Abstract
Background and Objectives: Pediatric chest pain is usually benign, but identifying children who require admission or have a cardiac diagnosis remains challenging. We aimed to identify factors associated with these outcomes, with a focus on recurrent presentation and the combined value of C-reactive protein (CRP) and predefined red-flag findings. Materials and Methods: This retrospective cohort included children aged 0–18 years presenting with chest pain to a tertiary pediatric emergency department between January 2021 and January 2026; visits with insufficient documentation were excluded. Red-flag findings were predefined as effort-related chest pain, syncope, palpitations, dyspnea, fever, or a family history of sudden cardiac death. Independent predictors were assessed using multivariable Firth logistic regression, and cluster-robust standard errors were used in a sensitivity analysis to account for recurrent visits. Results: Of 1703 visits (1435 patients), 452 (26.5%) were recurrent presentations. Admission occurred in 64 visits (3.8%), and 91 (5.3%) had a cardiac diagnosis. Red-flag findings (OR, 5.15), abnormal ECG (OR, 4.00), CRP > 5 mg/L (OR, 3.71), male sex (OR, 2.13), and recurrent presentation (OR, 2.51) were independently associated with admission (all p ≤ 0.009). Recurrent presentation was not associated with a cardiac or psychogenic diagnosis. Admission and cardiac diagnosis rates increased from 1.4%/2.2% in children with neither elevated CRP nor red-flag findings to 22.2%/24.8% in those with both. Routine ECG, troponin, and chest radiography had low diagnostic yields (2.1–6.0%), whereas echocardiography performed selectively yielded abnormal findings in 79.7%. Conclusions: Red-flag findings, abnormal ECG, elevated CRP, and recurrence were associated with admission, whereas recurrence was not associated with diagnosis. Combining CRP with red flags may improve risk stratification, though prospective validation is needed.