of blood and resulting in other symptoms, ie nausea, abdominal pain. This diagnosis is made by obtaining a careful history, thorough physical examination, careful review of the patient's vital signs, thorough physical examination, an electrocardiogram, and an echocardiogram. The electrocardiogram (ECG) looks for signs that the electrical system of the heart may be inflamed. The echocardiogram (echo) looks directly at the heart and allows us to make sure that the heart valves and heart muscle are working properly; it also enables us to look for fluid that may develop around the heart as a result of the inflammation. 

 

Anomalous Origin of the Coronary Arteries

The heart is a muscle, and just like any other muscle of the body needs it's own blood supply to ensure that it receives the proper levels of oxygen and other nutrients it needs to function normally. Very cleverly, the heart is the first organ of the body to receive oxygenated blood! This happens thanks to two blood vessels, called the "coronary arteries" that leave the aorta (the first major artery of the body) and supply the heart with blood. There is one coronary artery for each side of the heart (right and left). Each coronary artery will then distribute tiny branches that ultimately supply the entire heart muscle with blood. Sometimes, however, these coronary arteries originate from the wrong part of the aorta. In doing so, the path they have to travel to get to their ultimate destination is different and subsequently may expose them to being compressed by surrounding structures or may result in a more narrow or more acute-angle opening because they become stretched. This may result in inadequate amounts of blood reaching the heart muscle, and therefore cause injury ("ischemia") or even death ("infarct") to the heart muscle. 

 

Arrhythmias

The electric activity of the heart provides a "rhythm" that enables the different segments of the heart to circulate unoxygenated blood to the lungs and oxygenated blood to the rest of the body in an efficient and coordinated manner (analogous to the electric circuit of a car powering the car's engine). Abnormal heart rhythms may cause chest pain by virtue of diminishing the heart's ability to pump blood effectively, thereby decreasing the heart's own supply/demand ratio. This results in injury to the heart muscle. 

 

Hypertrophic Obstructive Cardiomyopathy

Hypertrophic Obstructive Cardiomyopathy (HOCM) refers to a complex and fascinating condition whereby the heart muscle is unable to pump blood efficiently by virtue of it's abnormal makeup ("morphology"). In this condition, the heart muscle itself is abnormally thickened ("Hypertrophic"). If this thickening is significant enough, it may impede the left side of the heart's ability to pump blood to the rest of the body by physically obstructing the flow of blood out of the heart. Through a variety of complex physiological mechanisms, this increases the heart muscle's demand for energy, while the supply is reduced by virtue of the obstruction. This results in an inadequate blood supply to the heart muscle ("ischemia") with resultant muscle injury.

 

Aortic Stenosis

Aortic stenosis refers to the narrowing of the aortic valve (the last valve that blood must travel through before being supplied to the rest of the body). In children and young adults, this narrowing is most often a consequence of a physical abnormality of the valve, such as a "bi-cuspid" aortic valve, where the valve, which naturally has three doors/leaflets or "cusps", only has two cusps (bi = two, cusps). Similar to the physiology seen in patients with hypertrophic obstructive cardiomyopathy, aortic stenosis may impede the left side of the heart's ability to pump blood to the rest of the body by physically obstructing the flow of blood out of the heart, thus increasing the heart muscle's demand for energy, while the supply is reduced by virtue of the obstruction/narrowing. This results in an inadequate blood supply to the heart muscle ("ischemia") with resultant muscle injury.

 

Dissecting Aortic Aneurysms

An "aneurysm" refers to the abnormal dilation of a blood vessel, in this example, the aorta. This condition may be seen in patients with connective tissue diseases, such as Marfan syndrome or Ehlers-Danlos syndrome (EDS). As the name impies, "connective tissue" refers to the tissue that connects or holds adjacent structures together. In the case of Marfan syndrome or EDS, the composition of the tissue that holds the blood vessels together (particularly in the aorta) is abnormal, allowing the tissue to be more elastic or stretchy than usual. This property allows the blood vessel to dilate over time. However, this causes the wall to become thinner, and more susceptible to "dissection", tearing, or rupture if it is unable to withstand the stress exerted by the ejection of blood flowing through it.    

 

Mitral Valve Prolapse

Mitral valve prolapse refers to a condition in which one or both doors/leaflets of the mitral valve turns backwards, entering the left atrium of the heart. The exact explanation of chest pain in this condition is unclear, though the association has been reported several times. The function of the heart is almost always preserved in these cases and the pain is benign (not harmful). 

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