hidden

How will COVID-19 Affect Return to High School Sports and ECG Screening?

August is traditionally very busy month in the pediatric cardiology office; visits for “sports clearance” flood the schedule due to something picked up on a high school sports physical such as chest pain. Most of these will be non-cardiac and receive reassurance; however, the cardiac causes in the pediatric population can be quite distressing. With the current COVID-19 pandemic we are seeing many cardiac effects of the virus— myocardial inflammation, dysfunction and coronary artery dilation or MIS-C (multisystem inflammatory syndrome in children). There has also been a reported increase in out of hospital cardiac arrest in the adult population, which could be attributed to those afraid to seek care, but none the less, a concern.

Cardiac effects play an important part in the recent discussions on return to school, as eventually return to school will mean return to school sports. Sports cardiologists have been following this closely and have been working to establish a safe way for return to sports in competitive athletes who have had COVID-191(click here for recommendations and see flowchart below), which may include extensive cardiac testing of those who had symptomatic COVID-19, most of which is based on the return to play myocarditis guidelines.2 These important decisions require individualization, knowledge of risk and what is happening in the community.

So what does this mean for the high school athletes? There is no doubt that exercise is great for everyone, especially with the rising obesity and the sedentary lifestyle. Organized sports participation has shown to have a positive impact on mental and physical health that extends beyond childhood.3 Many have raised concerns about the development and health of children by not attending school, along with decrease in social interaction and activity from organized sports during the stay-at-home orders and while we work to defeat COVID-19 spread.

Prior to the pandemic, the question of universal ECG testing for high school athletes always started a conversation, but could that change? Critics say that the false positives create distress and extra healthcare cost, that follow up is problematic and that it has not been shown to change outcomes. Others argue saving one child from the devastating event of collapsing and dying on the field is worth it, and a recent study showed ECG with H&P is more likely to detect a condition associated with sudden cardiac arrest (SCA) than H&P alone, and also improved cost efficiency when interpreted in the right hands.4 All agree it is important to have a good plan in place for SCA at all sporting events, including an emergency response plan in place specific to cardiac arrest.

With so many affected by the virus, at varying severity, I can’t help but wonder if this will change the way we assess our young athletes for participation in sports when it is safe to do so. While healthcare costs are always a problem, with a new virus and unclear long-term outcomes, we must be conservative. Perhaps this may provide an opportunity to learn more about ECG screening, as we will likely see a larger amount of patients who have had COVID-19 coming to our offices for clearance. This may provide an opportunity to gather evidence on the continued debate of whether ECG screening is effective.

Until we know more, what we do know is it is safer to be conservative, to assess benefit and risk and provide appropriate counseling to families on signs and symptoms of SCA. We also must continue to reassess and stay up-to-date on new knowledge and testing related to COVID-19 recovery and sports. Most importantly, it is important that we continue to advocate for heart safe schools which include having AEDs, training in CPR, and emergency response plans related to Sudden Cardiac Arrest. With more kids participating in school from home, this could be a great opportunity to engage the whole family in CPR and AED education to improve the safety and survival of our communities and at home.

 

References

  1. Phelan, Dermot, et al. “A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection.” JAMA Cardiology, 2020, doi:10.1001/jamacardio.2020.2136.
  2. Maron, Barry J., et al. “Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task  Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis.” Journal of the American College of Cardiology, vol. 66, no. 21, 2015, pp. 2362–2371., doi:10.1016/j.jacc.2015.09.035.
  3. Logan, Kelsey, and Steven Cuff. “Organized Sports for Children, Preadolescents, and Adolescents.” Pediatrics, vol. 143, no. 6, 2019, doi:10.1542/peds.2019-0997.
  4. Harmon, Kimberly G, and Jonathan A Drezner. “Comparison of Cardiovascular Screening in College Athletes” Heart Rhythm, 2020, www.heartrhythmjournal.com/article/S1547-5271(20)30406-9/pdf.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

A Graduating Fellows Guide to Pediatric Cardiology Resources

July is an important month for medical education— whether it’s graduating from med school and starting intern year, finally becoming a senior or starting fellowship.  With fellowship ending for me, and starting for many, I started to compile a list of resources for pediatric cardiology to share.

Many of these resources were passed down to me by seniors or mentors, but also many were found on twitter (read more about how you can use this to your advantage in my previous blog). Some emerged recently during COVID-19 in an effort to bring pediatric cardiology together virtually and bridge education gaps for webinars, lectures and more.

For online resources, I recommend creating a folder on your browser and saving sources for easy access later. Another helpful thing for me was saving the links to Moss & Adams, Mayo Clinic Board Review, & Lai echo e-books in this folder so that you can access them anytime and not have to carry the books around(you can find the codes in the front cover of the book).

