Dr. Rob Steele (Host): Welcome to Pediatrics in Practice, a CME Podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. And you can do so by visiting cmkc.link/cmepodcast, and then click the Claim CME button.

Today, we are joined by Dr. Amanda McIntosh to discuss chest pain in the primary care setting. Dr. McIntosh is a pediatric and fetal cardiologist at the Ward Family Heart Center at Children's Mercy and Clinical Assistant Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. She received her medical degree at the University of Kansas School of Medicine and completed her Pediatric Residency and Pediatric Cardiology Fellowship at Children's Hospital Colorado through the University of Colorado School of Medicine.

She has been at Children's Mercy since August of 2020. She has served as the Associate Program Director for the Pediatric Cardiology Fellowship Program since 2022 and has been the Director of Stress Echocardiography since 2021. Her clinical responsibilities include general inpatient, outpatient pediatric cardiology, fetal cardiology, and transthoracic, transesophageal, fetal, and stress echocardiography. That is a lot of imaging, that's for sure. Her other teaching, research, and quality improvement interests include the development of simulation education for critical conversations in pediatric and fetal cardiology, improving provider and family communication in prenatal cardiology, expanding and developing the use of pediatric stress echocardiography and delivery planning for neonates with prenatally diagnosed critical congenital heart disease. She has a passion for physician and healthcare provider career development at all stages and values collaboration and communication across healthcare systems within the academic medicine. Whoo! Dr. McIntosh, welcome.

Dr. Amanda McIntosh: Thank you for having me.

Host: You know, I got to tell you, when I had gotten some of the notes about you, you are living my best life, because word has it you're taking sailing lessons, you're an avid cyclist, and you're heading to Greece at some point here. Is that all true?

Dr. Amanda McIntosh: That is all true. I wouldn't say that I'm great at anything, but I will try all of the things.

Host: Well, that's fantastic. When I grow up, I want to be you. I think that's awesome. I love the variety of interests. That's fantastic. Well, why don't we jump right into it, talking about chest pain in the primary care setting? As a primary care pediatrician, when a family member brought their child in for chest pain, they're always worried about the heart. That's usually the first question that I would get. What are the most common causes of chest pain in the primary care setting? Is it the heart or is it not the heart?

Dr. Amanda McIntosh: I think that's the first question to ask, because when I think about chest pain, I think about what's the most common, but also what is the family worried about? Because the interplay of that is really going to guide your testing and reassurance and how the family feels when they leave. So just like you mentioned, I start every conversation with the reassurance that chest pain due to a heart issue in kids is just extremely uncommon and rare. So, we're trying to find zebras. And I think that helps just to set the tone, because I think that turns down the temperature and everyone has a story about an uncle or a grandfather or someone who's had a heart attack, and that's what they come in worried about. But if you really look at breakdown, it's probably one of the least common causes. And when we say the heart, we think about rhythm issues, or heart muscle issues, or coronary artery issues. And there's been multiple studies looking at this breakdown and the heart is anywhere from 1-7%. And really, if you take out rhythm issues or pericarditis, you get down to less than 1%. Whereas if we look at all the other causes, significant proportion musculoskeletal between a third to 40%. Gastrointestinal causes about 1%, breathing causes 10-20%, and then this idiopathic bucket being the largest, meaning that we just can't find a clear cause, but we know it's not one of these other things after testing.

Host: Yeah. So, that's really great perspective with respect to that. And I would say that echoes my personal experience, pun intended, on the echo. But in the end, of course, we do want to rule out any real serious cardiac possibility. So, give us a sense of particularly for the primary care pediatrician, what warrants a cardiology referral versus just simply reassurance from the primary care provider?

Dr. Amanda McIntosh: So, I think it's all going to come down to really your history and physical. So, as a cardiologist, I have to make it a cute little mnemonic. So, the one that I use and I teach to learners is PQRST, like the EKG, which is we always use, position, quality, radiation, severity, and timing. But specific to the ones that I worry about, I'm really looking for those that suggest either ischemia, so a coronary insufficiency like an anomalous coronary, or something that suggests a cardiomyopathy, so a hypertrophic cardiomyopathy, dilated cardiomyopathy, or something suggesting kind of arrhythmia.

So, my red flags are really exertional chest pain. And I think everyone knows that, but I think what we don't always do is really get into the nuance of that. So when I, think about exertional chest pain, I think about kind of peak chest pain. So, for an example, a track athlete who their warmup's fine, they're kind of going, and then they push themselves on that last hundred-meter dash, and they get this chest pain right then. But dial it back, it goes away. Versus, the person who may be not very active, sits on the couch, gets up and goes to run. And as they start breathing a little faster, you know, they're like, "My chest kind of hurts." That is exertional chest pain, but it's not that kind of peak chest pain that to me, suggests some sort of like coronary insufficiency, myocardial ischemia. And along with that, that's that kind of anginal pain, the squeezing pressure type pain.

