pediatric

hidden

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

Alyssa Vermeulen, DO, FAAP

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

Baby Steps in Heart Failure and Palliative Care

David Werho, MD

Any fellow or NP who has worked with me in the CVICU can tell you, I’m notoriously conservative when it comes to my treatment plans in infants and children recovering from acute on chronic heart failure.  After witnessing first-hand how fragile these patients can be throughout my training, and seeing all the sequelae of patients who were weaned too quickly, I have become very strict about how quickly I allow my team to de-escalate the critical care therapies in these children.  Of course, baby steps in moving patients forward need to be balanced with ICU length of stay, central venous access, and other drivers of patient outcomes/complications.  Honestly, I don’t think there’s a right or wrong answer, but I do think that the following scenarios are not uncommon:

  • “Let’s wean the dexmedetomidine every 8 hours so we can get off by tomorrow…”
    • Three days later, the patient is on an even higher dose, in addition to clonidine and milrinone, because he had an acute decompensation during withdrawal.
  • “Let’s increase the feed volumes to 160cc/kg/day because we’re only gaining 10g/day of weight…”
    • One week later, the patient has lost 300g because she’s been NPO for feeding intolerance.

Treating critically ill heart failure patients, even when they’re in recovery-mode, is an art.  It’s really hard to find the balance.  My experience thus far has pushed me to the conservative side of the spectrum in this patient population.

So, as I have come to accept the importance of baby steps in my clinical practice, recently I began asking myself: Why am I so hesitant to bring up palliative care in my patients with complex disease?  I sometimes feel like I’ve waited too long to broach the subject, despite knowing that perhaps meeting the palliative care team early and taking baby steps forward with setting goals and accessing resources would be beneficial for the families of many of our complex patients.  One of my friends and former co-fellows, Hayley Hancock, recently published this study, which showed the benefits of early palliative care consultation for families of patients with prenatally diagnosed single ventricle heart disease.  These families were introduced to palliative care, even before their children were born, yet there was still a benefit to the family, including less anxiety and better family relationship and communication scores.  I know that palliative care teams are often quite busy and may not have the resources to get involved with every single patient with complex heart disease, but I do see the value in introducing the concept early.  As palliative care resources become more available, I hope to be able to encourage baby steps in this important area with my complex patients earlier when it’s appropriate.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.
hidden

What Exactly Does A Pediatric Cardiac Intensivist Do?

David Werho, MD

When someone asks me what I do, my answer is usually pretty short and vague.  “I’m a physician.” “I’m a pediatric cardiologist.” “I work in an ICU.”  This is frequently enough detail to move the conversation along to other topics and I rarely dwell on the nitty gritty of what I actually do at work. 

However, recently, I’ve noticed that when physicians, nurses, or other healthcare providers ask what I do, my vague response is seldom enough.  Many are very curious, but have no clue what the scope or responsibilities of my subspecialty actually are.  Someone even recently asked, “So, do you just follow the surgeons around all day and help them take care of their patients?” 

This lack of awareness is partially because it’s such a relatively young subspecialty, though it continues to grow rapidly.  It doesn’t fit what people think of when they envision other realms of perioperative care.  Many people are used to systems where patients are primarily cared for by their surgeons in the perioperative period.  There are also vast differences in the way that congenital heart centers are structured, which affects how adult cardiology care and pediatric cardiology care are delivered differently.  The complexity and varied physiologies of congenital heart surgery patients is also quite different from the adult cardiac surgical population.

Another reason is because there are so many different ways to become a pediatric cardiac intensivist.  Based on the history and development of our subspecialty, we have sprouted from the convergences of multiple different fields; cardiac intensivists can bloom from various taxonomies including pediatric cardiologists, pediatric intensivists, neonatologists, anesthesiologists, and surgeons.  The training pathways are varied, but our ultimate job description remains the same: to care for critically ill pediatric and adult congenital patients with heart disease. 

Of course, this is an oversimplification.  Because of the heterogeneity and newness of pediatric cardiac critical care, the scope of practice and care delivery models can be different from center to center.  In some centers, there isn’t a dedicated cardiac ICU and pediatric intensivists care for cardiac patients at the same time as they manage traumatic brain injury and liver transplant patients.  In others, cardiologists primarily manage these patients with occasional consultation from critical care.  In such a diverse specialty, it’s actually quite difficult to say definitively what exactly a pediatric cardiac intensivist does.

However, our field is currently in the stage of development where we are striving for more standardized and formalized training curricula and well-defined competencies.  With more regionalization of care and new dedicated cardiac intensive care units opening up with the expectation in many centers for 24/7 in-house attending coverage, we will need more young physicians to commit to undergoing the training required to become pediatric cardiac intensivists.  And it may be difficult to convince people to train for 7-8 years after medical school without firm agreement on the legitimacy and scope of the field.

Accordingly, I am currently working with a team on a mixed-methods study to define entrustable professional activities for our field (essentially, the core responsibilities expected of those who practice independently).  Hopefully, soon we will have a well-established and broadly accepted answer to the question, “what does a pediatric cardiac intensivist do?