Below are websites for great lectures, webinars and reading, clinical resources, apps, podcasts, important organizations and ways to find job postings. Enjoy and please share!

Websites for Lectures, Reading and Resources:
Heart UniversityEducational video on pediatric and adult congenital heart disease (ACHD) includes pathology lectures by Dr. Robert Anderson. They also host great webinars on various topics with leaders in the field.
SPCTPD PC-NES (Pediatric Cardiology National Education Series), a lecture series that was started to provide education to fellows during the pandemic— you can access all the previous lectures that were given on various topics with lecturers from around the country, this is planned to continue in the fall.
SCMR– Cardiac MRI case based webinars.
ACHA– ACHD association with webinars on various topics.
Dr. Robert Pass EP lectures; Excellent weekly EP conferences(Mondays 7am EST) with the Mount Sinai pediatric cardiology fellows, past conferences are on this YouTube page and the link to join live is sent via pediheartnet(see below), you can also find Dr. Pass on his podcast(below) and on twitter!
Multimedia Manual of Cardio-thoracic Surgery Surgical videos and descriptions geared towards surgeons but helpful to explain and see common CHD procedures).
Cardiology Notes– Summaries of various chapters from Moss & Adams, Lai Echo, as well as other pediatric cardiology tests and resources.
Parameterz website for Z scores to use for echo, easy to use on desktop or phone
Virtual TEE (Toronto) – TEE simulator.

Podcasts:
Pediheart– Peds Cardiology Podcast hosted by Dr. Robert Pass (above) – review of recent literature and topics usually with a great guest, tune in each week (released Friday) and learn to appreciate Opera too.
CardionerdsMostly geared toward adult cardiology with some overlap to Peds.
PCICS– Cardiac ICU topics and discussion with various leaders in the field.

Apps: (links are to the apple store, but they should be available through google play too!)
EP tools lite– Various EP calculators including WPW pathway localization tool.
Heartpedia Great resource for education for patients, medical students and residents with easy to use interactive diagrams of common CHD and repairs.
Pacemaker Using the patient’s chest XR, snap a picture of the pacemaker and this will tell you who the maker is (Medtronic, St. Jude, etc.)
Practice Update– Follow topics (i.e. Cardiology) and receive virtual “stacks” of the latest literature on that topic with quick reviews and links to full text.
Dimity– Use this app to make patient phone calls from your phone so your number shows up as the hospital line and not your number or unknown. Very helpful for home call!

Conferences/Organizations: all conferences through 2020 are now virtual allowing you to access more content. Remember as a fellow your membership and registration is usually discounted or free, take advantage while you can!
ACC Annually in March.
ASE Annually in the summer (virtual August 8-10) and only $75 for fellows).
PICS-AICS Cath focused conference annually in September.
AHAAnnually in November.
PCICS Annually in December for those interested in cardiac ICU. Bonus fact- they are also hosting virtual meetings on experience and research related to COVID-19 and pediatric cardiac care.
PAC3, PC4 & NPC-QICCollaborative organizations to improve outcomes in congenital heart disease, along with these are great organizations for quality improvement and outcomes research and hold an annual conference along with webinars.
CHOP pediatric cardiology update  Annual dedicated pediatric cardiology conference in February.

Job Postings: below are links to sites that may be helpful as you are looking for jobs, don’t hesitate to reach out to people, have your mentors reach out or cast a wide net, you may find opportunities that aren’t posted.
Pediheartnet- A list server with job postings; this also facilitates discussion between cardiologists around the world, this is the server that the weekly EP conferences (above) will be sent out on and other great opportunities- a must join!
Other sites for job postings-
Congenital Cardiology Today
CareerMD Pediatric Cardiology Job Bulletin
NEJM Career Center ACC Career & AHA Career Centerrefine your search by specialty and receive emails with new postings.

Happy July, and don’t forget to be kind and welcoming to someone new in the hospital, you were there once too!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

How My Hospitalization During COVID Changed Me as a Physician

Takatsubo Cardiomyopathy, known as “broken heart syndrome,” is a form of heart disease that occurs following a traumatic or stressful event; people may present after the death of a loved one or other tragic accident. Thanks to COVID-19 we are currently in a time of great stress. The stress response of a global pandemic is something that we will see the effects of long after the treatment and vaccine are developed. There are many new reports and articles focusing on the stress related to COVID-19, tips to help combat that stress and guide wellness, and even some hospitals setting up wellness teams and meetings in the hospital to support the staff.

Early on we saw the stress associated with staying home— stress of the unknown and the lack of human contact, as well as stress with going to the hospital for any illness. Many saw a decrease in typical ER consults and patients who wanted to come to the outpatient clinics for fear of the disease, many were furloughed or lost their jobs. Patients admitted for COVID and non-COVID alike have experienced a different kind of stress: on top of the typical stress of hospitalization, there are often no visitors or family allowed at their side.

