Running head: PEDIATRIC CHEST PAIN

Pediatric Chest Pain:

Body Mass Index Effect on Exercise Stress Test Findings
Anna Howery
Carroll University

PEDIATRIC CHEST PAIN

Pediatric Chest Pain:

Body Mass Index Effect on Exercise Stress Test Findings
The increasing prevalence of children presenting with chest pain has become a relatively
common complaint. According to Anwar and Kavey (2012), chest pain in pediatrics accounts for
six in every 1000 emergency department or clinical visits. Due to an increase of pediatric
patients presenting with chest pain, over the past decade the role of the pediatric exercise
physiology laboratory has expanded (Paridon et al., 2006). According to Anwar and Kavey
(2012), children are reporting missed school time and restricted activity due to chest pain. It was
reported that approximately 50% of children reported missed school time and 69% of
adolescents reported restricting their own activity due to chest pain. When children present with
exertional chest pain, palpitations, lightheadedness or syncope and have no known congenital
heart defects, it is estimated that 29% of patients are referred to an exercise physiologist for
exercise stress testing (Verghese et al., 2012). Technological advances in noninvasive imaging
have allowed for the study of structural and functional properties of the arterial system.
According to Lambiase, Dorn and Roemmich (2012), this noninvasive approach is currently
being used for the adult population, but it can also be used in pediatrics to identify those children
who are at a greater risk for developing cardiovascular disease throughout their life.
According to Thull-Freedman (2010), children under the age of 18 presenting to the
emergency department with chest pain had a median age of 12 to 13 years old. For these
children, the reported male to female ratio ranges from 1:1 to 1.6:1, indicating a fairly even ratio.
It has been reported that the majority of children that present to the emergency department with
chest pain have had the pain for less than one day in duration. According to The Childrens
Hospital of Philadelphia (2013), many different factors can cause children or adolescents to
experience chest pain. Many times, the chest pain they are experiencing is not specifically due to
heart problems, but due to other morbidities such as obesity. As a large number of children
present to their pediatric cardiologist with chest pain, it is important to determine a useful and
cost effective approach to assist in determining the cause of their chest pain. Throughout the
present study, the use of BMI classification will be explored to determine its effectiveness in
diagnosing chest pain in children.
Literature Review
When a child or adolescent presents to a physician with chest pain, they are referred to a
pediatric cardiologist for further testing. The pediatric cardiologist will likely perform multiple
tests to determine the cause of the chest pain. Testing includes an electrocardiogram, an
echocardiogram, Holter monitoring and an exercise stress test. Initially, a pediatric cardiologist
will attempt to eliminate specific etiologies. This includes, previously undiagnosed structural
abnormalities associated with ischemic pain, acquired myopericardial or coronary disease and
arrhythmias with palpitations, which may be described as pain by the child (Anwar & Kavey,
2012). A patient with a history of exertional chest pain associated with palpitations,
lightheadedness or syncope will likely be referred to an exercise physiologist for exercise stress
testing. An exercise stress test can provide the pediatric cardiologist with information regarding
the hearts rhythm during exercise, information regarding the hearts blood supply and if normal
changes in heart rate and blood pressure are occurring throughout exercise. Many times when an
adult presents with chest pain, it indicates a significant cardiac problem, whereas in children,

PEDIATRIC CHEST PAIN

some of the most common etiologies of chest pain include musculoskeletal and pulmonary
causes (Friedman et al., 2011).
Exercise Stress Testing. In a retrospective chart review performed by Anwar and Kayey
(2012), the results of exercise stress tests in which children presented with chest pain were
reviewed. Participants were aged six to eighteen years of age. Data was reviewed from exercise
stress tests that occurred from 2003 to 2007. Each of the participants presented with a chief
complaint of chest pain and were referred by their pediatric cardiologist to participate in an
exercise stress test. For the study, exclusion criteria included those who were found to have
hemodynamically significant heart disease or gave an inadequate effort during exercise testing
defined as maximal heart rate <90% of predicted maximum for age/sex or a respiratory quotient
<1.1. For each of the exercise tests, the following information was collected from the
participants: age, sex, weight, height, BMI, body surface area, chest pain history: location,
quality, severity, chronicity, duration, radiation, chest pain with exercise, syncope or palpitations
with chest pain, family history of cardiac illness/sudden death and results of all cardiac testing.
For the study, treadmill exercise testing was performed according to the standard Bruce
protocol. According to the American Heart Associations statement regarding pediatric clinical
exercise stress testing, the Bruce protocol has normative data on exercise response and endurance
times for children aged four to fourteen years of age (Paridon et al., 2006). An advantage of
using the Bruce protocol is that it can be used for subjects of all ages. Therefore, as a child
grows, the Bruce protocol can continually be used as a means for comparison between testing
results. (Paridon et al., 2006). Of the participants, 118 patients met inclusion criteria for review.
The mean age of participants was 13.3 years. Of the participants, 64% were male. For each of the
participants, descriptive chest pain information was recorded. This included: occurrence (88% of
participants exertional chest pain), duration (25.4% of participants less than 10 minutes), quality
(38% of participants sharp pain), associated symptoms (21% of participants palpitations),
location (36% of participants substernal), and chronicity (30% of participants greater than 6
months). In this study, pulmonary function testing was only performed if requested by the
cardiologist.
After review of each of the participants exercise tests findings, results of the study
indicated that one participant had significantly prolonged QT intervals, while another had EKG
findings suggestive of Wolff Parkinson White with QRS normalization during exercise and no
manifest tachyarrhythmia. Of the participants, 96% of children had echocardiograms performed
and 90% were interpreted as normal. Eleven of the participants had minor, hemodynamically
insignificant abnormalities identified. All participants had normal heart rate and blood pressure
responses during exercise. Of the participants, 25% experienced chest pain during the exercise
stress test, while in 28 of these participants the EKG remained normal. Three of the participants
displayed ST changes during exercise. Thus further testing was performed, which included
myocardial perfusion imaging. Results from the myocardial perfusion imaging were normal,
therefore suggesting that exercise stress test results displayed a false positive. Of the participants
who completed the pulmonary function test, 28% of participants displayed an abnormal result,
indicating reactive airway disease or exercise-induced asthma.
The findings from this study confirmed the results of previous studies, indicating that the
majority of children with chest pain who participate in exercise testing will have normal cardiac
results. Although historically chest pain has been associated with symptoms of cardiac disease,
this study was not able to demonstrate that concept. Therefore the results of this study suggest
that exercise testing has minimal utility in the work-up of pediatric chest pain. Although cardiac

