Precordial catch syndrome

Precordial means in front of the heart. Precordial catch syndrome (PCS) also known as “Texidor’s Twinge”, is a common benign cause of sharp chest pain that comes on and disappears quickly often experienced by otherwise healthy children and adolescents ¹. Precordial catch syndrome also occurs, though less frequently, in adults. Precordial catch syndrome is characterized by a sharp, stabbing pain that is painful to breathe through, often on the upper left-hand side of the ribs. PCS episodes most often happen at rest, while sitting or lying down or during a sudden change in posture. Precordial catch syndrome often leads to unneeded tests, specialist appointments, and anxiety. The good news is that the pain will usually go away by itself within a few minutes and doesn’t cause any health problems ².

It is not uncommon for patients to be concerned that this sharp chest pain is due to a heart attack, but fortunately the type of chest pain seen with precordial catch syndrome is localized and short lived, typically lasting only 30 seconds to 3 minutes (although sometimes the chest pain can last for up to 30 minutes). In contrast, the chest pain associated with a heart attack is a generalized type of pain which does not improve. The frequency of precordial catch syndrome episodes varies by patient, sometimes occurring daily, multiple episodes each day or years between episodes.

However, it’s always wise to treat chest pain seriously. If there are any other symptoms accompanying your child’s pain, like nausea, vomiting, headache, dizziness or shortness of breath, or the pain doesn’t go away quickly, you should seek immediate medical help.

The exact cause of precordial catch syndrome is unknown, it is speculated that it could be triggered by the pinching of a nerve and may be due to a spasm of intercostal muscles fibers. There is also a correlation between precordial catch syndrome and stress and anxiety.

In all cases, the chest pain is resolved quickly and completely. Although deep inspiration during a precordial catch syndrome attack intensifies the pain, many have reported that forcing themselves to breathe as deeply as possible will cause a small “bubble” popping or cracking sensation in the chest, which results in the pain going away. There is no known treatment or cure for precordial catch syndrome. As the chest pain, in most cases, resolves quickly and completely, pain medications are not required.

In summary, precordial catch syndrome is a self-limited type of chest pain which most commonly occurs at rest and is typically not associated with other symptoms. If your child experiences chest pain during exercise along with palpitations, dizziness and/or fainting, other cardiac causes including cardiomyopathies, coronary artery anomalies or rhythm disturbances should be considered. Exercise symptoms including chest pain, palpitations, dizziness and fainting are red flags for cardiologists. If your child experiences any of these symptoms, you should discuss these complaints with your child’s pediatrician or seek medical attention as these symptoms can be signs of serious cardiac problems.

How do I know if my chest pain not something serious?

Your health care practitioner should take a careful history of your symptoms and be alert to the possibility of other problems. Viral and other infections, congenital heart valve deformities, inflamed esophagus or stomach may cause similar symptoms, but will be associated with other findings, such as fever, cough, relationship to certain foods or activity, etc. Your doctor should physically check your chest by observing, feeling for tenderness, and listening to your heart and lungs.

Precordial catch syndrome causes

Doctors don’t quite know what causes PCS, though it’s thought precordial catch syndrome might have something to do with irritation of the nerves that line the chest cavity called the pleura. In some, it may originate in the chest wall – ribs or cartilage and may be due to a spasm of intercostal muscles fibers. There is also a correlation between precordial catch syndrome and stress and anxiety. Some also think that precordial catch syndrome is more common during growth spurts. It seems to happen most when a child is at rest, sitting or lying down, and isn’t accompanied by other symptoms. Precordial catch syndrome becomes much less common after the age of 20.

Precordial catch syndrome most certainly does not come from heart, the lining over the heart (pericardium) or lung disease.

Other possible causes of chest pain in children

The causes of chest pain in children are classified as idiopathic, musculoskeletal, pulmonary, cardiovascular, gastrointestinal, psychogenic, malignant, and miscellaneous ².

Causes of chest pain in children:

• Idiopathic
• Musculoskeletal causes
  • Muscle strain, direct trauma to chest wall
  • Painful xiphoid syndrome
  • Costochondritis
  • Tietze’s syndrome
  • Slipping rib syndrome
  • Precordial catch syndrome
  • Epidemic pleurodynia
  • Herpes zoster
  • Adolescent breast development
  • Myositis
• Pulmonary causes
  • Bronchitis
  • Pneumonia
  • Asthma
  • Pleural effusion
  • Pneumothorax
  • Pulmonary embolism
• Cardiovascular causes
  • Structural abnormalities (aortic stenosis, subaortic stenosis, idiopathic hypertrophic subaortic stenosis, pulmonary stenosis, mitral valve prolapse, dissecting aortic aneurysm, anomalous coronary artery)
  • Coronary arteritis
  • Pericarditis
  • Myocarditis
  • Arrhythmias
• Gastrointestinal causes
  • Esophagitis
  • Foreign body in esophagus
  • Referred pain from peptic ulceration, cholecystitis, hepatitis, subphrenic abscess, pancreatitis
• Psychogenic causes
• Malignancies
• Miscellaneous causes
  • Sickle cell anemia
  • Abuse of cocaine
  • Cigarette smoking

