Five Pediatric Heart Health Practices That May Be Unnecessary

Marcia Frellick

November 05, 2020

Five common therapies and practices related to children's heart health may be unnecessary, and physicians and parents should be careful about using them, the American Academy of Pediatrics (AAP) explains in guidance released this week.

The AAP Section on Cardiology and Cardiac Surgery developed the recommendations as part of the Choosing Wisely campaign after reviewing evidence pertaining to practices common during pediatric visits, such as routinely ordering an electrocardiogram (ECG) as part of a sports exam.

The guidance lets physicians know what is not necessary or not indicated, with noted exceptions, Christopher S. Snyder, MD, chair of the section, told Medscape Medical News.

In all cases, family history is key, said Snyder, who is also chief of the Division of Pediatric Cardiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio. That means taking the time necessary to ask about aunts, uncles, and all first-degree relatives, not just asking the single question of whether a patient has a family history of cardiac problems.

The following are the targeted practices and the AAP's guidance on each.

ECG for Sports Participation

A screening ECG should not be ordered as part of a routine sports entry examination in otherwise healthy patients who have no symptoms and no personal or family history of cardiac disease, the committee says.

Some medical societies argue that all children who participate in sports should have an ECG, but, Snyder said, "Currently there are no data that support that, especially in the United States."

ECGs often yield false positive findings, he noted: "About 10% of them will say the child is a little abnormal."

That can be a particular problem in places with few or no pediatric cardiologists, because kids can become sidelined from sports without access to experts who could clear them.

"In the US," he said, "we believe that the preparticipation physical exam and screening, which is routine for all high school athletes for sure and most athletes who compete in sports, is currently good enough."

However, he warned, patients with a family history of heart disease need to see a pediatric cardiologist, and "those patients need an ECG."

The test is not perfect, though, he notes: "You could get your screening, go home, get a fever, COVID, something like that, and come back and have myocarditis and drop dead."

ECG Before ADHD Therapy

Similarly, a screening ECG is not routinely needed before initiating therapy for attention-deficit/hyperactivity disorder (ADHD) in asymptomatic, otherwise healthy children who have no personal or family history of cardiac disease, according to the new guidance.

Snyder says that it has become routine for children to undergo an ECG before ADHD therapy, but evidence doesn't support the practice, and with the rise in the number of ADHD diagnoses, the tests have increasingly become a burden.

Twenty years ago, the prevalence of ADHD was 3% to 4%, Snyder says. It is now almost threefold higher.

The AAP committee points out that when ECG abnormalities are identified, they rarely lead to a change in ADHD therapy.

Additionally, the typical stimulants used to treat ADHD "have never shown any major effect on the heart," Snyder said.

"Black box warnings have been put on these medications, but nothing has been found in the very routine stimulants in normal, routine doses to warrant an ECG," he said.

Echocardiogram for Syncope

The committee says routine use of echocardiograms for children with syncope is unnecessary unless a child has a concerning history or ECG abnormalities.

Most patient who have true syncope or are passing out or fainting are diagnosed through thorough family history, Snyder said.

"The vast majority of those need an ECG to rule out one other cause that can do this and a physical exam. If those things are normal, there really is no indication to do an echocardiogram," he said.

"If the patient passes out while they're running, they pass out doing strenuous exercise, or they pass out for 10 to 15 minutes as opposed to 20 seconds ― those are the ones that need a thorough cardiac workup. But routine passing out, waking up in seconds, those do not."

Echocardiogram for Chest Pain

Children with chest pain do not need an echocardiogram unless an ECG is abnormal or the patient has a concerning history, according to the new recommendations.

Too often, Snyder said, providers treat kids as they would adults.

"Often it comes down to what you learn in medical school," Snyder said. "In medical school, we have 6 weeks of cardiology and we had 1 hour of pediatric cardiology."

That younger patients will clog their arteries with fatty foods and high lipids "is really exceptionally rare," Snyder said.

Chest pain "rarely, if ever" means heart attack in younger children, he added.

A thorough history and complete physical exam are critical, "without jumping immediately to an echocardiogram, which 99.9% of the time is going to be normal," he said.

Troponins for Chest Pain

In addition, a typical workup for pediatric chest pain need not include prescribing troponins unless there is a concerning history or ECG abnormalities.

Snyder notes that kids with chest pain are often brought to emergency departments that are not pediatric-specific, and thus clinicians turn to the standard treatment for adults with chest pain: ECG and troponin.

"The reason we in pediatric cardiology don't love this is that troponins tend not to be specific just for heart in kids," Snyder said. "If someone has anginal chest pain — shortness of breath, chest pain doing anything and everything, [chest pain that] occurs when they're exercising, feels like an elephant standing on their chest — then we do encourage troponins on those patients."

The guidance discourages ordering troponins without careful consideration of the patient's age and condition, he said.

This list was developed by faculty in Pediatric Cardiology at University Hospitals in Cleveland, Ohio. It was revised and approved by the AAP Section on Cardiology and Cardiac Surgery and the AAP Executive Committee.

Are there other procedures you see commonly performed that you consider unnecessary? Share your examples in the comments.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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