Practical Tips for Paediatricians: Precordial catch syndrome

WHAT IS PRECORDIAL CATCH SYNDROME?

Precordial catch syndrome (PCS) is a common but underrecognized cause of chest pain in children and youth (1), often observed during growth. Paediatricians report that precordial catch accounts for 80% to 90% of chest pain once any chest trauma is excluded (2). Although, PCS is benign, the pain may be intense and recurrent, leading to patient and parental anxiety and may prompt cardiac testing and referral. The classic pain history can help identify PCS, often eliminating the need for further testing or referrals. Once PCS is diagnosed, further testing is rarely needed and PCS can be managed conservatively. The purpose of this article is to increase awareness to help primary care physicians identify PCS in paediatric patients experiencing this phenomenon.

HISTORY OF PRECORDIAL CATCH SYNDROME

In 1955, Miller and Texidor (3) were the first to diagnose PCS in 10 young, healthy patients all of whom described their pain as a sudden, severe, non-radiating chest pain unrelated to exercise. In 1978, Sparrow and Bird reported PCS in 45 college students (4). Authors commented on its high frequency in the young and healthy. In 1981, Pickering (5) reported 17 cases of PCS in Oxford which was the first study in paediatric population. His patients also described the syndrome as a sharp, needle-like pain, felt near the apex of the heart, seemingly within the chest wall.

TIP #1: RECOGNIZE PRECORDIAL CATCH SYNDROME AND ITS CLASSIC SYMPTOMS

Precordial catch syndrome is associated with the symptoms outlined in Table 1. It is neither cardiac nor precordial (3) and it is neither conversional nor psychological in origin (1). Miller and Texidor (3) proposed that the pain originates from the parietal pleura because it was closely associated with the precordial region of the chest wall. Precordial catch syndrome also resembles a chest wall injury to the ribs or cartilage, hence some physicians suggest it could be arising from the chest wall.

Table 1.

Pain characteristics of precordial catch

Characteristic	Description
Onset and duration	Acute, sudden, and unexpected onset, lasting for seconds to minutes (sometimes up to 30 min) in young patients (6). The pain resolves completely but may be recurrent and frequent. The pain starts predominantly at rest and is not associated with exercise or physical activity
Quality and intensity	Sharp and knife-like or needle-like pain which patient feels to be associated with their heart without radiation. The pain is typically intense, though intensity is variable from episode to episode
Location	Location of pain is identifiable (by index finger) often below the left breast, but it could be felt in other locations too, such as on the right sternal border
Aggravation and alleviation	Pain intensifies upon inspiration, which is why the patient often feels the need to breathe through shallow excursions or hold their breath—to avoid the intensification and discomfort. If the patient is lying down when the pain starts, then it may be difficult to get back up, doing so is perceived as impossibly painful. Precordial catch syndrome causes the patient to freeze in place
Associated symptoms	Some patients report that breathing in deeply will cause a ‘cracking’ sensation or a painful bubble to burst
Offset	The pain tends to subside on its own. Although painful to take, one deep breath can sometimes relieve the attack

Precordial catch syndrome is most common in teenagers, which may be because they verbalize their symptoms better than younger kids, but children as young as 6 years old as well as young adults can also experience it (4). While it usually goes away as you get older, some cases do continue into adulthood. The syndrome is typically seen in children and youth who have a low to medium build (3,5), and anecdotally seems to be correlated with a history of recent growth spurt. At presentation, parents are typically worried, many of them are anxious because they think their child has heart disease. All reported some form of anxiety either in the child or in the parents (6). Episodes of PCS may exacerbate worry and fear especially in those predisposed to anxiety (7). It can be helpful to ask the child and family what worries them about the pain so the anxiety can be addressed.

TIP #2: BE ALERT TO ATYPICAL FEATURES THAT MAY WARRANT FURTHER INVESTIGATION

A comprehensive assessment should consist of almost exclusively detailed history taking and physical examination. Clearly demonstrate to patient and family that the concern is being taken seriously.

• Be thorough and attentive to child’s history of the pain including frequency and duration, quality, intensity, onset/offset, association with exercise/rest, aggravating and alleviating factors, and associated symptoms.

• Listen for indications of a possible alternative diagnosis: including symptoms suggestive of underlying cardiovascular or pulmonary pathology especially exercise-related symptoms, cardiac/pulmonary past medical history, history of trauma, family history of cardiovascular conditions, signs/symptoms suggesting a primary anxiety disorder such as pain associated with feelings of anxiety, or stress and chronic school absenteeism (7).

• If there are findings of concern for alternative pathology while taking history and physical examination, such as exercise-related pain, persistent, and worsening discomfort, recent cough/fever, syncope, and/or palpitations, then cardiology assessment with electrocardiogram and echocardiography is encouraged.

• If the PCS presents in the setting of a pre-existing condition, for example, history of Kawasaki disease, known coronary artery anomaly, cardiomyopathy, congenital heart disease, or non-cardiac condition such as pulmonary disease or asthma, reflux, immunodeficiency, connective tissue disorder, or skeletal abnormality, more work-up may be needed.

• Ancillary testing includes electrocardiography, echocardiography, radiography, barium studies typically to exclude alternative diagnoses when there are atypical features. Evaluation by cardiology may help clarify questions and determine whether further testing is needed. Unnecessary or excessive testing may lead to more anxiety about the pain or concern for diagnostic uncertainty.

TIP #3: CONSERVATIVE MANAGEMENT AND PATIENT REASSURANCE IS ADVISED FOR PRECORDIAL CATCH SYNDROME

The following recommendations can be considered once PCS is diagnosed:

Monitor posture—Avoid slouching in general, maintain an upright posture. Avoid slouching when sitting on a couch or lounge chair. Some patients notice a correlation between onset of attack and body position, including lying on left side, bending over, or slouched posture (6). Patients can try to notice when it happens and what body position they were in right before it happened to learn the triggers and then avoid them.

During the attack—If the pain starts, roll the shoulders back, straighten posture while trying to gradually take deeper breaths. If the pain is starting to come on, try to ‘break’ out of it early on by standing upright, maintaining shallow but frequent breathing while adjusting posture until it passes.

Following up—A follow-up phone call to the patient and family may be appropriate. Physician should offer to be available for future re-evaluation should symptoms change, or condition persists, especially if the symptoms are recurrent and lead to school absenteeism (7).

Patient and Family Reassurance—Be aware that this is a benign condition that is not related to heart disease. Begin by explaining that idiopathic chest pain is a common complaint among children and is rarely cardiac in origin. Discuss specific features of the pain description that are consistent with PCS and distinguish it from alternate medical diagnoses. For majority of patients, the pain occurs frequently and then subsides and may resolve completely. Giving the symptoms a name (PCS) emphasizes familiarity with diagnosis, and may serve to alleviate anxiety about ‘unexplained pain’.

Summary of practical tips

• - Precordial catch syndrome is a common complaint in children and youth. Be aware of the pain description for PCS (Table 1).

• - Take a thorough and detailed history to rule out alternative diagnoses (Tip 2).

• - If PCS is diagnosed, see Tip 3 for recommendations in management.

• - Explain to patient and family that it is not heart-related, and usually stops happening as the child grows up. Recognizing that PCS is a harmless condition will often relieve the associated anxiety.

FUNDING

No funding to report.

POTENTIAL CONFLICTS OF INTEREST

All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.