Choosing Wisely:

Don’t order an echocardiogram for the routine evaluation of pediatric chest pain in the absence of a concerning history or ECG abnormalities.

Rationale and Comments: Chest pain is a common presenting symptom in pediatrics but is rarely life-threatening, and the vast majority of cases are not cardiac in origin. Therefore, the addition of an echocardiogram only adds diagnostic value in very limited circumstances and increases the cost of care. If the patient has a concerning personal history (exertional chest pain with an abnormal ECG) or family history of sudden or unexplained death or cardiomyopathy or ECG abnormalities, consultation with a pediatric cardiologist is generally recommended prior to obtaining an echocardiogram. Therefore, it is important to obtain a complete personal and family history,* physical examination, and screening ECG, if the treating physician feels that the chest pain is cardiac in nature, prior to proceeding with cardiac consultation and echocardiography. (*Family history should assess specifically for the following types of cardiovascular diseases: connective tissue disorders; cardiomyopathies; arrhythmias, including need for pacemaker or defibrillator implantation; storage diseases; sudden unexplained death; premature cardiovascular disease prior to the age of 50 years.)
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Cardiology and Cardiac Surgery
  • Sources:
  • Expert consensus
  • Disciplines:
  • Pediatric
  • Cardiovascular
  • References: • Campbell RM, et al. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol. 2014;64(19):2039-2060.
    • Friedman KG, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011;128(2):239-245.
    • Chamberlain RC, et al. Evaluating appropriate use of pediatric echocardiograms for chest pain in outpatient clinics. J Am Soc Echocardiogr. 2017;30(7):708-713.
    • Nguyen T, et al. Application of the pediatric appropriate use criteria for chest pain. J Pediatr. 2017;185:124-128.

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