Sunday, March 13, 2011

Chest Pain in Young People

Chest Pain in Children and Adolescents

Heart disease is extremely common in this country, especially in older people, so it is natural that anyone with chest pain would immediately worry about having some sort of heart problem. We see people collapse with chest pain on TV every day, and occasionally read about sudden death in an apparently healthy athlete.
In children and adolescents, chest pain is a surprisingly common symptom, and accounts for a lot of trips to Emergency departments, a lot of anxiety, and lots of referrals to me for evaluation. The reality is that chest pain in this age range is rarely due to a heart problem, however, and when it is, it is usually very clear by checking a few key points from the story and the physical exam. I often do an EKG but testing is not usually helpful in this setting as compared to a good history and exam. And the evaluations almost always show that the pain comes from somewhere other than the heart: the lungs, the chest wall, the esophagus, etc.
As a cardiologist, my primary goal is finding those unusual cases where the chest pain is indeed coming from the heart. If it is not from the heart, I may or may not be able to identify a specific cause of the pain, and even if I do, I may not have a specific treatment to make it stop.
Either way, I can generally reassure everyone that the pain is not a dangerous or life-threatening problem, even if it is very annoying or disruptive.

Time permitting, we can discuss the problem in a very open-ended fashion. However in order to direct our conversation to some key points, there are a few questions I will want the patient and family to think about:

1) Is there any Kawasaki disease; any connective tissue disorder like Marfan syndrome; or any inflammatory condition like lupus, rheumatoid arthritis, etc. in the family or patient history?

2) Has the patient ever had any type of heart disease? Does he or she have any other medical issues, such as asthma?

3) Has anyone in the family been born with any type of heart problem?

4) Has anyone in the family died suddenly (or collapsed) under the age of 50 years, including car accidents, drowning or other accidental deaths?

5) Has the patient ever fainted in any situation?

6) How long has the pain been going on? Where is it located and what does it feel like? How long does it last? Does anything seem to make it better or worse (certain positions, breathing, drinking something, resting, etc.?)

7) Does it consistently happen with physical activities, exercise or other exertion? If so, does it happen only with exertion (that is, does it also occur during quiet activities sometimes?) Does strenuous exertion usually bring it out, or just occasionally?

8) Is the pain associated with fever, rash, swollen joints, or other signs of illness?

9) Is the pain associated with a sense of a racing heart?

Innocent Murmurs

Innocent Heart Murmurs

What is a heart murmur?

A heart murmur is a sound made between beats of the heart. The sound is made by turbulent blood flowing through the heart. It is similar to the sound water makes as it flows through a pipe. Many people have heart murmurs – it all depends on the acoustics of the individual. When a murmur is present, it may or may not mean that there is something wrong with the structure of the heart. ALL children have heart murmurs at some point or another!

What is an innocent heart murmur?

Innocent heart murmurs are murmurs found in people with normal hearts. Innocent heart murmurs - also called functional, normal, vibratory, or physiologic murmurs - are harmless. They are TYPICAL in children and may disappear and reappear throughout childhood – they change depending on the varying acoustics with growth, and the amount of blood flow though the heart (just as more water flowing through a pipe makes a louder sound even if the pipe is normal). If you/your child has an innocent heart murmur, the sound may become louder whenever he or she is excited or frightened or has a fever. Innocent heart murmurs cause no problems, and most disappear, or not heard after a child nears adulthood because of the changes in heart rate, acoustic (most adults are bigger and thicker,) and relative amount of blood flow through the heart.

How does it occur?

Your heart makes sounds ("lub-dub") when the heart valves close. Normally it is silent between beats. An innocent murmur is a sound between beats that does not indicate something is wrong with the structure of the heart. It is just a sound made because of the way the blood is flowing through the heart. The doctor will often be able to tell what is causing the turbulence when he or she notes the location of the murmur and listens to all the sounds the heart makes. Other tests are done if the sounds suggests a possible problem with the heart.

How is it diagnosed?

