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Chest Pain Referral Guidelines

Chest pain is a common complaint in pediatrics but infrequently caused by a cardiac problem. Standardized Clinical Assessment and Management Plans (SCAMPs®) is a quality improvement tool aimed at reducing practice variation, decreasing unnecessary utilization of resources, and improving patient care and outcomes. A SCAMPs® for the evaluation of chest pain in a pediatric cardiology clinic for children between 7 to 21 years of age was designed. Over the 4 year SCAMPs® period, cardiac cause of chest pain was identified in 8/3167 (0.25%; 95% confidence interval [CI] = 0.11% to 0.50%) patients. In this cohort the presence of any red-flag criteria identified patients with a cardiac cause of chest pain with 100% sensitivity. The SCAMPs® methodology gives primary care providers evidence-based guidelines to better assess the child who presents with chest pain rather than immediately sending the child to a cardiology consultations.

Initial Evaluation and Management

Initial Evaluation

  • Detailed history of the event, past medical history and family history
  • Physical examination

Initial Management

  • In the absence of medical red-flag criteria, children presenting with chest pain ought to be reassured that their heart is healthy and that there is no need for any further cardiac workup. The pediatrician is encouraged to investigate and treat non-cardiac etiology (ex. asthma, exercise-induced asthma, costochondritis, musculoskeletal, panic disorder, gastroesophageal reflux disease).
  • Patients with medical red-flag criteria for referral ought to restrict exercise until fully evaluated by cardiology. It’s to be noted that a normal chest X-ray and/or electrocardiogram (ECG) does not rule out cardiac disease and is not a substitute for a full cardiology evaluation in the patient who has medical red-flag criteria for referral.

When to Refer

Red flag for referrals (Harahsheh et al. Clinical Pediatrics (Phila). 2017 Jan 1) 

Patient History

  • Chest pain with exertion
  • Exertional syncope
  • Chest pain that radiates to back, jaw, left arm or left shoulder
  • Chest pain that increases with supine position
  • Chest pain temporally associated with fever (> 38.4°C)
  • Syncope with no warning, sudden onset 

Past Medical History*

  • Hypercoagulable state
  • Arthritis/vasculitis
  • Immobilization
*Chest pain SCAMPs® excluded patients with known cardiac disease which otherwise would have represented a red-flag for referral.

Family History 

  • Sudden unexplained death
  • Cardiomyopathy
  • Hypercoagulable state

Physical Examination

  • Respiratory rate > 40 bpm
  • Temperature > 38.4°C
  • Ill-appearing
  • Painful/swollen extremities
  • Non-innocent murmur
  • Distant heart sounds
  • Gallop to suggest heart failure
  • Pulmonic component of S2
  • Pericardial friction rub
  • Peripheral edema

How to Refer

  • Cardiology Administration: 202-476-2020
  • Administration Fax: 202-476-5700
  • Evenings and Weekends: 202-476-5000
  • Nurse Triage Line: 202-476-4809
  • Appointment line: 202 576 2090

If you have a question about referral criteria please email Ashraf Harahsheh, M.D., F.A.C.C., F.A.A.P.

What to Expect from a Visit to Children's National

  • Detailed history of the event, past medical history and family history
  • Focused physical examination
  • Possible ECG
  • Possible echocardiogram
  • Possible stress test

Fax Referrals

Allergy and Immunology Clinic Physical Exam

Fax referrals at 202-476-7651. For assistance or more information, call Michelle Durham at 301-572-3075.

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Liaisons respond to concerns, actively seek feedback from staff and work with practices in the community to ensure that referral processes are convenient and operating well.

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