Definition

Angina pectoris is a sensation of pressure or pain in the chest, often accompanied by anxiety. This condition arises when the heart muscles lack oxygen due to reduced blood flow. While angina pectoris in children is rare, it frequently causes concern among parents when their child experiences chest pain. Pediatric chest pain often stems from different causes compared to adults.

Causes

In children, chest pain can be attributed to various factors, including musculoskeletal issues, lung problems, or idiopathic origins (unknown causes with no identifiable issues).

Musculoskeletal issues

Chest pain due to musculoskeletal problems occurs when there are issues with the chest wall muscles. Research indicates that musculoskeletal disorders are the most common cause of chest pain (37.1%).

Lung issues

Chest pain from lung problems can be caused by asthma and pneumonia (lung infections).

Heart disease

Chest pain resulting from heart disease is rare in children. When it does occur, it may be due to inflammation of the heart's lining (pericarditis) or angina pectoris caused by oxygen deficiency in the heart muscles. Certain congenital artery abnormalities can lead to low oxygen levels in the arteries, preventing the heart muscles from receiving adequate oxygen. In other cases, the heart muscles require more oxygen due to thickening, known as cardiomyopathy. Blocked blood vessels from the heart can also force the heart muscles to work harder, leading to thickening.

Narrowing of the arteries due to fatty plaque buildup, common in adults, is exceedingly rare in children. When blood flow is reduced due to artery narrowing, it usually results from diseases involving the arteries, such as:

• Kawasaki disease
• Familial high cholesterol
• Congenital coronary artery abnormalities
• Complications from congenital heart disease affecting the coronary arteries

Risk factor

Risk factors for angina pectoris in children depend significantly on the underlying conditions. For instance, in Kawasaki disease, the occurrence is influenced by age, with children under five years being at the highest risk. Additionally, boys are more commonly affected than girls, and children of Asian Pacific descent, such as Japanese or Korean, are more susceptible. The disease also shows seasonal patterns, more prevalent in North America in late winter and early spring.

Symptoms

Angina pectoris in children typically manifests as chest pain radiating to the left arm or jaw, often described as a heavy, crushing sensation. Breathlessness can occur, but breathing does not exacerbate the pain. The pain is usually dull and difficult to pinpoint, lasting less than five minutes, often triggered by physical activity and relieved by rest or medication.

In children, angina may present with atypical symptoms, such as:

• Irritability or anxiety due to the sensation of angina
• Nausea and vomiting
• Abdominal pain
• Fainting or syncope
• Seizures
• Sudden cardiac arrest

Diagnosis

Diagnosing angina pectoris in children involves a process similar to adults. The doctor will inquire about the history of chest pain and any congenital heart disease. Further examinations may include:

1. EKG (Electrocardiography)
• An EKG monitors the heart's electrical activity. Patches are placed on the chest, wrists, and ankles to detect this activity.
2. Echocardiography
• An ultrasound examination of the heart using sound waves to visualize blood flow.
3. Stress Test
• Assesses heart function before and after physical activity or medication-induced stress, involving treadmill running or cycling.
4. Chest X-ray
• Provides images of the heart, lungs, and other organs in the chest cavity.

Management

Treatment for angina pectoris in children depends on the underlying cause. Generally, it aims to reduce the heart muscles' oxygen demand or enhance blood flow to the heart. Reducing physical activity is one approach, though it has limitations. Medications, particularly nitrates, may be administered to increase blood flow to the heart and reduce the heart's workload by dilating blood vessels and lowering blood pressure.

Angioplasty or Coronary Artery Bypass Surgery (CABG)

In severe cases, surgical interventions like angioplasty or CABG may be necessary. Angioplasty, a non-surgical procedure, involves opening the heart's arteries using a balloon or stent inserted via a catheter. CABG, a surgical procedure, uses a blood vessel from another part of the body (e.g., leg) to bypass a blocked artery, ensuring proper blood flow to the heart muscles.

Medication Therapy

If angina pectoris is due to cholesterol buildup in the arteries, a diet to control cholesterol and fat levels may be recommended alongside cholesterol-lowering medications.

For Kawasaki disease, treatment focuses on managing fever and inflammation, using gamma globulin and aspirin to prevent heart damage. Gamma globulin reduces blood vessel inflammation, while aspirin alleviates pain, joint inflammation, and fever. Post-fever, long-term aspirin therapy may be necessary to prevent blood clots.

Complications

Similar to adults, the primary complication of angina pectoris is a heart attack. In Kawasaki disease, complications can include blood vessel inflammation leading to aneurysms. An aneurysm, where a blood vessel weakens and abnormally enlarges, can rupture, causing life-threatening internal bleeding or a heart attack. Other issues may involve myocarditis (heart muscle inflammation) and heart valve problems.

Warning Signs of a Heart Attack

• Intense, crushing chest pain lasting more than five minutes
• Pain radiating to the shoulders, arms, back, or jaw
• Fainting
• Severe, unbearable pain
• Increased episodes of pain
• Nausea and vomiting
• Stomach pain
• Shortness of breath
• Excessive sweating

If your child exhibits these symptoms, seek immediate emergency medical attention.

Prevention

Preventing angina pectoris in children is challenging, often tied to congenital artery abnormalities or Kawasaki disease, whose precise causes remain unknown. However, understanding your child's specific condition and collaborating with healthcare providers can help mitigate the risk of complications.

When to see a doctor?

If your child reports chest pain, consult a doctor. Based on the symptoms, the doctor can determine if further testing is needed. For Kawasaki disease, symptoms include fever lasting more than three days, body rash, red and watery eyes, dry mouth with swollen tongue, and red, peeling skin on the palms and soles. Prompt medical attention within the first ten days can prevent long-term blood vessel damage.

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