Precordial catch syndrome symptoms

Precordial catch syndrome is a benign and self-limited disorder of unknown origin occurring in healthy teens and young adults, but can start even earlier. Precordial catch pain develops suddenly with no warning, is easily localized to the periapical region, does not radiate, and lasts only seconds ³. The chest pain is not related to exertion and is increased by deep breathing, which induces the painful sensation of “something being caught.” The chest pain causes patients to hold their breath or to breathe shallowly while they have the pain.

Precordial catch syndrome symptoms:

• Normally occurs at rest. It may occur when you sit in a slouched position.
• Sudden onset – no warning.
• Most often is in one place on the chest (localized) – its area being nobigger than 1 or 2 fingertips, with sharp, stabbing, or needle-like pain.
• It does not radiate, or shoot to another area.
• Often made worse by deep breathing.
• Normally lasts for a very short time from 30 seconds to 3 minutes.
• Goes away suddenly and completely.
• May happen just one time or more than once in a day.
• May cause you to feel light-headed from shallow breathing.
• The chest pain has no link to eating.
• No other symptoms.
• No physical changes.

Precordial catch syndrome may start as young as six years old, but more commonly happens in the late teens to early twenties. Precordial catch syndrome usually occurs at rest, often in a partly slouched position, such as while watching television, sitting on an old couch. It may happen during light activity, such as walking. It has no relationship to meals and never occurs during sleep. Attacks can be as often as weekly or as rare as once only ⁴.

The pain is well-localized, its area being nobigger than 1 or 2 fingertips ⁵. Most commonly it is located in the front or sides of the chest. Precordial means “in front of the heart.” It does not radiate, or shoot to another area. It begins suddenly without provocation. Changing position may make it worse or better — taking a deep breath usually hurts more, but can sometimes “fix” the problem. Most people just breathe shallowly for the few seconds or minutes until it disappears spontaneously. It may last as long as 30 minutes, but this is rare.

Other than appearing to be in pain, the affected person doesn’t have symptoms such as paleness, flushing (red face), or wheezing, but he/she may get light-headed from prolonged shallow breathing. The pulse rate and rhythm are normal.

Unexplained chest pain might cause you or your child some understandable anxiety. Even if your child’s chest pain is brief and doesn’t seem to be connected to other health concerns, raise it with your doctor. If it’s precordial catch syndrome, have them explain what’s happening to you and your child, so the condition doesn’t keep causing you unnecessary worry.

Precordial catch syndrome diagnosis

A thorough history and physical examination are important to evaluate children with chest pain. Precordial catch syndrome is diagnosed clinically based on medical history and physical examination.

Medical history

Age

The younger the child, the more likely that an organic cause will be found. A psychogenic cause is more likely during adolescence.

Onset and duration of chest pain

Transient attacks of chest pain could be due to the precordial catch syndrome. Chest pain due to myocardial ischemia usually lasts for several minutes to less than an hour ⁶. Noncardiac organic causes of chest pain often last for hours. Patients with sudden onset of chest pain are more likely to have organic causes ⁷. Chest pain that lasts for more than 6 months is most likely psychogenic or idiopathic.6 Nocturnal chest pain suggests an organic cause.

Severity and frequency of chest pain

Severe and frequent chest pain can affect a child’s activity. Ischemic chest pain is usually severe, but severe chest pain does not always imply a serious etiology.

Type and location of chest pain

Superficial pain localized to the chest wall suggests a musculoskeletal cause. Pleuritic pain is usually sharp, stabbing, and superficial. Ischemic chest pain is described as a crushing pressure, squeezing, strangling, or constricting with radiation to the shoulder, neck, or jaw. A burning sensation in the retrosternal area suggests esophagitis.

Precipitating or relieving factors

Pleuritic pain is often accentuated by deep inspiration, coughing, or sneezing ⁸. Pain that is relieved by sitting up and leaning forward suggests pericarditis. Chest pain that is aggravated by exercise suggests a musculoskeletal or cardiac cause. Chest pain that is temporally related to eating specific foods and that increases in a recumbent position suggests esophagitis.

