Emergent stress testing in young people

Editors-In-Chief: Brenna Southern ; Ernest Gervino, Ph.D.

Overview
Stress testing has frequently been used to assess adult patients with suspected or known coronary artery disease (CAD) based on pre-test probability. Pre-test probability is the assessment of a patient and their likelihood of CAD based on clinical history and symptoms. Stress testing to diagnose myocardial ischemic syndrome is usually indicated only in patients with an intermediate pre-test probability.

The average age of a patient who undergoes a stress test is typically between 45-60 years. Increasing age is one of many positive risk factors for CAD. However, there have been several cases in which young adults and adolescents have presented with chest pain and were found to have had a myocardial infarction (MI). Since chest pain can be a complaint among children, the question becomes whether or not an emergent stress test is needed.

The most common reason for stress testing is chest pain. All patients who present with acute or chronic chest pain need to be evaluated to determine the course or urgency of further non-invasive vs. invasive testing. Inpatient stress testing can be done if a recent MI or an acute unstable coronary syndrome has been excluded. .

Among children presenting with chest pain, the symptoms often tend to be benign. Given the fact that the majority of children have no probable cardiac risk factors, their pre-test probability is already very low. Yet there are several conditions that can cause ischemic chest pain and other cardiac abnormalities so a thorough careful history and physical examination should always be performed. The presenting symptom can be secondary to congenital defects as well as acquired diseases. Kawasaki disease has a common manifestation of coronary artery aneurysms which can progress to coronary stenosis. Acute MI is one of the main causes of death in children with Kawasaki disease. Another acquired condition is sickle cell disease in which children can frequently present with chest pain, have an MI and have normal coronary arteries. Other issues that could cause ischemic chest pain are coronary vasospasm, pericarditis or myocarditis, cocaine use, or other conditions causing anatomic congenital cardiovascular abnormalities.

Acute symptoms in children should be dealt with accordingly to rule out an MI, congenital defects or diseases. Based on above indications, an emergent stress test may not be warranted. To help determine the etiology of the symptom, ECG, echocardiogram, MRI, cardiac enzymes, drug screening, blood testing for hypercoagulability and coronary angiograms may be more useful. Or for chronic chest pain associated with exertion, an outpatient stress test could also be helpful. Whether or not stress testing is emergent in children should again be considered similarly to adult emergent stress testing. Comprehensive assessment of acute or chronic problems and the consideration of the child’s pre-test probability being significantly low are compelling points that an emergent stress test may not be necessary.