An innocent heart murmur is usually diagnosed by the doctor listening to the heart through a stethoscope. Sometimes an electrocardiogram or an echocardiogram may help the doctor in deciding if what they heard is normal or not. An electrocardiogram is a recording of the heart's electrical activity. An echocardiogram uses ultrasound waves to record pictures of the structures inside the heart. Rarely, chest x-rays are ordered. All of these tests are painless, and usually none of them are needed. In fact, none of the tests can really tell the doctor what they heard, but they may help in making decisions.

How is it treated?

Innocent heart murmurs never require any treatment. You do not need to schedule follow-up visits to the doctor nor do you need to limit physical activity.
Please note: If you or your doctor ever has any new questions or concerns about this murmur, or any other sign, symptom or problem that might be due to the cardiovascular system, the door is always open for a follow-up visit!

About Palpitations

Palpitations are a sense of a change in the heart rhythm, usually with it being faster and/or more irregular. In young people with structurally and functionally normal hearts, early beats, extra beats, pauses, etc. are common and normal, and also in unborn and newborn babies. These are usually intermittent and brief. Long "runs" of a rhythm change lasting more than a few beats are more unusual.

People often underestimate how fast a child's heart can normally go- a rate of 120 in a 10 year old is not that uncommon, and esp. not if there is any anxiety or symptom at the time!

Things that make palpitations more worrisome include:
1) Any such episodes associated with syncope (faitning), or near syncope.
2) Episodes that seem to be provoked by exertion, excitement, sudden fright, sudden pain, etc.-- anything that raises adrenaline levels in the body.
3) Any family history of heart rhythm issues in people LESS than 50 years old, or any history of things like Dilated or Hypertrophic Cardiomyopathy, Long QT Syndrome, Brugada Syndrome, etc. If there is such a history known or suspected, it is useful for the family to get specific records.
4) If the person involved has any known cardiac history- palpitations are still usually benign but a possible connection needs to be considered and reviewed.
5) Runs of uncountably fast, regular heart rate, especially with sudden onset and termination, are suspicious for "SVT." In a normal heart and in the absence of syncope or other significant symptoms, this is still NOT life-threatening unless it goes on uninterrupted for hours to days. It does need to be documented and in some cases treated (though not all will need treatment, in fact.)

Palpitations that last long enough should be counted by someone able to do it-- the person or an adult, and a journal of these is always useful. Long runs can be caught on paper at a clinic, ER, or on an event monitor, and this is very helpful.

Long runs that can often be terminated by "vagal maneuvers" like bearing down, face into ice water, carotid massage (ONE side only!), or gagging are suggestive of SVT. If we have never caught an episode on paper, I'd usually rather have the family do that one way or another first. Once we have a firm diagnosis and have made a plan, any method to stop subsequent episodes is fine.

As with syncope and chest pain, the great majority of cases are benign. Primary care providers can and should evaluate these sorts of symptoms first UNLESS one of the listed warning signs is present-- then I at least need to speak with the family/patient to establish some guidelines.

About Fainting


Fainting, near fainting and lightheadedness are problems that any normal person might have at one time or another. Some perfectly healthy people, for one reason or another, have significant problems with this. It is a somewhat peculiar part of our human body and its physiology that we sometimes faint. In general, it results when the brain sends signals out to the body that lower the heart rate, lower the blood pressure, or some combination. Paradoxically, the brain often does this at a time when it is least tolerated by the body, and because of decreased blood flow up to the brain, the fainting or near fainting occurs. This is because the brain is a very needy, fastidious organ that does not function well if its supply of nutrients and oxygen is slowed down even a little bit.

A common factor that predisposes people to having this problem is some degree of dehydration. This does not need to be dehydration as severe as someone who has had vomiting or diarrhea, for instance, but simply a relative dehydration which prevents the heart from filling well before each beat. The poor filling itself can initiate the series of events that leads to fainting. Even if dehydration is not a particular issue, improving one’s hydration status by taking in more salt and water may alleviate the symptoms without need for any medicines.

