1. Cardiology Journal Club Meghan Martin PGY 6 8/6/2015

2. Pediatric Chest Pain Evaluation

3. Study Objectives/Purpose The primary outcome was the frequency of chest pain as the presenting symptom for these patients with any 1 of 9 cardiac diagnoses. Secondary outcome measures included the sensitivity of historical features, clinical findings, and laboratory screening in diagnosing these cardiac conditions.

4. Background Chest pain in children is generally benign, but significant parental anxiety exists secondary to the concern for coronary artery disease and myocardial ischemia which is present in the adult population. Etiology for chest pain cannot be determined in 21– 45% cases of pediatric chest pain. Musculoskeletal, respiratory, and gastrointestinal causes of chest pain are quite common in pediatrics.

5. Methods/Study Design Retrospective chart review Searched Cardiology Department database identified all children coded with myocarditis, pericarditis, coronary anomalies, pulmonary hypertension, pulmonary embolus, aortic dissection, Takayasu arteritis (TA), hypertrophic cardiomyopathy (HCM), and dilated cardiomyopathy (DCM) January 1, 2000 and December 31, 2009.

6. Patient Selection Diagnoses in children between 7 and 21 years were obtained from cardiac catheterization, echocardiography reports, discharge diagnoses, or cardiology billing codes. Prior diagnosis of congenital heart disease were excluded 484 patients included in study group –Medical records were reviewed by a physician –EKGs evaluated by a pediatric cardiologist –Demographic data –High risk conditions –Family history

7. Results

8. Results

9. Results

10. Results/Statistical Analysis 171 (35%) of these patients presented with the complaint of chest pain. 130 of 171, or 76% of diagnoses were made in hospital/ED –41 were diagnosed at a first time visit to an outpatient clinic Pericarditis and myocarditis comprised the largest number of patients with chest pain as part of their presenting constellation of symptoms. –One patient with aortic dissection (MVC) –TA (n = 8) None of these patients presented with chest pain. The most common outpatient diagnosis as a result of chest pain was an abnormality of the coronary arteries, while pericarditis and myocarditis were the most frequent diagnoses in the ED.

11. Results/Statistical Analysis 116 out of these 130 (90%) children with chest pain and underlying cardiac disease presenting to an inpatient or emergency setting had myocarditis, pericarditis, or pulmonary embolus. 34 of 131 patients with a coronary anomaly presented with chest pain

12. Results/Statistical Analysis

13. Conclusions Only 32 patients over a 10-year period presented to the outpatient cardiology clinic with a complaint of chest pain and had serious underlying cardiac pathology. Over 95% of our patients with myocarditis and pericarditis were diagnosed in the ED or inpatient setting –referral base of pediatricians are recognizing disease and triaging it appropriately or that families are bypassing primary care due to the inherent anxiety produced by the symptom of chest pain.

14. Conclusions These data reinforce the importance of two- dimensional echocardiography to delineate coronary origins when patients present with exercise-induced symptoms –Exercise stress testing has little diagnostic yield. –Coronary anomalies tended to have normal ECGs, and the abnormal studies (n = 4) may have been incidental findings that were not a manifestation of the underlying pathology.

15. Commentary The results are illuminating, and suggest that a careful and focused history and physical examination, along with a screening EKG, will find essentially all the patients we are looking for. Limitations include only focusing on “needles” means we are unable to evaluate the specificity or the predictive values of these historical features, physical exam findings, and ECG abnormalities.

16. Regional Implementation of a Pediatric Cardiology Chest Pain Guideline Using SCAMPs Methodology

17. Study Objectives/Purpose Chest pain is a common complaint for which children are frequently evaluated. Cardiac causes are rarely found despite expenditure of considerable time and resources. We describe validation throughout New England of a clinical guideline for cost-effective evaluation of pediatric patients first seen by a cardiologist for chest pain using a unique methodology termed the Standardized Clinical Assessment and Management Plans (SCAMPs).

18. Background Chest pain in children is a common reason for referral in both academic and community pediatric cardiology practice. Evaluation is resource intensive and costly despite the low incidence of cardiac pathology ranging from 0% to 5%. This low incidence has been documented in the emergency setting as well as ambulatory care.

19. Background Many previous reports on pediatric chest pain have been observational and lack guideline recommendation. We have designed and reported on a quality improvement tool termed Standardized Clinical Assessment and Management Plans (SCAMPs). –Guides care of patients with a single presenting symptom or condition according to an algorithm designed by clinicians that improves outcomes, narrows practice variability, and reduces unnecessary testing.

20. Methods/Study Design Developed a SCAMP algorithm for pediatric chest pain using history, physical examination, and electrocardiogram (ECG) to suggest when further diagnostic testing is indicated using methodology previously developed and described. Designed to identify cardiac causes of chest pain while effectively using resources in the outpatient cardiology clinic setting.