PEDIATRIC CHEST PAIN

abnormalities were not displayed in this study, of the children who completed the pulmonary
function screening, 30% of participants displayed results indicative of reactive airway disease or
exercise-induced asthma. Therefore, it can be concluded from this study that pulmonary function
testing should be routinely obtained with exercise stress testing in order to rule out cardiac
abnormalities.
As previously discussed, the number of children who present with chest pain and actually
have cardiac disease is relatively low (Danduran, Earing, Sheridan, Ewalt & Frommelt, 2008).
As a result of these findings, much debate has occurred regarding resource utilization. According
to Danduran et al. (2008), some health care professionals find exercise stress testing to be a
nondiagnostic, costly and burdensome test for patients. A study by Danduran et al. (2008) was
performed to determine the effectiveness of stress testing in determining a cause of chest pain in
children and adolescents presenting to a pediatric cardiologist. A retrospective chart review was
performed for patients between five to twenty-two years of age. A group of 263 participants took
part in the study having a mean age of 13.4 years old. Exercise stress tests occurred between
2003 and 2005 for patients being referred for assessment of potential cardiac etiology, including
arrhythmia or ischemia. For this study, exclusion criteria included those with known congenital
heart disease.
For this study, exercise testing was performed using the standard Bruce protocol.
Participants took part in the test until they reached voluntary exhaustion. As a part of the Bruce
protocol, incremental increases in speed and grade occur throughout the duration of the test. A
test was considered maximal if (a) peak heart rate exceeded 90% of age predicated maximum,
(b) a plateau occurred in oxygen consumption that did not rise with increasing work or (c) the
respiratory quotient exceeded 1.10. Participants also took part in pulmonary function testing.
Using a spirometer, FVC, FEV1, PEFR and FEF25-75 was obtained. Echocardiograms were also
performed at rest on 70% of participants. No significant cardiac abnormalities were identified in
the participants.
Upon completion of participant exercise stress testing, results from pulmonary function
testing found that 26% of participants showed abnormal baseline pulmonary status as defined by
a reduction in FEV1 and FEF25-75. For these participants, a bronchodilator was given, which
resulted in significant improvements in FEV1 and FEF25-75. Based on these findings, baseline
pulmonary testing has been found to be helpful in distinguishing symptoms among patients.
Therefore, for patients who are presenting with chest pain, participation in an exercise stress test
along with pulmonary function testing can assist in determining the cause of the chest pain.
As a part of this study, racial differences were also analyzed. It was found that Hispanic
participants displayed decreased endurance times when compared to Caucasian and African
American participants. VO2/kg was found to be significantly reduced in African American and
Hispanic participants. The author attributed these decreases to economic disparities between
participants. It was discussed how minority individuals have less access to health care resources.
Also, these individuals could have less access to healthy nutritional options, which could
influence their BMI.
Results of this study suggest that the etiology of chest pain in the absence of cardiac
pathology can be multifunctional and could reflect underlying patient morbidities. Through the
data collected for this study, it was found that a comprehensive exercise assessment is
informative in identifying reactive airway disease, poor physical condition, obesity and age
contributing risk factors for chest pain symptoms. As the researchers concluded, deconditioning
and respiratory compromise influenced the development of chest pain in children and