Visitor restrictions have left patients and parents facing already stressful admissions, with less support from family and/or caretakers. While hospital staff have adapted and learned unique ways like video chat and providing more frequent updates to families to bridge this isolation, it is still a difficult and stressful process.

I experienced being a patient during COVID-19 when I delivered my first baby this May, followed by what any pediatrician, including myself, would consider a minor/routine readmission for my daughter a few days after birth. We were admitted at the hospital where I work, so it was more familiar to me, and my husband was allowed to visit us during the birth (but not my daughter’s admission). While there was no lack of empathy or care from the staff, this was still a very stressful time for me without the physical presence and support of my family and friends being allowed in the hospital with us. I cannot imagine how much more stressful this would have been for someone who does not work in a hospital, had never been in a hospital, or was not allowed any family members present.

One positive thing that came out of this stress for me was a new appreciation and respect for my patients and their parents. Despite being able to FaceTime family, I was surrounded by new faces and a new experience; it was a scary and isolating few days. I realized that something I always felt was routine or minor as the treating physician, didn’t seem that way when I was laying in the hospital bed myself or hovering over my newborn’s crib. I realized that I can use this experience to better myself as a clinician and that what may be routine or minor for me the physician, may be that patient or parent’s worst day.

The way healthcare workers have gone above and beyond to try to engage and support those in the hospital is to be applauded and respected, and I think the lessons learned during this time will go a long way into life after COVID-19. We need to continue to find ways to incorporate family and friends who cannot physically be present, and reduce some of the stress and isolation that admission to the hospital carries.

COVID-19 doesn’t discriminate based on age, race, gender, occupation, identity, or even infection status; it affects everyone whether you have the virus or not. The physical effects of stress may not always be as obvious as something like Takatsubo Cardiomyopathy, but they are nonetheless important to recognize and treat. We as physicians should continue to take the time to respect and assess the mental health of not only ourselves, but all of those around us, and engage the full person into our care while adapting to new and uncomfortable situations.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Changes to CPR and Response to Cardiac Arrest with COVID-19

When it comes to survival of out of hospital cardiac arrest (OHCA), many advances have been made over the years, 1 early and high-quality chest compressions and defibrillation are key components of this. However, even prior to coronavirus and COVID-19, many bystanders are still hesitant to perform CPR for a variety of reasons; fear of litigation, fear of causing harm, or due to concerns about infectious disease transmission.2 In the new age of social distancing and a highly infectious disease causing stress on our world, the hesitancy may increase. In addition, many programs who have been key in providing education, such as CPR training, have come to a halt during this time.

CPR is generally considered an “aerosolized” procedure, 3 a procedure conveying high risk of transmission of disease via respiratory droplets. Resuscitation efforts in and out of hospital require multiple people in close proximity to each other to respond. In addition, COVID-19 has been reported to cause myocardial injury and ventricular arrhythmia that may predispose someone to cardiac arrest, 1 and despite a pandemic, sudden cardiac arrest and other causes of death do not decline. A concern rising in the medical community since shelter-in-place laws and changing stresses on our medical system, is a notable decrease in visits to the Emergency Departments for common complaints and concerns, such as chest pain, syncope and other things that may dispose someone to a cardiac arrest. We need to be aware of this happening in the community and the potential need for lay and EMS response in these situations.

Lay persons and dispatchers play a key role in survival efforts such as initiating CPR and early defibrillation. There has been documented success with telephone CPR and CPR guidance by dispatchers. An important component of ensuring the best survival of the community and those with COVID-19 or potential COVID-19 is communication and a well-developed community plan to ensure timely and quality resuscitation to patients while protecting rescuers. Recently, Circulation has released Interim Guidance and Advanced life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19,1 a quick review is here. Resources from King County EMS in Washington are available for establishing a community response and plan here.

Overall, the common themes are aimed at adequate personal protective equipment (PPE), reducing the number of people responding to an event, and in the case of OHCA for lay people, focusing on hands-only CPR.

For lay persons, the majority of SCA occurs at home. The likelihood of already being exposed to a household contact is high and should be considered when responding to an arrest; for adults hands-only CPR with high-quality compressions is encouraged with early activation of EMS and defibrillation(not an aerosolizing procedure), if available. In the case of pediatric resuscitation, due to the high likelihood of respiratory arrest causing cardiac arrest, it is advised that if willing, after weighing the risk and benefit, that rescue breaths are provided along with compressions. You may use a cloth or mask covering over the victim’s mouth to help reduce transmission in the event it is not a household member.1

For EMS providers, dispatch is crucial in screening calls for any possible risk of exposure to COVID-19, based on symptoms in the victim or any recent contact or household members, and advising whether doing PPE is recommended to the EMS team.1 In Seattle, they have shown a very low rate of transmission to EMS providers when wearing the appropriate PPE.4

