CARDIOLOGY: Red flags in pediatric cardiology

A wide range of cardiovascular signs and symptoms present to the pediatrician’s office, and clinician knowledge of key “red flags” alerting them to a higher likelihood of significant pathology or more urgent need for subspecialty referral is paramount. These symptoms were highlighted by Timothy Slesnick, MD, in his presentation “Five Critical Cardiac Problems Commonly Missed in Office Practice.” Cases included:

• A newborn is brought for a “worried” well visit and found to be in shock. Although the initial diagnosis was neonatal sepsis, the child was found to have hypoplastic left heart syndrome, illustrating the need to always consider obstructive left heart lesions whenever neonatal sepsis is on the differential diagnosis. This fact is also highlighted in the 2011 AAP recommendation for newborn screening for critical congenital heart disease (CCHD).

• Adolescent chest pain is common, but when it is exertional in nature, the incidence of underlying cardiac disease increases, and, in particular, hypertrophic cardiomyopathy (HCM) must be ruled out. As the most frequent etiology of sudden cardiac death (SCD) in the young, HCM should always be on the differential diagnosis for children with exertional chest pain, characteristic physical exam findings, or a concerning family history.

• Coarctation of the aorta displays a wide spectrum of presenting findings based on age. In neonates, decreased femoral pulses and an ejection type murmur over the back are common, while in older children, differential blood pressures and systemic hypertension are often the first clues.

• A teenager collapsed running a marathon and is subsequently found to have an anomalous origin of her left coronary artery, the second most common cause of SCD in the young. Like chest pain, syncope is a common pediatric complaint, but exertional syncope is far less common and necessitates further investigation.

• A 6-year-old presents with recurrent wheezing that responds poorly to inhaled bronchodilators and is found to have a double aortic arch, illustrating that unexplained gastrointestinal or respiratory symptoms merit evaluation for a vascular ring.

Timothy Slesnick, MD, FAAP, is a pediatric cardiologist in Atlanta, Georgia.

At the recent AAP meeting, Timothy Slesnick, MD, reviewed the “red flags” that every provider of primary pediatric care must take into account in order to identify cardiac disease. Slesnick reminds us that we must harken to the principles we learned as we began our medical careers: Take a good clinical history, pay careful attention to family history, and perform a focused physical examination. By following these foundational principles, the vast majority of cases of congenital heart disease, cardiomyopathies, and arrhythmias will be detected before clinical deterioration develops. These principles apply irrespective of whether we are caring for the newborn or the young adult. In fact, there is little difference in the application of this model of care as compared with that required for taking an effective preparticipation athletic screening history and physical examination (Maron, et al. Circulation. 2007;115(12):1643-1655).

We are greatly assisted in early detection of CCHD by the recent AAP policy statement regarding newborn pulse oximetry screening (Mahle, et al. Pediatrics. 2012;129(1):190-192). Nevertheless, the burden remains squarely on the shoulders of the primary provider: Maintain a working knowledge of the spectrum of pediatric cardiac disease and remain prepared to implement a thorough evaluation in order to ascertain disorders that will prompt expeditious referral for pediatric cardiac specialty care.

Mark B. Lewin, MD, is professor and chief, Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle, and co-director, Heart Center, Seattle Children’s Hospital.