PEDIATRIC CHEST PAIN

adolescents. By having children take part in exercise stress testing to evaluate their symptoms of
chest pain, it can provide the pediatric cardiologist with information regarding the cause of the
chest pain.
Exercise Test Protocol. In the two previous studies, the Bruce protocol was selected for
exercise stress testing in children presenting with chest pain. Originally the Bruce protocol was
designed to diagnose coronary artery disease in adults. During the last decade, the Bruce protocol
for exercise testing in the pediatric population has gained great popularity among pediatric
cardiologists (Parison et al., 2006). One of the advantages of this protocol is the presence of
normative data for individuals of all ages. Therefore this protocol can be used throughout ones
lifetime for means of comparison. Through the use of this protocol, the cardiologist is provided
with comparative exercise data, which can be used and referred to as the child grows.
According to van et al. (2010), the Bruce protocol can effectively be used for children as
young as four to five years of age. Prior to this study, reference values for children had only been
established in multiple small-scale studies and one large-scale study. According to van et al.
(2010), many of these studies were performed over 30 years ago. The researchers believe that
exercise capacity has begun to deteriorate over the last 30 years. A large gap between the most
conditioned and deconditioned children has begun to form. Currently, children have higher BMI
values than in the past, but also intense sports participation has increased over time, therefore
influencing endurance times for childrens norms.
Van et al. (2009), attempted to determine new reference values for exercise testing for
children ages 6-13. Participants took part in the Bruce protocol. A total of 53 children took part
in the study. The maximal endurance time on the treadmill was the sole criterion of exercise
capacity for the participants. Results of the study indicate that children aged up to 10 years old
performed at a lower maximal endurance than previously published in the literature. However,
values obtained for children older than 10 were similar to previously published values. It is
believed that a decline in maximal endurance occurred for children under the age of 10 due to the
increased prevalence of obesity along with lower levels of physical activity. Therefore the results
of this study indicate that in order to obtain optimal results, it is important to establish norms
specifically for the population for which one is working with. Norms should continue to be
updated based on the society and the environment the participant is living in.
Although the previous study was able to produce more relevant reference values for the
current population, disadvantages of the Bruce protocol continue to exist. According to Parison
et al. (2006), for younger children, the work increments between stages may be too great,
resulting in children stopping the test during the first minute of a new three-minute stage. If a
child is stopping too soon, vital information pertaining to their chest pain may not be obtained.
On the other hand, for subjects that are well trained, the first four stages of the protocol are too
slow, leading to boredom, therefore early exercise test dropout may also occur. Although the
Bruce protocol is useful in determining if cardiac abnormalities are occurring while an individual
is exercising, there are disadvantages associated with the protocol, which may cause inaccurate
results to occur.
Standardized Clinical Assessment and Management Plan. Many times when children
present with chest pain, they are referred to a pediatric cardiologist. At this time, the cardiologist
will likely order additional testing to assist in determining the cause of the chest pain. As
discussed previously, many children will be referred for an exercise stress test. A resting
electrocardiogram, echocardiogram and cardiac MRI are also ordered. As previous studies have
shown, participation in exercise stress testing does not provide the pediatric cardiologist with

PEDIATRIC CHEST PAIN

conclusive evidence regarding the cause of chest pain. Therefore, more cost-effective diagnosis
methods have been studied. In a study by Friedman et al. (2011), a retrospective chart review
was performed for patients aged seven to twenty-one years of age. Exclusion criteria included
those with a known heart disease or those who have previously been seen by a pediatric
cardiologist. Clinical characteristics along with demographic information were collected for each
participant. These included: past medical history, family history and presenting symptoms,
including chest pain characteristics and associated symptoms. Participants also had results from
an ECG, echocardiogram, cardiac MRI and exercise stress test as apart of their medical record.
According to the demographics of the study, 51% of participants were males, while the
median age of participants was 13.7 years old. Of the participants, 37% presented with exertional
chest pain, while 16% presented with associated palpitations. In the study, 6% of participants
presented with abnormal electrocardiogram findings. Based on these results, an algorithm was
created for determining which tests would be most beneficial for individuals to participate in.
According to Friedman et al. (2011), the Standardized Clinical Assessment and Management
Plan (SCAMP) was created with the goal of decreasing practice variation, improving patient care
and reducing unnecessary resource utilization. As part of the algorithm, patient history, physical
examination and ECG results were used to suggest when additional testing should be performed.
The results of this study indicated that of the participants, only 1% presented with a
cardiac etiology for chest pain. The findings of this study are consistent with previous studies
showing that cardiac etiologies for pediatric chest pain are rare. As mentioned previously,
extensive and costly cardiac testing is common in children who present to their physician with
chest pain. Therefore it is believed by the authors that a 21% reduction in medical charges could
occur if the algorithm is followed in diagnosing chest pain. As a result of the study performed by
Friedman et al. (2011) and findings from previous studies indicate that exercise stress testing has
little influence in determining the cause of chest pain in children, further studies need to be
performed to determine if other factors such as a childs weight can influence their development
of chest pain.
Obesity in Children. The increasing prevalence of obesity in children and adolescents is
associated with both long and short-term health consequences (Oude Luttikhuis, 2008). It is
estimated that two-thirds of US children aged two to nineteen are classified as overweight or
obese (Larson, 2012). According to Thivel, Blundell, Duche and Morio (2012), imbalance
between energy expenditure and energy intake is the main factor accounting for the progression
of obesity. Therefore when obese children participate in physical activity, it can be challenging
and very fatiguing for them. In some cases, these individuals develop chest pain while
exercising. This chest pain could be due to being obese and deconditioned or it could be due to a
cardiac etiology. It will be important to determine the influence an individuals BMI has on the
results of their exercise stress test when these individuals present with chest pain.
According to McDonnell and White (2010), patients with chest pain who are overweight
may benefit from lifestyle interventions to assist in decreasing their symptoms and risk factors.
Children who are overweight are at a significantly higher risk for coronary artery disease
(McDonnell & White, 2010). In a study by Vetter, McDaniel, Dugan, Haley, Cosgriff and Shults
(2014), it was analyzed whether electrocardiograph values correlated with echocardiograph left
ventricular geometry and mass in obese children. In the study, participants were aged 5 to 19
years old. Participants medical history, blood pressure, BMI, cardiac exam, ECG and ECHO
results were obtained. In participants, ECG left ventricular hypertrophy (LVH) values in lead V6
were compared to LVH ECHO measurements. The purpose of this comparison was to determine