And none of these are exclusive to kind of a cardiac etiology, but these are things that kind of perk my interest. Certainly, any chest pain that precedes syncope would suggest some degree of cardiac insufficiency. I also think really about high level of athletic activity. So, those are the patients that are going to exert themselves to the point that if they have a coronary issue, like an anomalous coronary issue, they're really going to have that squeeze of the coronary to that exercise.

Things like dyspnea or if it's progressive in nature, those are things that make me think about either a hypertrophic cardiomyopathy or a dilated cardiomyopathy. A murmur is not really one of my red flag symptoms, just because they can be so common. And in the most concerning cardiac conditions that could cause chest pain, such as an anomalous coronary artery or a cardiomyopathy, they generally don't have a murmur. So, it's not either a red flag nor a reassuring sign. It's just something to note.

And then, I bring up positional. We typically think about pain that's reproducible being more related to chest wall issues. And pain that's related with breathing or positions maybe less likely to be related to cardiac ischemia or obstruction. But I do take note if it's pleuritic upon a deep breath or worse with lying flat, improved with leaning forward that kind of suggests, either pericarditis or pleuritis. So, those are my things.

And then, I also have some reassuring signs. And, some of my reassuring signs are what I call random timing. So, this is the kids, you talk to them, and they just can't come up with like a specific scenario. If it only lasts a few seconds, kind of unlikely to be worrisome. If there's really no associated symptoms, I think it can be there. But usually, if someone's having cardiac ischemia, they're going to be short of breath. They're going to have that sense of doom. They're not just going to have a chest pain that goes away. I think if it only happens in one setting that's not related to athletics, like if it only happens at school or it only happening at home, I think more of those kind of idiopathic or even, you know, anxiety causes.

And then, one of my recent ones is when someone comes in and says, "This only happens at night when I'm lying in bed." So generally, you're not very active and generally that's going to be a setting where I tend to find the more anxious kiddos, when their body finally calms down from tough day, that's when they start to be more aware of their heart. So, it's actually more of a reassuring sign, not that it makes it any easier to treat, but more reassuring from a heart standpoint. And then, if it tends to shift positions or it's over the lower ribs, those really make me a little less concerned.

Host: Yes. Boy, very comprehensive. That was really great. I'll tell you what I hear from you as you're going through really a good list of questions is that it's like we all learned in med school is that 90% of the diagnosis and/or decision to refer is based on the history. So, taking a good history is important. So, we've gone through a really good history asking all the questions of what causes it, what doesn't cause it, what makes it worse, and those type of things as a positional. Once you kind of get through that, are there some specific tools for screening that providers ought to keep in mind, particularly in the primary care setting?

Dr. Amanda McIntosh: I kind of have two different screening tools I think about. And the first is less specific to chest pain, but I think is more specific to just cardiac risk in general and the otherwise healthy-appearing individual, and that's actually listed on the sport pre-participation exams. It's been green-lighted by both the American Heart Association and the American Academy of Pediatrics. And it's quite sensitive for sport screening, it's not the most specific tool, but it's quite sensitive.

And so, one of the first ones is just related to what I call channelopathy, so arrhythmia diseases related to abnormal cardiac channels that lead to dangerous arrhythmias. And so, it's a four-question screening tool. And I think it's really best performed exactly as it's written, because I think we all tend to ask a version of these. But in my experience, unless you ask them very specifically, you won't elicit the positive result, and I'll give you an example.

So, the first one's pretty straightforward. It says, "Have you ever fainted, passed out, or had an unexplained seizure with or without warning, especially during exercise or response to sudden loud noises, such as doorbells, alarm clocks, and ringing telephones?" And this may seem like hyperspecific, but actually certain types of Brugada syndrome or sodium channelopathies, as we call them, are like specifically elicited or have this kind of seizure history. So, that's where that comes from.

The next one is the one that I think is the trickiest. Have you ever had exercise-related chest pain or shortness of breath? This is going to be very sensitive, but not specific whatsoever. I think a lot of our kids are deconditioned, especially as we get past the age of COVID, when there was a lot of kids who are at home or doing virtual pieces. And then, they're coming back to sports or PE, and they run a mile, and they're like, "My chest hurts," and that's often a deconditioning. And if they're short of breath, again, that's going to be more deconditioning. So, I think that one, you have to think about how you ask it, but it's in the question.

And then, the next are the ones that I really encourage when I speak to trainees to ask very specifically. Because I think if you say the words, "Has anyone in your family ever had a heart problem," you're, A, going to get a lot of less helpful history of folks who've had, heart murmurs, who may have been innocent or folks who've had coronary artery disease in their 70s. But you're also going to maybe miss a wide swath of cardiac history that they didn't really clue in as a heart problem. And so, the way this question is worded is anyone in your immediate family, so first-degree relatives, died of heart problems or an unexpected sudden death before the age of 50. And this is where you say specifically drownings. I used to say single car crashes where they were driving, but I think perhaps in the age of texting and driving that may not be as specific, or sudden infant death syndrome, which I think is what we don't often think of, but that's an important one to ask.

