Wednesday, July 17, 2019

Chest Pain in Teens: Anxiety Could Be the Culprit


By Molly Ray, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

“Do you ever feel like your heart is beating so hard it wants to jump out of your chest?” If you tell your doctor you have chest pain, he or she might ask this question.

Sometimes chest pain, chest tightness, or palpitations (a feeling of pounding/racing heart beat) are an indication of a serious condition such as a myocardial infarction (a heart attack) or severe allergic reaction (anaphylaxis).

However, what might seem surprising is that more teenage patients are visiting the emergency department or their physician complaining of chest pain. The cause of this pain in this unlikely group of patients? Acute anxiety.

Anxiety is becoming a more common diagnosis in the world of adolescent medicine. The National Institutes of Health (NIH) reports that nearly 32% of adolescent patients surveyed on the National Comorbidity Survey - Adolescent Supplement (NCS-A) have an anxiety disorder, with girls affected more often than boys. Signs and symptoms of an acute presentation of anxiety (an anxiety or panic attack) include chest pain, palpitations, shortness of breath, difficulty sleeping, poor academic performance, and feelings of uncontrollability, among various others.

How will my doctor determine if there is a serious problem?

If an adolescent patient says chest pain is the main reason for their visit to the emergency department or other acute-care facility, the most important thing the doctor will do is get a thorough medical history of that patient. It is important to know if the adolescent has any underlying medical conditions that might raise suspicion of something more serioussuch as a history of heart surgery or murmur, a bleeding disorder, any medications the patient may be taking, a family history of anyone with heart problems including sudden death at a young age (less than 50),  or if the young patient has a pacemaker. It is also important to note the factors and timing of the chest pain – time of day the pain first started; where the patient was; what they were doing; and how long the pain has been occurring. The answers to these questions will determine which tests, if any, are necessary for the doctor to perform.

What are some of the most commonly used tests?

Two of the most frequently used tests to determine the cause of chest pain in adolescents include:
  •         Electrocardiogram (ECG/EKG) – This is a tracing of your heart beat to see how fast, or slow, your heart is beating and if there are any indications of an abnormal rhythm (an arrhythmia) such as skipped beats, premature beats, or abnormal communication between the upper and lower chambers of the heart. This test is performed by placing 12 or 15 stickers containing electrical leads across the chest to capture the electrical current present in the heart. This creates an interpretable picture of the electrical activity in the heart.
  •         Chest X-ray – This is an image of the chest which allows your doctor to look at the size and shape of your heart (cardiac silhouette). We also look at the surrounding structures such as the lungs, ribs, sternum, and portions of your abdomen, which may also contain clues to the source of your chest pain.

In a healthy adolescent with anxiety these tests will likely be normal.

What can you do to help prevent acute anxiety?
  •        Recognize your triggers – Keep track of what you are doing, what you are thinking about, who you are with, and where you are when you note feelings of chest pain or other symptoms of anxiety.
  •         Develop coping strategies – This is not an easy thing to do. Finding people, places, and things that will help prepare you for interactions with your triggers or distract you from them can be helpful.
  •         Find someone to talk to – All primary care physicians and providers likely use some type of screening tool to help identify patients with signs/symptoms of anxiety early so they can help patients and connect them to the right resources. Your primary care doctor is a great place to start.

In this modern age, there are many internal and external pressures and stressors that can trigger anxiety in teens; this is something to note as more of them report chest pain and anxiety disorder diagnoses continue to rise. This article only briefly addresses one possible cause of chest pain. If you or your teen are experiencing chest pain alone, or with any other symptoms, it is important to talk to your physician.

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