For in-hospital cardiac arrest, it is again important to reduce the personnel involved in the resuscitation, close the door when possible, and consider adding PPE to the code carts.  It is also important to use HEPA filters and closed circuit ventilation strategies when it comes to ventilation. The guidance also encourages early intubation by the provider with the highest qualification with the best chance for successful intubation, and use video laryngoscopy when able to minimize aerosolizing the virus while securing a closed circuit airway. The guidance also suggests that if patients are prone and intubated to perform CPR without moving the patient in the standard T7-10 vertebral bodies, however, if they are not intubated to attempt to place them supine and proceed with resuscitation.1

The article also discusses the importance of clarifying goals of care and advanced directives upon arrival, as well as proposes a careful evaluation in the cases of out of hospital cardiac arrest with inability to obtain ROSC, suggesting in some cases, this may be a reason to avoid transport to the hospital due to low likelihood of survival. However, it is important to take into consideration with the benefit, risk and ethics involved.1, 3

Another important update is in regards to maintenance of certification such as BLS/ACLS/PALS. As of March 13, the AHA has offered a 60 day extension for instructor cards and also recommends extension of provider cards for the same length, this allowance is open to be extended based on the evolving threat and CDC/public health recommendations, read the statement here. 5

Many people are looking for things to do in this time of sheltering in place, perhaps this could be an opportunity for education and learning on CPR and AED’s. There are many online resources available, and with the advent of telemedicine, zoom learning and video visits increasing, perhaps we could use this as an opportunity to increase our virtual presence for CPR education.

If you’re interested in some online resources, check out the ILHR website, or your local education center’s website.

  1. Edelson, Dana P, et al. “Interim Guidance for Life Support for COVID-19.” Circulation, ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463.
  2. Scquizzato, Tommaso, et al. “The Other Side of Novel Coronavirus Outbreak: Fear of Performing Cardiopulmonary Resuscitation.” Resuscitation, vol. 150, 2020, pp. 92–93., doi:10.1016/j.resuscitation.2020.03.019.
  3. Defilippis, Ersilia M., et al. “Cardiopulmonary Resuscitation During the COVID-19 Pandemic: A View from Trainees on the Frontline.” Circulation, Sept. 2020, doi:10.1161/circulationaha.120.047260.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 

hidden

COVID-19; Patients with Congenital Heart Disease (CHD)

This week, the ACHA (American Congenital Heart Association) hosted a webinar in regards to Coronavirus aka SARS-CoV-2, and the illness it causes, COVID-19, 3,000 attended (view the recording here.) CHD patients, parents of CHD patients and CHD providers had the same question, how does this virus affect this special population? Unfortunately, the data is lacking on coronavirus those with CHD and there is a lot we don’t know.

A recent study1 in China looked at 2143 pediatric patients with COVID-19, the majority (94.1%) were asymptomatic or mild, more severe cases, were seen in infants (<1 year old) than older children, and there was only one death. This study lacks details, such as what other medical conditions they may have. Severe cases were 5.9% compared to 18.5% in adult population studies. Although reassuring for the general pediatric population, we still don’t know how this applies to pediatric patients in the United States and those with CHD.

What we do know.

There is a trend toward overgeneralization of “heart disease,” particularly in the media. It has been noted that the COVID-19 affects older adults and those with “heart disease,” meaning cardiovascular disease(CVD), such as coronary artery disease and hypertension, more severely.2 This does not include Congenital Heart Disease.

The virus may also cause myocardial injury, with reports of myocarditis and arrhythmias in those with severe cases.2-4 The effect is thought to be related to Angiotensin-converting enzyme 2(ACE2), which, in animal studies, has a role in the cardiovascular, and immune system and has been identified as a functional receptor for coronaviruses.2,3

Many patients with CVD and CHD take a medication known as ACE inhibitors or an Angiotensin Receptor Blockers (ARBs). The use of these medications is common in both populations, but for different indications, as their “heart disease” is not the same. There are trials assessing the use of these medications and effect on COVID19 in adults, and varying theories on whether they are protective or not, with that said, the HFSA/ACC/AHA currently recommends continuing these medications as prescribed.5

Are patients with CHD considered high risk?

The answer is we don’t know. With a wide range of congenital heart disease, from repaired/“normal” hearts, to those with altered blood flow, lung abnormalities, and arrhythmias. As  mentioned, the CDC places those with “heart disease,” meaning those with CVD, and older adults, at high risk of severe illness,6 this does not include CHD, however, CHD patients aren’t immune to CVD and if a patient has CVD and also CHD they are considered high risk.

With data lacking in many populations, it is important for those considered at high risk for other viruses, like influenza, such as CHD, asthma and those who are immunocompromised, to take appropriate precautions. It is better to be over prepared and over cautious.

