**3. Cardiac chest pain**

The anamnesis has great value in the determination of whether or not the chest pain is from cardiac origin. In the case of a child presenting with chest pain, it must be determined from the family when the pain started, how often the child has experienced chest pain, how long the pain lasts, where the pain radiates to, the relationship with exercise, factors that increase or decrease the pain, whether or not there is any relationship with feeding or respiration, whether there is any trauma anamnesis, whether or not there is any fever, or accompanying complaints such as shortness of breath, sweating, palpitations or nausea [10, 11]. It must also be determined whether the child or any family member has any CHD and whether or not any family member has recently experienced any chest pain, or MI.

enzymatic diagnostic criteria of MI have been well defined in adults, in children there are some difficulties [2, 3]. As the cardiac structure changes with age, there are sometimes dif-

Although MI is seen more often in the presence of congenital heart disease (CHD), it may also be seen in patients without CHD. Unlike atherosclerotic coronary artery disease in adult patients, ischaemia and infarct in children are often associated with coronary artery abnormalities and CHD [4]. In addition, congenital prothrombotic diseases, vasculitis, surgical or interventional procedures may also cause ischaemia and infarction [5]. Subendocardial ischaemia, especially aortic stenosis characterised by hypertrophy in the left ventricle is often seen

The most important risk factors in neonates and infants are the presence of CHD, coronary artery abnormalities and perinatal asfixia [5, 6]. The most frequently seen causes of Paediatric myocardial infarction (PMI) are abnormal left coronary artery originating from the pulmonary artery (ALCAPA) and Kawasaki disease [7, 8]. Patients undergoing arterial switch opera-

The anamnesis in Paediatric myocardial infarction (PMI) and Paediatric myocardial ischaemia and physical examination findings show differences from adult cases. The anamnesis of infants and young children is taken from the family and carers [2]. The complaints usually reported in this period are generalised findings such as feeding problems, lack of appetite, irritability, diarrhoea, vomiting, cold extremities, pallor and tachypnea. Older children may be able to describe chest pain well and can explain the spread of pain. A compressive of chest pain spreading to the left arm and shoulder should suggest chest pain with cardiac origin [10, 11]. However, some children may not be able to describe the character of the chest pain. In the physical examination, patients are generally anxious, pale and interactive. They may have dyspnea or tachypnea. If tachycardia, hypotension or cardiogenic shock develop, these can be determined [2]. In the cardiac examination, rhythm irregularity and gallop rhythm can be determined. Extremities may be cold and the pulse may be weak on the electrocardiography (ECG), ventricular arrhythmia or cardiac block may be determined [2, 12–14]. Patients with ventricular arrhythmias may have symptoms of palpitations, syncope and loss of conscious [12].

The anamnesis has great value in the determination of whether or not the chest pain is from cardiac origin. In the case of a child presenting with chest pain, it must be determined from the family when the pain started, how often the child has experienced chest pain, how long the pain lasts, where the pain radiates to, the relationship with exercise, factors that increase or decrease the pain, whether or not there is any relationship with feeding or respiration, whether there is any trauma anamnesis, whether or not there is any fever, or accompanying

ficulties in the electrocardiographic diagnostic criteria of ischaemia.

in hypertrophic cardiomyopathy or hypertensive patients [2].

tions are also at increased risk for PMI [9].

**2. Anamnesis**

102 Myocardial Infarction

**3. Cardiac chest pain**

Chest pain, which is one of the most significant symptoms for adults presenting to the Emergency Dept, is generally has a benign character in children. However, it is extremely important to decide whether or not the pain frequently seen in children is of cardiac origin [15]. Chest pain with cardiac origin in childhood can be classified in 3 groups; as structural heart diseases, inflammatory causes and dysrhythmias [10]. Structural heart diseases can lead complaints associated with an increased need for oxygen or a reduction in coronary blood circulation. These include events such as hypertrophic obstructive cardiomyopathy or aortic stenosis because of an obstruction in the left ventricle outlet tractus. Coronary artery abnormalities may also cause coronary ischaemia.

Chest pain with cardiac origin generally presents in situations where an increase in cardiac output is required. It is typically in the precordial or substernal region, in a constricting form and radiates to the left arm, neck and jaw. In some cases, there may also be shortness of breath, sweating, nausea, vomiting or syncope. In infants, the findings may be seen as feeding difficulties, crying and screaming (**Table 1**), [2, 6, 15, 16].

After the anamnesis and physical examination, ECG examination must be made in all patients and X-ray imaging should be applied in order to exclude any respiratory causes [15]. In cases where the pain is thought to be of cardiac origin, troponin and creatine kinase myocardial band (CK-MB) levels must be examined and if necessary echocardiographic evaluation should be made [15, 17, 18].


**Table 1.** Symptoms and physical examination findings in Paediatric myocardial infarction.