Recent trauma or strenuous exercise

A history of recent trauma to the chest or strenuous exercise suggests a musculoskeletal cause.

Associated symptoms

Cough suggests a respiratory disorder or congestive heart failure. Fever suggests an underlying infection. Associated pallor, palpitation, or syncope suggests a cardiac cause. Multiple somatic complaints, such as recurrent headache or abdominal pain, behavioral problems, or school refusal, suggest a psychogenic cause.

Psychosocial history

Any psychosocial stress should be noted as a potential cause of psychogenic chest pain. The presence of active or passive cigarette smoking should be noted.

Drug use

Adolescents should be questioned about using birth control pills or cocaine because these drugs could cause chest pain.

Past health

Any previous hospitalization or significant illness should be noted. Response to previous treatment could help to confirm a diagnosis.

Family history

A family history of asthma or sickle cell disease suggests the corresponding illness. Although some cardiac disorders (eg, idiopathic hypertrophic subaortic stenosis, mitral valve prolapse) are familial, most children with a family history of a cardiac disorder or chest pain have nonorganic causes of their pain ⁹.

Physical examination

General

Weight, height, and head circumference should be plotted on standard growth charts. Poor growth suggests chronic disease. Vital signs, such as temperature, respiratory rate, heart rate, and blood pressure, should be noted. Cyanosis suggests an underlying respiratory or cardiac disorder.

Chest

The chest wall should be examined for bruises, tenderness, breast enlargement, or mass.

Discomfort with palpation of a specific muscle or tendon insertion site suggests a specific musculoskeletal syndrome. A prominent and tender costochondral or chondrosternal junction suggests costochondritis, whereas fusiform or spindle-shaped swelling at the sternoclavicular or chondrosternal junction suggests Tietze’s syndrome. Compression of the chest wall in the anterioposterior direction reproduces the pain of rib fracture.

Dullness on chest percussion can be associated with underlying pneumonia, atelectasis, or pleural effusion. Hyperresonance to percussion suggests pneumothorax or asthma.

Auscultation of the chest is important. Wheezing suggests bronchospasm. Decreased breath sounds suggest pneumonia, atelectasis, or pneumothorax. Arrhythmias, significant heart murmurs, and abnormal heart sounds suggest structural heart disease. Muffled heart sounds or a pericardial friction rub suggest pericarditis.

Associated signs

Associated signs could suggest the cause of the chest pain. Skin bruising on the extremities, abdomen, or head are a clue to coexistent chest trauma. A vasculitic rash or joint swelling suggests a collagen vascular disease. Fever, conjunctivitis, erythema of the oropharyngeal mucosa, dry fissured lips, strawberry tongue, erythema of the palms and soles with desquamation, fusiform swelling of fingers, polymorphous rash, and cervical lymphadenopathy suggest Kawasaki disease. Vesicles in a dermatone distribution suggest herpes zoster. Nervousness, tics, and hyperventilation suggest a psychogenic cause.

Are tests needed?

Further testing is only needed if your physician thinks there may be something else going on. For example, if a heart murmur or other abnormal sound is heard, an echocardiogram (ultrasound images), and/or chest X-ray may be ordered.

Precordial catch syndrome treatment

There is no known treatment or cure for precordial catch syndrome. Your health care provider will take a careful history of your symptoms and any health problems. Know that the pain is harmless and normally goes away on its own. Specific treatment is not needed. Your health care provider may have you take an over the counter anti inflammatory such as ibuprofen. It may help if you relax and take slow breaths. Watch your sitting posture. Improving your sitting posture and taking an occasional deep breath is likely to help prevent it.

Most children with precordial catch syndrome outgrow it by their early to mid twenties. Attacks of pain usually diminish with age. Some have found that taking a deep breath makes it go away, butmay do so at the cost of a sharper brief stab. Most prefer to breathe shallowly until it goes away.

As for treatment of chest pain in general, treatment should be directed at the underlying cause whenever possible. Most cases of musculoskeletal and nonorganic chest pain can be treated with reassurance, analgesia, rest, and relaxation techniques ¹⁰.

Those with idiopathic chest pain require reassurance that the chest pain is benign and regular follow-up appointments. Rowland and Richards ¹¹ reported a follow-up study on 31 patients with idiopathic chest pain who were assessed an average of 4.1 years after diagnosis. Forty-five percent of the patients reported persistent symptoms. In 70% of cases, the chest pain was less frequent and less severe than when first evaluated. The chest pain disappeared in 81 % of the patients who were followed for more than 3 years. Occult disease did not appear in any patient ¹¹.

References

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