Follow up and Communication.

CHD patients should keep in close contact with their medical team and stay updated with recommendations of their team and the CDC (found in detail here), like social distancing, good hand hygiene and staying home if you are sick. Concerning symptoms that require further evaluation include shortness of breath (or fast breathing in infants), chest pain, and palpitations.

 As far as visiting your doctor, you will likely be asked to either re-schedule or have a telephone visit. You can ask your medical team about this option and even anticipate it for the next few months. Elective procedures, catheterizations and imaging will likely be delayed. If one good thing comes out of this pandemic, it may be better options and availability for telemedicine in the future.

Keep your Mind Healthy

Use this time to support your mental health— pay attention to the news and social media, but set timers so you don’t over-saturate yourself. Find the book you’ve had on your shelves that you’ve been too busy for and set aside time every day to read, call or FaceTime friends, and maybe even fill up your bathtub and relax!

Meditation and exercise are also great options, and many apps offer free trials. Calm and Headspace have some free mediation content and free trials. Peloton & DailyBurn offer free day trials with a variety of classes(Tip: If you do choose a free trial, be sure to set an alarm on your calendar before the free trial is over so you can choose if it’s worth continuing for a fee or not.) There are also options to support your local gyms and studies virtually with on demand classes, just check out their websites and/or Instagram.

There is so much unknown, which causes us to worry and discomfort, but we are learning more each day. Stay informed, stay safe, wash your hands and try to keep your mental health in check.

For more on coronavirus and heart health, read Noora Aljerhi’s blog (3/9/2020) on the early career voice.

  1. Dong, Yuanyuan, et al. “Epidemiological Characteristics of 2143 Pediatric Patients with 2019 Coronavirus Disease in China.” Pediatrics, 2020, doi:10.1542/peds.2020-0702.
  2. Hui, Hui, et al. “Clinical and Radiographic Features of Cardiac Injury in Patients with 2019 Novel Coronavirus Pneumonia.” 2020, doi:10.1101/2020.02.24.20027052.
  3. Zheng, Ying-Ying, et al. “COVID-19 and the Cardiovascular System.” Nature News, Nature Publishing Group, 5 Mar. 2020, nature.com/articles/s41569-020-0360-5?code=85e25438-46d1-4753-bfdd-84496a98b564.
  4. Hu, Hongde, et al. “Coronavirus Fulminant Myocarditis Saved with Glucocorticoid and Human Immunoglobulin.” European Heart Journal, 2020, doi:10.1093/eurheartj/ehaa190.HFS/ACC/AHA statement
  5. “HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19.” American College of Cardiology, 17 Mar. 2020, acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19.
  6. “If You Are at Higher Risk.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Recognizing Congenital Heart Disease (CHD) as an Important Part of #HeartMonth; Important Considerations for Healthcare Providers

Congenital Heart Disease (CHD) is a diagnosis that often causes confusion, concern, and fear, not only for family and patients but also for healthcare providers who are not exposed to them frequently. February is Heart Month; it is important that we take time to recognize the youngest of our heart patients, as well as those who are now adults living with Congenital Heart Disease.

CHD is the most common congenital malformation in newborns and there are great than 1 million adults now with CHD in the United States,1 which makes it important for every health care provider to know about; it requires understanding of sometimes complex physiology, a high index of suspicion, and most importantly a multidisciplinary approach to care with the patient and often parent at the center. For a review on CHD you can click here3, but below are some important things to consider:

