Monday, July 25, 2011

Standardized Management Plan Improves Pediatric Chest Pain Outcomes

From Medscape Education Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
Pediatrics. Published online July 11, 2011.

Study Highlights

  • The investigators reviewed records for 406 children aged 7 to 21 years seen at a pediatric cardiology outpatient division for chest pain.
  • Diagnosis of chest pain was identified by the International Classification of Diseases, Ninth Revision, billing codes.
  • Exclusion criteria were a history of heart disease or previous evaluation by a pediatric cardiologist.
  • 461 cardiology clinic visits occurred.
  • All patients underwent ECG; 457 ECGs were performed.
  • 175 (43%) underwent echocardiograms.
  • 114 (28%) had an exercise stress test (EST).
  • 40 (10%) had event monitors, and 30 (7%) had Holter monitors.
  • 7 (2%) underwent a cardiac magnetic resonance imaging study.
  • 4 (1%) had a positive history of medical conditions, including systemic lupus erythematosus, juvenile rheumatoid arthritis, carnitine deficiency, and congenital adrenal insufficiency.
  • 4 (1%) had a positive family history of heart disease, including sudden death, cardiac arrest, resuscitated cardiac arrest, and hypertrophic cardiomyopathy in a first-degree relative.
  • 16 (4%) had positive cardiac findings on physical examination, including pathologic murmur, systolic click, friction rub, gallop, and abnormal second heart sound.
  • 25 (6%) had abnormal ECG findings, including increased left ventricular forces, pathologic ST-segment or T-wave abnormalities, axis deviation, frequent premature ventricular contractions, and Wolff-Parkinson-White syndrome.
  • 150 (37%) had exertional chest pain combined with dyspnea in 46 and with dizziness or lightheadedness in 21.
  • 66 (16%) had palpitations.
  • 44 (11%) had positive findings on initial evaluation of medical history, family history, physical examination, or ECG.
  • Cardiac cause was noted in 5 patients (1%): 2 children had pericarditis, 2 had supraventricular tachycardia, and 1 had nonsustained ventricular tachycardia.
  • Noncardiac chest pain diagnoses included musculoskeletal pain, costochondritis, or respiratory or asthma-related conditions.
  • Fewer echocardiograms were ordered by cardiologists with more than 5 years' experience or by cardiologists with higher volumes of annual clinic visits.
  • The number of ESTs was not associated with cardiologists' experience or clinic volume.
  • An algorithm was used to reassess the testing and costs for each patient and included the following:
    • Initial evaluation consisting of medical history, family history, physical examination, and ECG
    • Echocardiogram if any initial evaluation result was abnormal or if normal result on initial evaluation, but chest pain at high level of exertion without alternate explanation
    • No echocardiogram if negative result on initial evaluation plus nonexertional chest pain, plus exertional chest pain and alternative diagnosis suspected, or plus chest pain at low level of exertion without alternate explanation
    • No EST performed
  • The algorithm would decrease use of echocardiography, Holter monitors, and event monitors by approximately 20%, eliminate EST use, and reduce the cost of cardiac evaluation by 21%.
  • Use of a rhythm monitor would be proposed for patients with palpitations and chest pain.
  • Study limitations included use of clinic notes to assess symptoms, history, and examination; retrospective design; possible missed cardiac diagnoses; lack of data on events outside of the study institution; and cost analysis based on 100% compliance with the algorithm.

Clinical Implications

  • In children and adolescents evaluated by a cardiologist for chest pain, 1.2% of chest pain has a cardiac cause, including pericarditis and arrhythmias.
  • In children and adolescents with chest pain, an algorithm that uses pertinent medical or family history, physical examination, and ECG findings to determine additional testing and eliminates EST results in an approximately 20% reduction in echocardiogram and outpatient rhythm monitor use and a 21% reduction in costs.

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