It is important to bear in mind that both salt and water are needed. Our body fluids are salt water. In the old days, athletes were often given salt pills but this is not necessary and can be unsafe. In a nutshell, one adds salt to food, or eats salty foods, and drinks water. Water is in fact the best form for the fluid, although sports drinks, juices, and other drinks are fine as well. Milk should really be considered a food and not a liquid per se. Any drink that has alcohol or caffeine may cause more loss of fluid, so those do not count either. One must also be careful about soft drinks and juices, and even some sports drinks that contain a lot of sugar.

In order to make a significant difference, a typical teenager may need to add 2 – 3 or even more liters of fluid to his or her intake per day. If this is a high sugar fluid, this is a great deal of empty calories and can make weight gain a real issue. These also suppress appetite for more substantial food. This is why I recommend water unless a low calorie sports drink tastes so much better to an individual that he or she is willing to drink the one but not the other.

Skipping breakfast is a common problem in adolescents, or eating a breakfast that consists just of some simple carbohydrates like bleached flour and sugar. This is not the sort of morning meal that provides a steady blood sugar level throughout the day or facilitates a good intake of fluid. Start the day right with a good breakfast. In susceptible individuals salty snacks like pretzels and so forth may even be useful in addition to salted foods, spaced as needed throughout the day. If one eats enough salt, it is easy to drink enough because one feels thirsty naturally.

It is important to remember that although fainting in certain situations can be of concern, in the great majority of situations it is a normal, human thing to do. It does not indicate any underlying heart disease. It does not put on at any danger unless it is occurring while one is driving a car or in other situations where decreased alertness might itself be dangerous.

Some of the situations in which fainting would be taken much more seriously include
1. Fainting that clearly occurs after an unusually fast or slow heart rate,
2. With known structural or functional heart disease,
3. Fainting in response to an adrenaline surge. Examples of an adrenaline surge include during exercise, in response to emotion, excitement or fright, and so forth.
4. Fainting would also be taken more seriously if it occurred in an individual whose family had individuals with sudden death under the age of 50, known rhythm disturbances, or other heart conditions that might potentially be passed down in the family.

Almost all typical situations are not worrisome, on the other hand, and include after standing up after lying down or sitting, a minute or two after activities (but again, not during), after standing still and upright for a long time, after kneeling for a long time, in a hot or stuffy room, following illness involving poor intake or vomiting and diarrhea, at the sight of blood or while watching surgery on the Discovery channel, etc.

When the story suggests the usual, normal type of fainting, lots of testing and doctor visits are seldom helpful. An EKG is often done, but assuming this is normal the main focus is usually on the salt and water intake to prevent more issues.

Occasionally, medical treatment is needed because fainting is still an issue. A few important points need to be made, however. First of all, even if fainting is persistent, it does not make it any more dangerous, simply more annoying and disruptive to one’s life. The root causes are the same. The medicines that are given in problem cases will only work if a solid foundation of good salt and water intake has been instituted; the effectiveness of the medicine will be much less if this is not being pursued. Most importantly, when we use a medicine, it is because fainting is an annoying symptom, not because it is dangerous. We do this in the same way that we might take something to help reduce a cough or nasal congestion while we have a cold, a condition which we will otherwise get through perfectly fine, whether we take medicines or not.

If one is trying to increase salt and water and is wondering about if enough is being done, young people should need to urinate at least a couple of times in the morning, and a couple of times in the afternoon. The urine should be clear, not yellow or orange. The one exception is that a couple of hours after taking a vitamin pill that has B vitamins, the urine is often very yellow because of the vitamins passing out in the urine.

When first trying to add salt and water to see if it is enough to prevent fainting, a very concerted effort for 2-4 weeks may be needed. One may need to go a little overboard on the salt and water to test the theory properly. If it does seem to help, one can then back down a little bit and see what it takes to avoid the symptoms…then maintain that level into the future.

If you have any questions or concerns about any of the information in this handout, please speak with your primary care physician, or if need be, your physician can communicate with me as well. This is particularly true if you have concerns that the fainting in your case may fall into one of those unusual but alarming categories I listed above.