  • CHD does not always present at birth and can be missed on routine prenatal obstetric ultrasound, fetal echocardiogram, and the neonatal pulse ox screening. Fortunately, not all CHD requires surgery or intervention at all.
    • General OB ultrasounds and fetal echo will likely catch major congenital heart disease, but there are some smaller lesions that are difficult to diagnose due to normal fetal circulation, which is abnormal after birth.
    • The pulse ox screen was initiated in 2011 to improve detection and outcomes in critical congenital heart disease that could cause hypoxemia and a higher risk of death early on; these lesions are typically prostaglandin dependent and outcomes can be improved if addressed early on.2
    • CHD is often associated with extreme clinical situations, but many infants with CHD will not present this way and may not require surgery at all. They still require follow up with a pediatric cardiologist.
  • CHD is not always “cured” but often palliated, and these patients can have different hemodynamics to consider as a result.
    • While many patients receive surgery to create a “normal” heart, many infants born with complex congenital heart disease will require multiple surgeries, termed palliation, that create a new way of circulation (such as the Fontan Procedure4). Altered hemodynamics(blood flow) are important to understand and it is important to know what surgeries have been performed.
    • Some surgeries, while restoring normal or near-normal can still put patients at risk for long term issues that need to be followed closely such as heart failure, hypertension, valvar issues or arrhythmias.
  • There are now more adults living with CHD than children.
    • Thanks to advances in medicine and surgery, adults now represent the largest population of patients with CHD. While many of these patients are healthy and can live normal lives, they still need lifelong care with providers who specialize in CHD.
    • It is important to encourage adolescents with CHD to learn about their diagnosis early on and take their health into their own hands. The transition to an adult congenital heart disease (ACHD) provider is something that needs to be encouraged not only by pediatric cardiologists but primary care physicians and adult cardiologists
    • Most CHD patients can, and should be encouraged to, participate in a healthy lifestyle including exercise; however, this should be in discussion with a CHD provider to help provide guidance.
    • Click here5 to find an ACHD specialist near you.
  • CHD parents and patients are great resources of knowledge and want to be heard.
    • CHD parents and patients are their best advocates and are often the most knowledgeable about their heart and what they have been through. It is important to take their complaints and concerns seriously. Do not be afraid to ask them questions and learn their history.
  • CHD requires a multidisciplinary approach; CHD providers are willing to answer a call and collaborate.
    • CHD patients may be at higher risk for psychological issues such as depression and anxiety related to living with chronic disease.6 They are also not free from other cardiovascular problems that are not necessarily congenital, such as coronary artery disease and stroke1, which is why collaboration amongst specialties is crucial.
    • If you have a question, concern or need more help; never hesitate to reach out to your hospital or patient’s CHD specialist. We are here to help, educate and provide the best care for our patients.

CHD represent a population of heart patients that is consistently growing with continued advances in medical care. Everyone in healthcare is likely to be exposed to these patients during their career, therefore a multidisciplinary, patient-centered approach is important to continued success in the field.

 

  1. Wang, Tingting, et al. “Congenital Heart Disease and Risk of Cardiovascular Disease: A Meta‐Analysis of Cohort Studies.” Journal of the American Heart Association, 9 May 2019, ahajournals.org/doi/10.1161/JAHA.119.012030.
  2. Engel, Melissa S, and Lazaros K Kochilas. “Pulse Oximetry Screening: a Review of Diagnosing Critical Congenital Heart Disease in Newborns.” Medical Devices (Auckland, N.Z.), Dove Medical Press, 11 July 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4946827/. Puri, Kriti, et al. “Congenital Heart Disease.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Oct. 2017, pedsinreview.aappublications.org/content/38/10/471.
  3. Puri, Kriti, et al. “Congenital Heart Disease.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Oct. 2017, pedsinreview.aappublications.org/content/38/10/471.
  4. “The Royal Children’s Hospital Melbourne.” The Royal Children’s Hospital Melbourne, rch.org.au/cardiology/parent_info/Information_for_patients_and_parents_about_the_Fontan_Operation/.
  5. “Adult Congenital Heart Association – Home.” ACHA, achaheart.org/.
  6. Areias, Maria Emília Guimarães, et al. “Long Term Psychosocial Outcomes of Congenital Heart Disease (CHD) in Adolescents and Young Adults.” Translational Pediatrics, AME Publishing Company, July 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4728933/.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

We Need to Be Better About Recognizing Sudden Cardiac Arrest

“10-year-old dies of an apparent heart attack on Delta flight,” “High School Football Player Dies Suddenly,” “Teen Dies on the Court,”— these stories shock the community, cause people to ask questions, and are too soon forgotten. We need to be better about recognizing cardiac arrest in the young, and that starts with better cardiac arrest education. Many people do not realize the difference between cardiac arrest and myocardial infarction or “heart attack.” While a heart attack is often preceded by chest pain and other symptoms, cardiac arrest is usually not.

Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating; 1 this can be due to a structural abnormality of the heart, a rhythm disturbance, or often an unknown cause.2 A heart attack usually has a different cause, occurring when the supply of blood to the heart becomes blocked, typically by a plaque or blood clot in an artery.3

Sudden Cardiac Death (SCD) is the leading cause of death in athletes during a sport.4 Delay in recognition leads to a rapid decline in survival, with a decline of survival by 10% for every 1-minute defibrillation is delayed.5 Studies show that survival can be improved if AED is applied and used within 3-5 minutes of arrest. Schools with on-site AED demonstrate survival from SCA as high as 71%.4 However, in order for proper AED use to occur the arrest must be recognized quickly.

What makes it hard to recognize sudden cardiac arrest?