PEDIATRIC CHEST PAIN

if an individuals ECG abnormalities associated with obesity could be used to predict early
cardiac effects later associated with adult onset cardiac disease. Results of this study found ECG
V6 QRS areas significantly correlated with ECHO measurements for LVH. Also, all ECHO
measurements of LVH correlated with BMI. When an overweight child presents to their pediatric
cardiologist with chest pain and an ECG is performed as a baseline test, this test could be used to
assist in identifying those children who are at the greatest risk for future coronary artery disease.
If no cardiac etiology is determined as part of the testing, it may be recommended that lifestyle
interventions such as increased physical activity and dietary changes occur. These lifestyle
changes could assist in decreasing their symptoms associated with chest pain along with
decreasing their risk for future cardiac disease.
Therefore, in order to better understand the cause of pediatric chest pain, the purpose of
this study is to evaluate the effect of an individuals BMI on exercise stress testing results. Sex
and age will also be studied as secondary factors. Based on the findings of this study, when a
child presents with chest pain and their BMI is considered and categorized as underweight (BMI
5th percentile for children of the same age and sex), healthy weight (BMI 5th percentile and
85th percentile for children of the same age and sex), overweight (BMI 85th percentile and
95th percentile for children of the same age and sex) and obese (BMI 95th percentile for
children of the same age and sex), less costly testing may be ordered to determine the cause of
their chest pain (Centers for Disease Control and Prevention, 2011). By participating in less
costly testing, it can be less burdensome for the family and help to decrease the amount of
unnecessary testing ordered. It is hypothesized that for subjects presenting with chest pain, there
will be differences between participants BMI classification and exercise stress test results.
Methods
The exercise stress test is commonly used as a diagnostic tool for pediatric patients who
present to their physician with chest pain. According to Stephens and Paridon (2004), the
exercise stress test is commonly used to evaluate specific symptoms or signs induced by
exercise. As previous research has shown, there is controversy regarding the effectiveness of the
exercise stress test for diagnosing chest pain in pediatric patients. According to Saleeb, Li,
Warren and Lock (2011), chest pain due to a cardiac etiology is relatively rare in children. As
part of this study, a childs exercise stress test results along with BMI classification will be
analyzed. Based on the findings of this study, in future patients, a childs BMI classification
could assist in the determination of their chest pain etiology.
Participants. A retrospective chart review was performed of all patients 7 to 18 years of
age seen in the Heart Center clinic between June 1, 2013 and June 1, 2014 at Nationwide
Childrens Hospital. Each subject presented with a chief complaint of chest pain. Each of these
subjects were classified as (1) underweight, having a BMI less than the 5th percentile for children
of the same age and sex, (2) healthy weight, having a BMI greater than the 5th percentile and less
than the 85th percentile for children of the same age and sex, (3) overweight, having a BMI at or
above the 85th percentile and lower than the 95th percentile for children of the same age and sex,
or (4) obese, having a BMI at or above the 95th percentile for children of the same age and sex
(Centers for Disease Control and Prevention, 2011). Subjects will be determined based on a
search of the exercise lab log along with a review of the subjects chart using Epic systems.
Patients were excluded from the review if they were found or known to have congenital heart

