407 - Screening for CVD in Children, ECGs and Children, Constipation

First of a Two-fer From the American Academy of Pediatrics (AAP)

1) Screening All Children for Evidence of Cardiovascular Disease

According to the American Academy of Pediatrics (AAP), sudden cardiac death (SCD) occurs in approximately 2000 patients younger than 25 years (excluding SIDS deaths) every year in the US. Autopsy studies of young individuals who have suffered SCD have shown that a structural cardiac cause (hypertrophic cardiomyopathy, congenital heart anomalies, and myocarditis) is present in the majority of the patients; however, the cause remains unexplained in 6-40%.

The AAP recently published an updated policy stating that all children — particularly those entering middle school — should be screened for conditions that can lead to sudden cardiac arrest (SCA) or sudden cardiac death (SCD), regardless of their athletic status. The updated guidance contains a comprehensive review of conditions that should prompt additional attention and cardiology evaluation.

The recommendations include:

• Clinicians should evaluate if a patient’s clinical history, family history and physical examination suggest a risk for sudden cardiac arrest or sudden cardiac death.
• The history portion of the evaluation should consist of the following 4 questions (developed based on expert opinion):

1. Have you ever fainted, passed out, or had an unexplained seizure suddenly and without warning, especially during exercise or in response to sudden loud noises, such as doorbells, alarm clocks, and ringing telephones?
2. Have you ever had exercise-related chest pain or shortness of breath?
3. Has anyone in your immediate family (parents, grandparents, siblings) or other, more distant relatives (aunts, uncles, cousins) died of heart problems or had an unexpected sudden death before age 50? This would include unexpected drownings, unexplained auto crashes in which the relative was driving, or SIDS.
4. Are you related to anyone with hypertrophic cardiomyopathy (HCM) or hypertrophic obstructive cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy(ACM), LQTS, short QT syndrome, Brugada syndrome (BrS) or catecholaminergic polymorphic ventricular tachycardia (CPVT), or anyone < 50 with a pacemaker or implantable defibrillator?

• If there is concern, an electrocardiogram (ECG) should be the first test administered, then interpreted by a physician trained to recognize electrical heart disease (ie, a pediatric cardiologist or pediatric electrophysiologist). Computer interpretation of an ECG should not be trusted.
• Clinicians should advocate for emergency action plans and CPR training with the community.

For children/adolescents who are athletes, this can be included as part of the preparticipation evaluation (PPE) exam. It is recommend the screening be performed at a minimum of every 3 years or on entry into middle or junior high school and into high school. Depending on family and PCP concerns, more frequent screening may be appropriate.

Mark’s Comments:

Certainly sudden death from cardiovascular disease in children is tragic, particularly if it might have bene prevented. At the same time, I find the level of detail of one of these questions to be quite vague (“Have you ever had exercise induced chest pain or shortness of breath?”), which should screen positive for anyone who is actually performing exercise, and one question to be quite confusing due to the level of detail (most patients/families would not have a clue about the specifics of question #4 above).

It is also not clear in this policy why the American Heart Association (AHA) 14-Point Pre-Participation Exam (PPE) screening for cardiovascular disease is not adequate for such screening (see 2^nd reference). The AHA tool is presently used as part of most PPE, though it is also based on expert opinion. The AAP policy also does not detail what components of the cardiovascular physical examination should be performed, which the AHA PPE does. My conclusion is that it is regrettable that the AHA and the AAP could not come together for a joint policy statement about this. I don’t know the politics at play but suspect there are some.

References:

• Erickson C, et al. Sudden Death in the Young: Information for the Primary Care Provider. Pediatrics July 2021. 148(1). Link
• AHA 14 Point Preparticipation Evaluation (PPE) for Cardiovascular Disease: Link

Second of a Two-fer From the AAP and Choosing Wisely

2) Electrocardiograms (ECG) and the Preparticipation Evaluation

The American Academy of Pediatrics – Section on Cardiology and Cardiac Surgery and Choosing Wisely recently released “Five Things Physicians and Patients Should Question.” Among the recommendations was, “Do not routinely order a screening ECG as part of a sports preparticipation examination in asymptomatic, otherwise healthy patients with no personal or family history of cardiac disease.”