  • Lack of Education on the subject— SCA is not on peoples’ radar for the young patient. Our brains are programmed to think about heart attacks involving older people clenching their chest, sweating, proclaiming pain, and not about SCA, which is much more silent. Anyone who suddenly collapses and is non-responsive to verbal stimuli should be treated as a sudden cardiac arrest until proven otherwise.5
  • SCA may present with seizure-like activity; in as many as 20% of SCA events, there will be myoclonic jerking activity such as shaking, quivering, or twitching.5 This activity may lead to observers mistaking the arrest for a seizure and not applying the right emergency protocol.
  • A victim of SCA may still be “breathing”; Agonal respirations/gasping appear like chest and abdominal movement. These breaths can be mistaken for breathing, but are ineffective to sustain life.4
  • Lack of AED’s or access to AED’s and Emergency Action Plans (EAP); some schools may not have AED’s, or they are locked after hours in an office or locations far from the athletic venue. Surveys have demonstrated that low socioeconomic status, schools with primarily black race, and rural schools are the most common barriers to AED use.6

Recently, the Parent Heart Watch has started a campaign to make the use of AED’s easier and to educate the public on their use with the campaign Call, Push, Shock. In addition, Dr. Jonathan Drezner and the NFL to educate the public on recognizing sudden cardiac arrest (Recognize, React, Rescue). These resources are helpful in sending a unified message to the public, providers and to everyone involved to help save lives.

What can we do to improve?

  • Early recognition and emergency activation – Suspect SCA in any collapsed or unresponsive athlete/person and call 911 immediately.
  • Access to early defibrillation – the goal is less than 3-5 minutes until the first shock.
  • Provide high-quality CPR and early access to advanced life support/EMS – Currently, the average time of EMS arrival is 6.1 minutes and can be longer in some communities.4 The more people trained and educated to start CPR while awaiting EMS, the better the outcomes.
  • Make sure all venues have EAP’s that encompass the above and more. An EAP should be established at any athletic venue and should be specific to the athletic venue. An effective EAP should encompass emergency communication (working with local EMS and having a detailed location/address of the venues available, including directions to access points from major roads), personnel, and equipment. They should be reviewed and practiced annually to ensure they work with mock SCA scenarios.
  • Continue to push for legislation to enforce the use of AED’s in schools. As of 2017, only 17 states required AED installation in schools, and only 5 of these offered funding for AED equipment.7

Want to learn more? Check out the Call, Push, Shock page to explore the mission and find local organizations— chances are there is a passionate person in your state or city who has been directly affected by SCA and could use your support and help!

 

Sources:

  1. “You Can Save A Life from Sudden Cardiac Arrest.” Call, callpushshock.org/.
  2. Harmon, Kimberly G. “Incidence and Etiology of Sudden Cardiac Death in Athletes.” IOC Manual of Sports Cardiology, 2016, pp. 63–73., doi:10.1002/9781119046899.ch7.
  3. “Heart Attack.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 30 May 2018, www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106.
  4. Toresdahl, Brett, et al. “Emergency Cardiac Care in the Athletic Setting: from Schools to the Olympics.” British Journal of Sports Medicine, vol. 46, no. Suppl 1, 2012, pp. i85–i89., doi:10.1136/bjsports-2012-091447.
  5. Drezner, Jonathan A., et al. “Inter Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement.” Prehospital Emergency Care, vol. 11, no. 3, 2007, pp. 253–271., doi: 10.1080/10903120701204839.Soun ds
  6. Saberian, Sepehr, et al. “Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.” The American Journal of Cardiology, vol. 122, no. 9, 2018, pp. 1565–1569., doi:10.1016/j.amjcard.2018.07.015.
  7. Lou, Nicole. “Few States Require AEDs in Schools.” Medical News and Free CME Online, MedpageToday, 27 Mar. 2017, www.medpagetoday.com/cardiology/arrhythmias/64159.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

hidden

Using Twitter to Your Advantage Professionally

Created in 2006, Twitter became a new form of social media. I joined, but wasn’t very active. If someone were to have told me that tweeting would be a way for me to stay up to date in my field of pediatric cardiology, to network with people professionally and to share in experience with a community of physicians, I probably would have laughed.

Fast forward to November of 2019 and I am sitting in my first conference as an AHA Early Career Blogger, busy “live tweeting” updates, “hash-tagging” and connecting, hoping I could help spread the work and engage the audience that couldn’t travel or make their way to the sessions. I also found myself searching the #AHA19 hashtag for information on other things going on at the conference or programs I may have missed. This allowed me to learn from the many different coinciding lectures without being in several places at once.

So why should you get on Twitter if you aren’t already?