PEDIATRIC CHEST PAIN

disease or inadequate effort on exercise testing defined as maximal heart rate 85% of predicated
maximum for age or respiratory exchange ratio (RER) 1.1.
Review of the patients electronic patient record from visit for exercise stress testing and
associated result occurred. The following information was collected from all patients: (a) patient
demographics: age, sex, height, weight, body mass index and 12-lead electrocardiogram (b)
exercise stress testing results: peak heart rate, relative peak VO2, and RER.
Exercise Laboratory Procedures. All patients were tested during an outpatient visit.
Standard pretest instructions were given to each patient. Pretest instructions are presented in
Appendix A. Consent to participate in the exercise stress testing was obtained prior to beginning
the test. Prior to each exercise stress test, anthropometric measurements and a resting EKG were
obtained. The process used for each of these measurements will be discussed in the following
sections.
Anthropometric measurements. Height, weight, and body mass index (BMI)
measurements were obtained to determine normalizing factors. Height was measured to the
nearest 0.01 cm using a mechanical telescopic measuring rod (Seca, Chino, CA). Weight was
measured to the nearest 0.1 kg using an digital scale (Seca, Chino, CA). Participants removed
their shoes prior to obtaining their height and weight and were wearing clothing that would be
worn throughout the exercise stress test. BMI was calculated using participants height and
weight measurements (kg/m2). When BMI is accurately measured in children and compared with
appropriate growth charts based on age and sex, BMI can be an excellent indicator of the
presence of obesity (Himes, 2009). According to Himes (2009), all measurements will be
recorded with some error, but if measurements are standardized, reliable and valid measurements
can be obtained. Based on the previous measurements, participants will be classified as
underweight, healthy weight, overweight or obese.
Resting electrocardiogram. A resting 12-lead electrocardiogram (EKG) (Case, GE
Healthcare Worldwide, Waukesha, WI) was also obtained. According to Hanson and Hokanson
(2011) obtaining and interpreting EKGs on pediatric patients can be challenging, as challenging
results are likely obtained. In a study by Hanson and Hokanson (2011), children presenting with
chest pain were referred for EKG testing. When initial EKGs were performed, abnormal or
possibly abnormal results may be obtained. When testing was repeated, normal results were
obtained. Therefore, a resting EKG may produce conflicting and unreliable results. When this
occurs, additional testing such as an exercise stress test may be ordered to determine the cause of
the chest pain.
Exercise testing. Exercise stress tests were performed using a standard Bruce protocol on
a treadmill. Sequence of events included obtaining blood pressure, heart rate, and a 12-lead EKG
every three minutes throughout the testing. Upon completion of the test, peak VO2, respiratory
exchange ratio and peak heart rate were collected.
Exercise protocol selection. According to Bruce, Knsumi and Hosmer (1973), this
multistage treadmill protocol is used to estimate the VO2max of active and sedentary males and
females, cardiac patients and elderly patients. The Bruce protocol can also effectively be used for
children as young as four to five years of age (van et al., 2010). An advantage of this protocol is
that normative data exists for individuals of all ages and thus can be used for stress testing in
children. As the child grows, the pediatric cardiologist then has data that can be compared from
one test to the next. According to the ACSM (2014), as the speed and grade increase every three
minutes, the Bruce protocol employs relatively large increments in workloads of two to three

PEDIATRIC CHEST PAIN

METs during each stage. According to Bruce et al. (1973), progressive increments in workload
every three minutes to maximal exertion are a reliable method of measuring VO2max.
Exercise testing data. Throughout the exercise stress test, heart rate was obtained every
30 seconds and blood pressure and a 12-lead EKG was obtained every three minutes or at times
of arrhythmia presentation. Oxygen consumption (VO2) was determined (CareFusion
Corporation, San Diego, CA) and computer recorded on a breath-by-breath analysis. Peak VO2
was recorded (ml/kg/min). According to Paridon et al. (2006), the use of a metabolic cart in
pediatric exercise laboratories has led to reliable oxygen consumption data along with data
related to VO2max. A test was considered maximal if peak heart rate 85% of predicated
maximum or their respiratory exchange ratio (RER) 1.1.
Data Analysis
Analysis of data will occur for those who completed an exercise stress test and their
maximum peak heart rate 85% of predicted maximum or their respiratory exchange ratio
(RER) 1.1. Descriptive statistics, which include mean standard deviation, will occur based on
a participants gender (male/female). Descriptive statistics will include number of participants,
age, height, weight, BMI, peak VO2, peak HR, and respiratory exchange ratio. Participants will
also be classified based on their BMI classification (underweight/healthy
weight/overweight/obese) when compared to their exercise test results. One-way ANOVA will be
used to determine differences among BMI classification, comparing each category to exercise
stress test peak VO2 results. Analysis will be performed with Microsoft Excel (Microsoft
Corporation, Redmond, WA). Statistical significance will be defined as P <0.05.
Results
Between June 1, 2013 and June 1, 2014, a total of 87 patients between the ages of 7 and
18 years met eligibility criteria. Each of these participants presented with a chief complaint of
chest pain. Patient demographics are summarized in Table 1. Sixty-six of the participants in the
study were male. The average age of male participants was 13.8 years, whereas the average age
of female participants was 13.6 years. Male participants had an average BMI of 21.8 kg/m2,
whereas female participants had an average BMI of 22.3 kg/m2.
TABLE 1. Patient demographics.
Variable
Males
Number
66
Age (y)
13.8 (8-18)
Height (m)
1.64 0.15
Weight (kg)
60.4 19.4
Body Mass Index (kg/m2)
21.8 4.50

Females
21
13.6 (8-17)
1.60 0.11
57.7 11.2
22.3 2.80

Years (y), meters (m), kilograms (kg)