And then, I ask when I ask about cardiomyopathies or inherited channelopathies, I literally say every single condition, because I cannot tell you how many patients have told me, "I don't have any family history." And then, I say a condition and they go, "Oh yeah, someone has that." And so, I think it takes a longer time, but you get more of an extensive history. So I say, "Have you had hypertrophic cardiomyopathy?" I usually say HOCM or HCM. I also say Marfan syndrome or other connective tissue. I say the words prolonged QT syndrome, short QT syndrome, CPVT, or anyone with a pacemaker. And I think this can sound really overwhelming. If you're like, "I'm a primary care doctor, how can I remember all of these?" The good news is you don't have to, like it's listed on a form. And if you make sure that they say this, I think you'll capture them.

Host: There was some really great pearls of wisdom on that one. My learning curve was actually pretty steep on that one. That's really great use of resources as well as just the approach that you're taking. I really appreciate that. You know, in the little bit of time we have remaining, what are some of the basic treatment strategies for the common causes of chest pain, particularly that the primary care, pediatrician is going to be comfortable in implementing.

Dr. Amanda McIntosh: So, one of the number one things that I think could reduce some of my referrals for chest pain that may seem a bit scary but perhaps is not as scary would be thinking about exertional chest pain, because I think one of the knee-jerk or reflex response may be, "Okay, it's exertional chest pain. All exertional chest pain goes to Cardiology." But I think there may be a stepwise approach. So, there hasn't been anything prospective looking at this, but there was this very interesting study a few years ago when they started expanding pediatric bariatric surgery and trying to get that approved with insurance and expand the indication. They had a lot of symptom questionnaires. And they found that before and after pediatric bariatric surgery, exertional chest pain can lead to decrease from 28% to 4%. which I don't think was just the weight loss. I think it also was all the other things related to carrying excess weight, the deconditioning, the decreased activity and all of that. And so, the correlate would be something, you know, they still are the exact same. We didn't change their hearts whatsoever, right? And they didn't have coronary artery disease, but just that decreased their chest pain. And I think anecdotally in my practice, this seems so common, but no one's formally evaluated. So. I would really do a deep dive into, and I know you asked about treatment and I'll get to that, but really trying to find those kids. And so, my clues are short bursts of activity in a relatively inactive kid. So, my clue is always someone who goes to P.E. one to two times per week that semester, but maybe not regular activity or those new to sports. And they are often associated with shortness of breath and lightheadedness. So, maybe starting with like a structured gradual exercise program, eight to 12 weeks and seeing if that makes a change and then referring. I think that would capture a lot of our kiddos.

And I think the second thing would be doing, if you have access in the office to some pulmonary function testing, pre and post exercise, even if it's running outside the building for 10 minutes and coming back in. I think I've had many patients that I've referred for exercise testing that we've found that and, you know, 10% of kids have asthma,. As I said before, less than 1% of kiddos have a heart defect. So, your pre-test probability is just that much higher. So, I think it's just low-hanging fruit.

And I think the other one I wanted to bring up was the costochondritis episodes and just say that my mainstay, if I suspect that, is to do naproxen 500 milligrams twice a day for five days for the teenagers and older kids. For the younger kids, I stick with ibuprofen where you can get solution. In addition, stretching protocols and really doing a very careful chest wall evaluation for pectus, because I have had patients with pectus abnormalities come to see me for chest pain that didn't know they had a pectus. And that we referred them and ended up actually getting surgery which helped their chest pain. But I will say with this note on the flip side of that, if chest wall pain like costochondritis or anything like that doesn't get better after five days of treatment or rest or stretching, that is not costochondritis and you need to think about something else, because I have had patients get started on ibuprofen, not be able to see me for a few weeks and then come in having taken three weeks' worth of NSAIDs, they're on the clock, which none of my kidney colleagues would appreciate. And so, just to kind of make sure you have it in daily, we're going to try this. But if it doesn't help, that's not what this is.

Host: Very good advice, particularly for the primary care pediatrician. So Dr. McIntosh, thank you, so much for that. I have one last question and that is, are you known as that pediatric cardiologist that bikes to work every day? Is that how the fellows refer the to you? That's what I want to know.

Dr. Amanda McIntosh: They've been gaining some videos of me, and I'm pretty sure they are putting it with the background of kind of like the Wizard of Oz, Wicked Witch of the West background. So now, I think it's a game for them to see who can capture a video or a picture of me on the Gillham bike lane.

Host: Perfect. Okay. Well, I'll be real careful to look both ways, as I'm heading out in my car that you're not coming my way on the bike. Well, Dr. McIntosh, thank you again for joining us today. As a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/cmepodcast and click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.