Chest pain in teens: When to worry

Few things can cause a parent’s heart to stand still like having a teenage child complain of chest pain. Unfortunately, it’s a common complaint. According to national data from 2016, people aged 15 to 24 years comprise 14.2% of all emergency room visits and chest pain is one of the top diagnoses.

Many people have experienced chest pain, and a variety of words are used to describe it, ranging from dull to squeezing. There are equally as many causes, the most serious of which usually involve the heart or lungs. Luckily, in teenagers, the most serious are not the most likely.

Frequently, the cause of chest pain in teens is chest wall pain. The chest wall includes the skin, fat, muscles, and bones that form a protective structure around the heart, major blood vessels, lungs, and esophagus. The bones in the chest wall include the ribs, sternum (breastbone), and spine. No wonder there are so many ways to have chest wall pain.

A leading cause of chest wall pain in teens is costochondritis –­­­ inflammation of the cartilage that connects a rib to the sternum, causing sharp chest pain which worsens with a deep breath. Costochondritis usually has no apparent cause and can last for several weeks or longer. Chest wall pain can also result from rib trauma or sore muscles due to chronic pain syndromes like fibromyalgia.

Deeper in the chest is the esophagus, no stranger to chest pain. Teens can have gastroesophageal reflux disease (GERD), which occurs when stomach acid flows backwards and irritates the lining of the esophagus. Symptoms often occur after eating or when lying down at night.

And let’s not forget the mind-body connection; stress, anxiety, and panic attacks can all cause chest pain. Panic attacks are dreadful and include rapid heartbeat, shortness of breath, sweating, nausea, dizziness, and a fear of dying.

Less often, chest pain in teenagers can be related to the lungs, heart, or blood vessels. For example, a pneumothorax is the sudden collapse of a lung without any apparent cause. Symptoms are sudden onset of chest pain and shortness of breath. Pericarditis is inflammation of the membrane surrounding the heart. It causes sharp pain that gets worse with breathing deeply and lying down. Usually a virus is to blame.

When it comes to chest pain, genetics count. Inherited conditions such as the factor V Leiden mutation can lead to a pulmonary embolism - a blood clot that travels from a leg and lodges in a lung. Symptoms include chest pain that worsens with breathing deeply, shortness of breath, and cough.

Hypertrophic cardiomyopathy (HCM) is a usually inherited disease in which the heart muscle becomes abnormally thick. A small number of people with HCM experience chest pain, shortness of breath, or an irregular heartbeat (arrhythmia). Due to the arrhythmia, HCM is the most common cause of heart-related sudden death in athletes and in people under age 30. Any teenager with a family member who has HCM should be screened for it by a cardiologist.

Certain inherited syndromes including Marfan, Ehlers-Danlos, and Turner can lead to aortic root dissection, another life-threatening condition that causes chest pain. In aortic root dissection, the inner layers of the main artery of the body separate. The aorta then ruptures causing sudden severe chest pain with a tearing or shearing sensation.

My advice: Even though chest pain in teenagers is usually not serious, it’s important to take it seriously. If it’s severe and sudden, please call 911 or go to the nearest emergency room. Otherwise, make an appointment for your teen’s primary care provider (PCP) to do a complete history and physical examination. The PCP might order tests such as an EKG or chest x-ray and/or refer your teenager to a cardiologist.

Rima Himelstein is a pediatrician and adolescent medicine specialist at Nemours/Alfred I. duPont Hospital for Children.