Anthropometrics. A total of 13% of participants were classified as being obese (defined

as BMI 95th percentile for children of the same age and sex) with 19% of participants being
classified as overweight (defined as BMI 85th percentile and 95th percentile for children of
the same age and sex). A total of 59% of participants were classified as a healthy weight (defined

PEDIATRIC CHEST PAIN

10

as BMI 5th percentile and 85th percentile for children of the same age and sex). No
participants met underweight criteria. Results are displayed in Table 2.
TABLE 2. BMI classification.
Variable
Patients with Chest Pain (N = 87)
BMI Classification, n (%)
Underweight
0 (0)
Healthy Weight
59 (68)
Overweight
17 (19)
Obese
11 (13)
Exercise stress test results. Exercise data for males showed an average peak VO2 of 53.6
ml/kg/min, whereas females had an average peak VO2 of 45.6 ml/kg/min. For peak heart rate
achieved, males showed an average of 196 bpm, whereas females showed an average of 189
bpm. Results are displayed in Table 3.
TABLE 3. Exercise stress test results.
Variable
Males
Peak VO2 (ml/kg/min)
53.6 11.21
Peak Heart Rate (bpm)
196 11.1
Respiratory Exchange Ratio 1.11 0.04

Females
45.6 7.3
189 37.7
1.12 0.06

Milliliters (ml), kilograms (kg), minute (min), beats per minute (bpm)

Peak VO2 and BMI classification. An average peak VO2 for healthy weight participants
was 54.8 ml/kg/min. Overweight participants had an average peak VO2 of 43.9 ml/kg/min. Obese
individuals had the lowest average peak VO2 of 41.6 ml/kg/min. Results are displayed in Table 4.
The relationship between average peak VO2 and BMI classification for participants is shown in
Figure 1.
TABLE 4. Distributions by BMI classification.
Variable
Count Average Peak VO2
(ml/kg/min)
Healthy Weight
59
54.8
Overweight
17
43.9
Obese
11
41.6

Variance
89.6
96.4
50.7

Milliliters (ml), kilograms (kg), minute (min)

Discussion
Chest pain is a common referral for the pediatric cardiologist. It has been well
documented in the literature that the presence of true cardiac disease in children presenting with
chest pain is relatively rare (Danduran et al., 2008). Many studies have tried to identify the
etiology of chest pain in children and adolescents. According to Danduran et al. (2008), when
cardiac disease is dismissed, the question of when to refer, when to reassure, and when to
use diagnostic evaluation is a controversial discussion. This review suggests that the etiology of
chest pain in the absence of cardiac pathology may be related to patient morbidities, such as
obesity. It was found that in the presence of an exercise stress test, a patients peak VO2 and BMI

PEDIATRIC CHEST PAIN

11

FIGURE 1Change in average peak VO2 based on body mass index (BMI) classification for
children aged 7 to 18 years with chest pain.
classification could assist in identifying the source of their chest pain. It was found that
participants with a BMI classification of overweight and obese, were found to have a lower
average peak VO2 than participants classified as a healthy weight. It is suggested that overweight
and obese patients have poor physical conditioning.
The American Heart Association recognizes the incidence of overweight and obese
children as an epidemic. Each year, millions of dollars are allocated to numerous prevention
programs to assist in preventing future cardiac disease. According to Heidenreich et al. (2011), if
similar childhood obesity trends continue, by 2030, it is projected that direct medical costs for
cardiovascular disease will cost $818.1 billion. In a study by Lloyd-Jones et al. (2010), the
substantial burden of obesity and adverse health behaviors and environment, which many times
begin in childhood are also discussed. Obesity in childhood can lead to an increased risk for
obesity in adulthood, as these adults are at an increased risk for metabolic syndrome, type II
diabetes, early-onset coronary artery disease and hypertension. This retrospective chart review
found that 13% of participants were classified as obese (defined as BMI 95th percentile for
children of the same age and sex) with 19% of participants being classified as overweight
(defined as BMI 85th percentile and 95th percentile for children of the same age and sex).
According to Larson (2012), it is estimated that two-thirds of US children aged two to nineteen
are classified as overweight or obese. As not all of these children have experienced chest pain, it
is very likely that values obtained from the present study are similar to the national average,
approximately one-third of participants in the study were classified as overweight or obese.
This study demonstrates that 32% of patients who experienced symptoms of chest pain
were classified as overweight or obese. It was also found that on average, participants classified
as obese (41.6 ml/kg/min) and overweight (43.9 ml/kg/min) had a lower average peak VO2 than
healthy weight (54.8 ml/kg/min) patients. This information, although speculative, suggests that
patients with increased BMIs perceive signs and symptoms of reconditioning as chest
discomfort. According to Danduran et al. (2008), this leads to a progressive cycle of chest pain
complaints, parental concerns, parental limitations in exercise, increasing weight gain/sedentary
lifestyle and then adult morbidities.
Based on the suggestive results of this study, children who experience chest pain and
have a BMI that is classified as overweight or obese may not need to participate in extensive
testing such as an exercise stress test. As children who present with chest pain very rarely have a

