Paediatric chest pain: evaluating diagnostic testing and clinical outcomes

Chest pain is a common reason for referral to paediatric cardiology clinics. Unlike adults, most paediatric chest pain is benign, yet uncertainty often leads to additional testing. The study aimed to evaluate the aetiology of chest pain in children referred to a tertiary paediatric cardiology clinic, determine the diagnostic yield of additional tests, and identify patients who truly benefit from further investigations using a risk-based approach.

A retrospective observational study of 368 children (5-18 years) presenting with chest pain among 1,631 outpatient visits was conducted. All patients underwent a detailed history, physical examination, and electrocardiogram (ECG). Additional investigations, including echocardiography, chest radiography, and laboratory analysis, were performed selectively based on clinical presentation and red-flag features. Red-flag features were defined as exertional chest pain, syncope, palpitations, abnormal cardiac examination, abnormal ECG, or family history of sudden cardiac death.

Cardiac causes were identified in 8 patients (2.2%), whereas 360 patients (97.8%) had non-cardiac aetiology: musculoskeletal (46.2%), idiopathic (24.9%), respiratory (18.8%), gastrointestinal (2.8%), psychogenic (5.8%), and miscellaneous (1.1%). ECG abnormalities were detected in 16 patients (4.3%), echocardiography was positive in 5/208 patients (2.4%), and cardiac biomarkers were abnormal in 2/15 (13.3%). Patients with red-flag features had a significantly higher rate of cardiac diagnoses (13.5% vs. 0.3%). Most additional tests were low-yield in patients without red-flag features.

Most paediatric chest pain is benign. A structured, risk-based approach using red-flag features helps clinicians identify children requiring further evaluation while potentially reducing unnecessary investigations and optimising resource use.