Pearls For Practitioners
CABG in children?
Yes! Surgical techniques developed to bypass diseased coronary artery disease in adultshave been used in infants and children. Dr. Constantine Mavroudis, Surgeon-in-Chief, Children’s Memorial Hospital, Chicago, IL, presented his experience in 208 infants and children with a variety of coronary artery diseases at the Canadian Congress of Cardiology in Quebec City in October. Of particular interest is the use of CABG in Kawasaki disease where coronary aneurysm can be seen in 25% of untreated cases. Those children with giant aneurysms measuring 8 mm or more may go on to develop obstruction with the possibility of myocardial infarction and death. Such patients are candidates for CABG,where the use of internal thoracic (mammary) artery(s) may offer good result in follow-up of 1 mo-11 yrs. The experience with saphenous vein grafts has been unsatisfactory, as they tend to block. Left and/or right internal thoracic arteries grafts are superior and have the added advantage of growing with the patient.
Hypertension in adolescents
Nearly 20% of adolescents are at risk for cardiovascular disease. For this reason, the new guidelines of the National High Blood Pressure Education Program Working Group have been updated (Cardiology Today, October, 2007). The changes mirror the Seventh Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure guidelines for adults. One change is that children with hypertension are now classifi ed as stage I or II hypertensive.
• Normotensive: average systolic and diastolic BP 90th percentile for age, height and sex at first screening.
• Prehypertensive: average systolic and diastolic BP ≥ 90th percentile, but 95th percentile at first screening; or average systolic and diastolic BP initially ≥ 95th percentile, but 95th percentile at either second or third screening.
• Stage I: average systolic and diastolic BP ≥ 95th percentile for 3 screenings, but less than 99th percentile + 5 mm Hg for at least two sessions.
• Stage II: average systolic and diastolic BP ≥ 95th percentile and > 99th percentile + 5 mm Hg for at least 2 screening sessions.
Hot off the press
Obesity as common comorbidity in children with congenital and acquired heart disease. As if they needed more aggravation, children with congenital or acquired heart disease face an additional ardiovascular risk. Study published in the Electronic Pages of the current issue of Pediatrics (November 2007), by Pinto et al., in 2921 outpatients, 1523 of them had a heart disease. Of those, 25 % were obese or overweight. In the majority of cases, the pediatric cardiologist failed to document obesity or overweight, or offer any counseling.
Carotid intima media thickness (IMT) increased in adolescents with type 1 diabetes
A recent study found an increase in the IMT in adolescents with type 1, indicating presence of subclinical atherosclerosis. In the study, 37/150 adolescents with diabetes vs. 58 controls had IMT greater than 2 SD, compared with nearly normal in the controls: mean IMT 0.463 mm ± 0.002 SD inpatients with diabetes vs. 0.421 mm 0.005 SD in the control group (p = .002) (Pozza RD et al. J Clin Endocrinol Metab 2007; 92:20053-2057). The authors wrote, “A significant increase of IMT… gives evidence for subclinical atherosclerosis. The IMT gives additional information about the vascular system and is now considered the most reliable index in the detection of early CVD.
ACE Inhibitors and Early Pregnancy: A Cause of Birth Defects?
In a study led by William Cooper, MD, at the Vanderbilt University Medical Center and published recently in the New England Journal of Medicine involving 29,507 infants, 209 of whom had been exposed to ACE inhibitors and 202 exposed to other anti-hypertensive drugs, there was a nearly fourfold increased risk of cardiovascular malformations (RR=3.72; 95% CI, 0.25-1.75), and more than fourfold risk of central nervous system malformations (RR=4.39: 95% CI, 1.37-14.02) in the ACE inhibitor-exposed group. What to do? Try other medications: chlorothiazide, chlorthalidone, hydrochlorothiazide, atenolol, acebutolol, pindolol, nifedipine (a calcium channel blocker) and reserpine have not been associated with birth defects and may prove to be a better choice.
A Word of Caution:
Stimulant drugs (Adderall, Adderal XR, Strattera, Ritalin) used to treat ADHD have made the headlines recently. In a government sponsored study reviewing 64 ER visits between. August 2003 and 2005, there were 188 events associated to unintentional use of the drugs, half of them children. The survey was prompted by reports of side effects among the estimated 3.3million children and 1.5 million adults taking these drugs. Twenty-five deaths were linked to ADHD drugs, 19 of them involving children, from 1999 to 2003. In addition, there were 54 other serious heart problems including heart attacks and strokes. In February 2006, the advisory committee of the FDA recommended that such drugs include a "black box" warning about heart risks.
More on Hypertension:
Adolescents with prehypertension and not on medical treatment or changing lifestyle are more likely to become adults with hypertension and having end-organ damage. In a study by Bonita Falkner, MD, and colleagues of Thomas Jefferson Medical College in Philadelphia and presented at the 21st Annual Scientific Meeting of the American Society of Hypertension, it was found a linear increase in the percent of adolescents classified with prehypertension to hypertension within 2 years. The progression was estimated to be 7% per year. Children and adolescents should have their blood pressure checked routinely. Those found to be prehypertensive should have their blood pressure monitored closely and encouraged lifestyle changes including a heart healthy diet and more physical activity.
SIDS and long QT:
Screening babies for long QT (LQTc) interval can save lives from SIDS. Swartz, a leading expert in LQTc in Italy, and coworkers found that approximately 12% of children diagnosed with SIDS actually have LQTc syndrome (QTc >470 msec, 2 SD above the mean). In their study, 0.9/1000-screened neonates had a long QTc. In this group, 53% had one of the known LQTc genetic mutations. LQTc syndrome is a treatable disorder with beat-blockers and AICD. "If one kid dies, it’s one kid too many". We full-heartedly agree!
Aspirin:A Wondrous Drug!
Once again aspirin (ASA) shows its place in medicine. At the American College of Cardiology annual meeting in Atlanta, a large study presented showed no significant advantage in adding the blood thinner clopidogrel (Plavix) to ASA to prevent heart attacks, strokes or death from cardiovascular diseases in high-risk adult patients. Would the same hold true for children?
Catheter ablation for asymptomatic WPW:
On 477 baseline electrophysiology (EP) studies performed by Angello et al in Italy in asymptomatic untreated patients with WPW and reported that ventricular fibrillation (VF) occurred in 1.3%, atrial fibrillation (AF) in 3.8%, and SVT in 12%. In this cohort, patients first became symptomatic at ages 12-25 years and were unlikely to develop symptoms after the age of 35 years. Cardiac arrest, syncope or sudden death occurred in 5.5% of patients. Three independent risk factors for these untoward events were: young age, inducibility of SVT or AF during EP studies, and multiple accessory pathways. Twenty-three per cent of all patients had all 3 risk factors. This particular group may benefit from prophylactic RF ablation. In our group, Dr.Ashok Mehta performs baseline EP studies in selected patients with WPW.