PEDIATRIC CHEST PAIN

12

cardiac etiology for their chest pain, it is suggested that pediatric cardiologists use the SCAMP
algorithm when determining the cause of chest pain. This approach uses only minimal resources,
which can be a cost-effective approach for families. When this approach was implemented at
Boston Childrens Hospital, of the 1016 participants with chest pain, only two were found to
have a cardiac etiology (Angoff et al. 2013). Based on the findings of this study and studies that
have effectively implemented the SCAMP algorithm, it is suggested that for children presenting
with chest pain and are classified as overweight or obese be evaluated using SCAMP in order to
determine the cause of their chest pain.
Limitations. Limitations of this study include its retrospective design and relatively
small sample size. For this study, data was only reviewed for one year in duration. During this
time frame, only 87 patients met eligibility criteria. In a future study, it would be recommended
to perform a study with a larger sample size to confirm these findings. Another limitation of this
study is that multiple health care professionals were conducting the testing. Therefore, based on
the health care professional conducting the testing, some patients could have been encouraged to
participate longer in the test. Thus, higher peak VO2 values could be obtained. It would be
recommended that a prospective study be performed in the future with one health care
professional performing the testing.
Conclusion
In conclusion, the present study suggests that BMI classification could be used to assist
pediatric cardiologists in diagnosing chest pain in children and teenagers. This agrees with our
hypothesis, that for subjects presenting with chest pain, there will be differences between
participants BMI classification and exercise stress test results. The results of this study indicate
that for those presenting with chest pain, with a BMI classification of obese or overweight, those
participants will have a lower peak VO2 value than participants classified as a healthy weight. As
it has been documented in the literature, the presence of true cardiac disease in children is
relatively rare, therefore, these results suggest that obese and overweight children are more likely
to experience chest pain due to poor aerobic conditioning. For most of these children, their poor
aerobic conditioning is due to their sedentary lifestyle. Understanding that a cardiac etiology for
chest pain in children is relatively rare, pediatric cardiologists are recommended to use the
SCAMP algorithm to diagnosis the cause of chest pain in children. When this approach is used,
less costly testing can be ordered, placing less of a burden on families of children with chest
pain. As we attempt to decrease the number of overweight and obese children, it will be
important to realize that for many of these children who experience chest pain, it will be most
effective to use the SCAMP algorithm when diagnosing their symptoms as many times, their
chest pain may be attributed to poor aerobic conditioning.

PEDIATRIC CHEST PAIN

13

References
American College of Sports Medicine. (2014). ACSM's guidelines for exercise testing and
prescription (9th ed.). Baltimore, MD: Lippincott, Williams & Wilkins.
Angoff, G. H., Kane, D. A., Giddins, N., Paris, Y. M., Moran, A. M., Tantengco, V., . . . Fulton,
D. R. (2013). Regional implementation of a pediatric cardiology chest pain guideline using
SCAMPs methodology. Pediatrics, 132(4), e1010-e1017. doi:10.1542/peds.2013-0086
Anwar, S., & Kavey, R. W. (2012). Pediatric chest pain: Findings on exercise stress testing.
Clinical Pediatrics, 51(7), 659-662. doi:10.1177/0009922812440842
Bruce, R. A., Kusumi, F., & Hosmer, D. (1973). Maximal oxygen intake and nomographic
assessment of functional aerobic impairment in cardiovascular disease. American Heart
Journal, 85, 546-562. Retrieved from http://articles.sirc.ca/search.cfm?id=42021;
http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3h&AN=SPH42021&site=e
host-live&scope=site; http://articles.sirc.ca/search.cfm?id=42021
Centers for Disease Control and Prevention (2011). Obesity and Overweight for Professionals:
Childhood: Basics - DNPAO - CDC. Retrieved June 8, 2014, from
http://www.cdc.gov/obesity/childhood/basics.html
Danduran, M. J., Earing, M. G., Sheridan, D. C., Ewalt, L. A., & Frommelt, P. C. (2008). Chest
pain: Characteristics of children/adolescents. Pediatric Cardiology, 29(4), 775-781.
doi:10.1007/s00246-008-9200-9
Friedman, K. G., Kane, D. A., Rathod, R. H., Renaud, A., Farias, M., Geggel, R., . . . Saleeb, S.
F. (2011). Management of pediatric chest pain using a standardized assessment and
management plan. Pediatrics, 128(2), 239-245. doi:10.1542/peds.2011-0141
Hanson, C. L., & Hokanson, J. S. (2011). Etiology of chest pain in children and adolescents
referred to cardiology clinic. WMJ: Official Publication of the State Medical Society of
Wisconsin, 110(2), 58-62. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=mnh&AN=21560558&site=e
host-live&scope=site
Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., . . .
Woo, Y. J. (2011). Forecasting the future of cardiovascular disease in the united states: A
policy statement from the american heart association. Circulation, 123(8), 933-944.
doi:10.1161/CIR.0b013e31820a55f5