  1. Twitter can be a great opportunity for you to learn from conferences you cannot attend in person, or parts of conferences you may miss. One of the best ways to get involved in this is following the society’s twitter page, such as @AHAmeetings and @AHAscience, this is often the source of the conference “hashtag” with updates on when, who and how to follow and when other conferences are coming. Your “twitter community” can also be a good source for these.
  2. Twitter is a great way to get to know people and science in your field. Finding your twitter community can take some searching, but it’s pretty easy. For example, there is #cardiotwitter, #medtwitter, #tweetiatricians, and more! Just do a simple search with key words and start looking for people, topics and hashtags to follow.
  3. Twitter is a great opportunity to discuss challenging or interesting cases (with patient permission of course) with a world of minds at your fingertips; providing an area to connect with healthcare providers at other institutions to share ideas and collaborate. You can use your community’s hashtag to help engage them and so it’s easily searchable. Twitter also allows you to create polls to ask questions.
  4. Twitter can provide a community of people who understand the stress, demands and struggles we deal with as physicians. Communities such as #SoMe and #womeninmedicine often post about what it’s like to be a physician and provide helpful “tweetorials” or online discussion on topics from medicine to wellness.
  5. Twitter provides a way to connect with the community, to advocate and to explore; there are more than just physicians on twitter and a world of opportunities to explore. Plus, some people on social media can be quite entertaining. Make sure to spice up your twitter with other things that interest you outside of medicine likes sports, news and entertainment!

 

Is there a downside to Twitter? As with any technology and social media, it can be addicting; if you post an opinion you may be met with resistance or a crowd of people who disagree; and some may simply find Twitter isn’t for them. But overall, the community, the learning and the networking opportunities to me, outweigh the downsides, and like all things, use in moderation is key.

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

hidden

Engaging the Youth with Technology in CPR Education

You would be hard-pressed to find anyone who would counter the argument that education in Cardiopulmonary Resuscitation (CPR) is very important; you would also struggle to find anyone in the healthcare field who would not counter you if you said you said you found the experience of becoming certified and re-certified exhilarating or “fun.”

Every year the AHA Resuscitation Symposium gathers minds from around the world, researchers dedicated to the advancement and promotion of advances related to CPR and traumatic injury. The areas of interest are vast, exciting, and enough to span two full days, arguably more, bringing people from all specialties and careers. It includes up and coming updates on intra-arrest monitoring, outcomes and also research in education and retention of CPR training.

One of the constant battles in training is getting CPR education taught in schools; fraught with barriers such as cost and time, and despite mandated legislation, not always successfully implemented (Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey)1. So what can we do to change this?

 

Make CPR training fun.

New areas of research and technology promise more realistic training; in exchange this can be more engaging. David Sarno and Dr. David Axelrod, a pediatric cardiologist at Stanford, are founders of Lighthaus Inc,2 who with the AHA, have developed VR (Virtual reality) CPR; the simulation takes VR equipment and recreates a real cardiac arrest victim, showing not only a more realistic interaction but demonstrating substantial improvement in students learning and reported more engaging and realistic learning.3

 

Use our youth to Teach CPR and teach them young.

Healthcare workers are not the only ones who can learn or teach CPR, this is not news; but how young is too young? Previous studies in Italy4 have shown success and understanding as early as primary school.

Children bring a level of excitement and offer a great module for not only testing new technology, but creating new technology. Eashan Biswa, son of UC Riverside cardiologist, Dr. Mimi Biswa, demonstrated this as a 6th grade science fair project. With support of  UC Riverside medical center and school district have they showed success teaching as young as 5th grade students CPR. They used traditional videos but also a video game developed by Eashan. They also demonstrated success in children retaining this knowledge and teaching their parents and community. You can read more about their story here: Kids as young as 12 should learn CPR.5

 

Repeat, Repeat, Repeat.

Repetition is important in CPR, as any skill, if you don’t use it you lose it. Virtual reality and early education offer great opportunities for retention and repetition and show an exciting step in the future of CPR education and learning, particularly in young kids and with opportunities for schools.

The future is bright; in order to continue to advance education of CPR we have to be creative, engage young minds, maybe even younger than previously thought, and work with new technology with the ultimate goal of continuing to spread knowledge to save lives.

 

References

  1. Malta Hansen C, Zinckernagel L, Ersbøll AK, et al. Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey. J Am Heart Assoc. 2017;6(3):e004128. Published 2017 Mar 14.
  2. (2019). Lighthaus. [online] Available at: https://www.lighthaus.us [Accessed 17 Nov. 2019].
  3. Gent L, Sarna D, Coppock K, Axelrod D. Successful Virtual Reality Cardiopulmonary Training in Schools: Digitally Linking a Physical Manikin to a Virtual Lifesaving Scenario. Circulation 2019 Nov 11. 2019;140(A396)
  4. Beeston, A. (2019). Kids as young as 12 should learn CPR. [online] Essential Kids. Available at: http://www.essentialkids.com.au/news/current-affairs/kids-as-young-as-12-should-learn-cpr-20171113-gzk2el [Accessed 17 Nov. 2019].
  5. Calicchia S, Cangiano G, Capanna S, De Rosa M, Papaleo B. Teaching Life-Saving Manoeuvres in Primary School. Biomed Res Int. 2016;2016:2647235.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.