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.

hidden

New Hypertension Guidelines: Should They Inform The Way We Care For Pediatric Cardiology Patients?

David Werho, MD

In reflecting on my time at the 2017 AHA Scientific Sessions, I can summarize my thought process about the new AHA Hypertension Guidelines as a complete 180.  When I first heard about the guidelines, my inner monologue went something like this:

“I don’t need to pay attention to these guidelines – they don’t affect me or my patients.  We already have separate pediatric guidelines.  Wasn’t there a new set of guidelines this year?  Maybe I should look at them a little closer…”

After reviewing the 2017 pediatric hypertension guidelines, I was pleasantly surprised how well they align with the AHA adult guidelines.  Of course, the pediatric guidelines are a little more complicated, since all of our patients have different cutoffs based on age, gender, and height.  And the cutoffs are now lower, due to the exclusion of overweight/obese children in the normative data.  But once our patients become adolescents, the cutoffs are the same as the new AHA adult guidelines.
After hearing that now nearly half of all U.S. adults will meet the diagnostic criteria for hypertension under the new guidelines, I realized: “OMG! Almost all of my patients are going to turn 13 and be hypertensive!”

Of course, as pediatric cardiologists, our patients are at especially high risk of cardiac events in adulthood, and the adult congenital heart disease population continues to grow every day, so we should be even more aware of hypertension as a significant risk factor for these children.  As Bradley Marino, MD (Chair of the Council on Cardiovascular Disease in the Young) stated during the CVDY Council Dinner, in light of current changes in the hypertension guidelines and national trends in increasing rates of obesity and heart disease-related morbidity, our role as pediatricians and cardiologists in prevention is becoming more and more important.

By the end of Scientific Sessions and in the weeks thereafter, I have become more cognizant and appreciative of my role in preventing my own patients from becoming hypertensive.  Of course, my ability to encourage lifestyle changes and long-term nutritional improvements is quite limited in the CVICU, but I am much more appreciative of my colleagues in the outpatient world and those who specialize in preventative pediatric cardiology.  I have also made a few lifestyle changes myself, since I am now uncomfortably close to meeting hypertension criteria.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.
hidden

The Pediatric Side Of AHA17: Advice And Lessons-Learned From The Council On Cardiovascular Disease In The Young (CVDY) Early Career Networking Luncheon

David Werho, MD

At large meetings like the AHA Scientific Sessions, the pediatric presence is usually smaller and less ubiquitous than our adult counterparts.  For trainees and junior faculty, it can be intimidating to navigate for the first time, but the CVDY Early Career Networking Luncheon is a great way to ease into it.  Not only do you get ample opportunities to meet leaders in our field, but they are open, accessible, and eager to give out free advice. 

There were faculty represented from almost every sub-discipline within pediatric cardiology (cath, echo, ICU, transplant, etc), and also representing nearly every type of career niche (division chiefs, program directors, researchers, clinicians, educators, etc).  We were able to sit in small groups and have round-table discussions about assorted topics.

Here are a few (paraphrased) nuggets I picked up from the round-tables:

  1. Dr. Peter Lang on Finding What You Love: No matter what you think you want to do within pediatric cardiology, you never know where you’re going to end up…you may love more than one thing…keep an open mind… it’s not completely crazy to change what you’re doing.
  2. Dr. Katie Bates on Finding Your First Job: You shouldn’t expect perfection – this probably won’t be the last job you ever have.It’s unreasonable to expect your perfect job in the perfect location, but it does seem to work out most of the time. As far as waiting to hear back from programs, you should not freak out if you don’t get immediate feedback. There is a big priority gap between you as the applicant and the program that’s potentially hiring you, and a great deal of things are going on behind-the-scenes, so it’s a slow process to get an offer. Once you have an offer, have mentors help you out, and consider reading a book about negotiation. Her suggestion is Getting To Yes by Roger Fisher and William Ury.
  3. Dr. Daniel Penny on Work-Life Balance: Finding interesting or exciting things to occupy your time outside of work will actually enhance your ability to do more productive work rather than detracting from it. Mindfulness can be very helpful, but it’s also important to find a hobby that you love and devote some time to it.

After the round-tables, we were able to hear take-home points from around the room.   Here’s just a small selection:

  1. There’s never a good time to have kids – just do it
  2. Be adaptable in your first job, but don’t say yes to things that you aren’t going to be able to honestly put your best efforts towards
  3. Find a mentor early and it’s ok to have more than one
  4. You can’t always control circumstances at your new job, as things can change, but you can leverage some challenges into opportunities for growth
  5. Make clear priorities – make time for things that are important (including schedule requests for things like spouse birthdays well ahead of time, etc.)

And finally, here are a few tips regarding involvement in AHA and time spent at Scientific Sessions:

  1. AHA and CVDY are full of opportunities for interested people; you just have to seek them out
  2. You can get involved in committees and find collaborators even very early in your career
  3. Don’t be afraid to introduce yourself – people are here to meet their colleagues and exchange ideas
  4. Everyone you meet is potentially a future colleague, friend, mentor, or boss
  5. Getting involved with the AHA has great potential to shape your career and long-term engagement in CVDY can be extremely rewarding

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.