PEDIATRIC CHEST PAIN

14

Heyward, V. H. (2010). Advanced fitness assessment and exercise prescription (6th ed.).
University of New Mexico: Human Kinetics.
Himes, J. H. (2009). Challenges of accurately measuring and using BMI and other indicators of
obesity in children. Pediatrics, 124, S3-S22. doi:10.1542/peds.2008-3596D
Lambiase, M. J., Dorn, J., & Roemmich, J. N. (2013). Systolic blood pressure reactivity during
submaximal exercise and acute psychological stress in youth. American Journal of
Hypertension, 26(3), 409-415. doi:10.1093/ajh/hps036
Larson, A. A. (2012). Childhood obesity in USA: A descriptive snapshot of current responses,
disconnects, and what could hold promise for additional mitigation. / Lobsit infantile aux
tats-unis : Un instantan descriptif des rponses actuelles, dconnexions, et ce qui pourrait
promettre une attnuation supplmentaire. Movement & Sport Sciences / Science &
Motricit, (78), 61-74. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3h&AN=85704230&site=e
host-live&scope=site
Lloyd-Jones, D., Hong, Y., Labarthe, D., Mozaffarian, D., Appel, L. J., Van Horn, L., . . .
Rosamond, W. D. (2010). Defining and setting national goals for cardiovascular health
promotion and disease reduction: The american heart association's strategic impact goal
through 2020 and beyond. Circulation, 121(4), 586-613. doi:10.1161
McDonnell, C. J., & White, K. S. (2010). Assessment and treatment of psychological factors in
pediatric chest pain. Pediatric Clinics of North America, 57(6), 1235-1260.
doi:10.1016/j.pcl.2010.09.010
Oude Luttikhuis, H. (2008). Interventions for treating obesity in children. Cochrane Database of
Systematic Reviews, (1) Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=chh&AN=CD001872&site=
ehost-live&scope=site
Paridon, S. M., Alpert, B. S., Boas, S. R., Cabrera, M. E., Caldarera, L. L., Daniels, S. R., . . .
Yetman, A. T. (2006). Clinical stress testing in the pediatric age group: A statement from the
american heart association council on cardiovascular disease in the young, committee on
atherosclerosis, hypertension, and obesity in youth. Circulation, 113(15), 1905-1920.
Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=rzh&AN=2009333579&site
=ehost-live&scope=site

PEDIATRIC CHEST PAIN

15

Saleeb, S. F., Li, W. Y. V., Warren, S. Z., & Lock, J. E. (2011). Effectiveness of screening for lifethreatening chest pain in children. Pediatrics, 128(5), e1062-e1068. doi:10.1542/peds.20110408
Stephens, P.,Jr, & Paridon, S. M. (2004). Exercise testing in pediatrics. Pediatric Clinics of
North America, 51(6), 1569. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=cmedm&AN=15561174&sit
e=ehost-live&scope=site
The Childrens Hospital of Philadelphia (2013, May). Chest Pain in Children and Teenagers |
The Children's Hospital of Philadelphia. Retrieved June 8, 2014, from
http://www.chop.edu/service/cardiac-center/heart-conditions/chest-pain-in-children-andteenagers.html
Thivel, D., Blundell, J., E., Duch, P., & Morio, B. (2012). Acute exercise and subsequent
nutritional adaptations: What about obese youths? Sports Medicine, 42(7), 607-613.
doi:10.2165/11632460-000000000-00000
Thull-Freedman, J. (2010). Evaluation of chest pain in the pediatric patient. Medical Clinics of
North America, 94(2), 327-347. doi:10.1016/j.mcna.2010.01.004
van, d. C., van, d. B., Willemsen, S. P., Stam, H. J., Tibboel, D., & IJsselstijn, H. (2010). Exercise
capacity in dutch children: New reference values for the bruce treadmill protocol.
Scandinavian Journal of Medicine & Science in Sports, 20(1), 1-7. Retrieved from
http://search.ebscohost.com/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3h&AN=47657290&site=e
host-live&scope=site
Vetter, V. L., McDaniel, D. J., Dugan, N., Haley, D., Cosgriff, L., & Shults, J. (2014). Body mass
index and blood pressure in children: novel electrocardiographic values
that correlate with echocardiographic left ventricular geometry and mass in obese children.
American College of Cardiology, 63(12). Retrieved from https://www-clinicalkeycom.pioproxy.carrollu.edu/#!/ContentPlayerCtrl/doPlayContent/1-s2.0S0735109714616405/{"scope":"all","query":"Body%20mass%20index%20and%20blood
%20pressure%20in%20children:%20novel%20electrocardiographic%20values%20that
%20correlate%20with%20echocardiographic%20left%20ventricular%20geometry%20and
%20mass%20in%20obese%20children"}

PEDIATRIC CHEST PAIN

16
Appendix A

Before Your Child has an Exercise Stress Test

They should have a meal and a non-caffeinated beverage two hours prior to the scheduled
testing time. After eating this meal, they cannot have anything else to eat or drink until
after the testing has been completed.
Please have your child wear loose, comfortable clothing and tennis shoes during testing.
Please arrive 15 minutes prior to the scheduled testing time to complete registration.
Please follow all instructions regarding the use of medications prior to testing. These
instructions will be provided to you when you schedule the appointment.