The rationale was that routine screening ECGs for preparticipation sports clearance are not currently recommended by the American Heart Association (AHA). Instead, it is recommended that the AHA’s 14-point screening guidelines, or the American Academy of Pediatrics’ “Preparticipation Physical Evaluation” be used in conjunction with a targeted personal history, family history, and thorough physical examination (see first Pointer). The goal is to identify warning signs or signs that raise suspicion of cardiovascular diseases that place certain athletes at risk of sudden cardiac death. These individuals should be referred for further evaluation by a pediatric cardiologist who may order an ECG or an echocardiogram as part of the work-up.

Routine ECG screening of healthy pediatric patients with no personal or family history of cardiac disease has demonstrated a high false-positive rate and has not been found to reduce mortality from sudden cardiac death. In addition, it can also lead to unnecessary secondary evaluations.

Mark’s Comments:

It should be noted that the AHA/American College of Cardiology (ACC) expert panels, composed of cardiovascular specialists, have also consistently rejected the notion of mandated broad‐based universal (including national) screening that relies on the 12‐lead ECG given the many limitations, which include the following: unacceptable numbers of false positives that overwhelm the screening system with expensive downstream noninvasive testing; false negatives that defeat the very reason for such screening initiatives; logistical challenges in reliably interpreting ECGs in large populations (eg, for QT‐interval duration); overall cost burden; and the failure to demonstrate that ECG screening reduces cardiovascular mortality.

In my research (and speaking of politics) there are some very strong opinions about this that are being played out in the literature, but at the end of the day, neither the AAP, the AHA, or the ACC presently recommend routine ECGs for student athletes, and based on reading, this conclusion is based on sound reasoning.

Reference:

Choosing Wisely and the AAP – Section on Cardiology and Cardiac Surgery. Released November 2, 2020. Link

From the Literature

3) A Tastier Alternative to Laxatives?

Comparative effectiveness trials are not common enough in the literature but are really helpful for our day-to-day practice. This study promises a practical food-as-medicine investigation that compares green kiwifruit, psyllium and prunes for relief of chronic constipation symptoms.

Sidenote: I learned today that there are green and gold kiwis – green ones have fuzzy skin, green flesh and more fiber than the hairless, yellow flesh variety. Kiwifruits (also known as Chinese gooseberries) are good sources of potassium, vitamin C and antioxidants.

Researchers in a US healthcare system randomized patients with chronic constipation (which they defined as fewer than three “complete spontaneous bowel movements” (CSBM) per week) to three groups: 2 kiwifruit per day, 100g of prunes per day, or 12g of psyllium per day for 4 weeks. The primary outcome measured was an increase of 1 or more CSBMs per week for at least 2 of the 4 weeks; and there were several patient-reported outcomes measured as secondary. The study was not blinded, but it would be very hard to do this. There was no statistical difference in the primary outcome at 4 weeks – the proportions of patients increasing their CSBMs was 45% for kiwifruit, 67% for prunes and 64% for psyllium. The secondary outcomes sometimes favored kiwifruits – less bloating compared to prunes and markedly better “satisfaction with therapy” than prunes and psyllium – and sometimes didn’t. There were no significant differences in harms between the three groups.

John’s Comments:

Using Kroger.com and some back-of-the-envelope math, I compared the daily cost of the tested regimens and got: kiwifruits ~ $1.18, store brand prunes ~ $0.94, and generic psyllium husk ~ $0.18.

I wanted this to be a useful comparative effectiveness study, but instead it ended up being a lesson in sneaky research reporting. When you see a study that purports to show “no difference” between the therapies as its main conclusion – dig a little deeper. In this case, the authors did not even try to get enough sample size to be able to see a difference, stating it was just a “pilot study.” Re-reading the outcomes, we note that there is a 20% lower proportion achieving the primary outcome with kiwifruit than the other therapies, but this is “not statistically significant” – because of the small sample size. When I see this sort of thing, I look at the conflict-of-interest statements, and, sure enough, the study was funded by Zespri, International who sells…wait for it…kiwifruits! Sigh…Kiwifruits might help with constipation, and they taste better, but they’re expensive. I’d stick with the proven results from prunes and psyllium for now.

Reference:

• Chey SW, Chey WD, Jackson K, Eswaran S. Exploratory Comparative Effectiveness Trial of Green Kiwifruit, Psyllium, or Prunes in US Patients With Chronic Constipation. Official journal of the American College of Gastroenterology | ACG. 2021 Jun;116(6):1304–12. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org