21. Methods The algorithm was used to analyze the combined patient population and to compare outcomes of those seen at BCH and NECCA sites. Over a 2- year period, representatives from NECCA and BCH reviewed the SCAMP data elements, discussed plausible findings, shared strategies, and, based on feedback, refined the guideline.

22. Methods Ambulatory patients between 7 and 21 years of age presenting to a pediatric cardiology practice for a first-time evaluation of the principal complaint of chest pain were enrolled. Those for whom chest pain was a secondary symptom were not included.

23. Patient Selection A total of 109 providers participated in the study, 35 of whom practiced at NECCA sites. Patients were enrolled from July 2010 to December 2011 at BCH and from October 2010 to December 2011 at NECCA sites. Children with known heart disease were excluded. Collected information about demographics, history, physical, ECG findings, family history (table 1)

25. Algorithm Table 2 shows positive findings  get echo Fever  CXR Exercise stress testing, ambulatory ECG (Holter) monitoring, and event recorder monitoring were not included in testing –based on previous study –Tracked as part of the adherence and outcome analysis

26. Table 2

27. Outcome Measures Assessed adherence to the SCAMP algorithm –Testing performed or not performed –All patients had at least 1 cardiology clinic visit –ECG was recommended at all visits –Resource utilization for echocardiograms, exercise stress tests, Holter monitors, and event monitors was compared between the BCH and the combined NECCA sites

28. Results/Statistical Analysis A total of 1016 patients (1025 visits) were enrolled 61% at BCH and 39% at NECCA sites Average age at initial visit was 13.1 years A total of 1007 patients were seen for a single visit and 9 patients (0.9%) for a second visit. –Repeat visit frequency did not differ between BCH and NECCA sites.

29. Figure 1- Site Comparison

30. History Many patients had multiple symptoms. –Chest pain was described as principally at rest in 51.3%, pleuritic in 32.2%, and at peak exercise in 33.7% of patients. Syncope, exertional syncope, and fever were infrequent symptoms Palpitations and exertional dyspnea were common. Of 117 patients with a pertinent family history, 83.6% had a normal echocardiogram, 15.5% had an incidental abnormality, and 1 patient was diagnosed with pericarditis.

31. History Asthma was noted in 20.3% of patients Other elements of past medical history contributed little. Significant family history elements were rarely elicited. Physical examination abnormalities were rare. Reproducible chest pain on palpation was present in 116 patients (11.4%).

32. ECG ECG abnormalities were infrequent and minor. 1000 ECGs –85 (8.5%) were abnormal on initial evaluation –Common findings included: LVH 14, 1.4% RVH 10, 1.0% Borderline right or left ventricular hypertrophy 18, 1.8%

33. ECG 2 patients with a cardiac cause of chest pain had an abnormal ECG (sensitivity 100% and PPV 2.4%). –Pericarditis showed ST elevation –Anomalous coronary artery origin had left ventricular hypertrophy.

34. CXR Chest x-rays were done for 86 patients (8.5%), of which 5 (0.5%)were abnormal. –3 were done in accordance with the algorithm 2 of the 3 showed pneumonia. Other findings were unrelated to the cause of chest pain

35. Echo Echocardiography was performed as recommended in 423 patients (41.6%) –Performed when not recommended in 81 (8.0%) –Abnormal in 48 (9.5%) of all studies (Table 3) –In 2 instances, the echocardiogram findings explained the chest pain (0.5% of the recommended tests, 0.4% overall).

36. Echo One patient presenting with fever, pleuritic chest pain, and dyspnea had acute pericarditis with pericardial and pleural effusions. The second, presenting with exertional chest pain at early and peak exercise, had anomalous origin of the right coronary artery from the left coronary sinus with an interarterial course.

37. Echo Echocardiograms done without SCAMP recommendation found no causes for the chest pain. Incidental findings were relatively common (Table 3). More were discovered on echocardiograms that were not recommended (18.5%), than on the recommended studies (7.3%, P,.002) due in part to abnormal physical findings that did not trigger a SCAMPs recommended test but drove the provider decision (Table 3).

38. Table 3

39. Deviation The most common reasons for echocardiograms performed when not recommended: –Parental or referring provider insistence –Non-first-degree relatives with congenital heart disease –Abnormal physical examination findings suggesting unrelated cardiac disease The primary reason for echocardiograms not done when recommended was assessment by the provider that the chest pain was noncardiac in nature.

41. Final Diagnosis Final diagnoses were the clinical impression of the consulting cardiologist. Noncardiac chest pain was described for 97.0% of the patients. Two patients (0.2%), as noted, had a cardiac cause for chest pain –Pericarditis and anomalous origin of the right coronary artery from the left coronary sinus.

42. Final Diagnosis Other diagnoses were pending or not submitted. Musculoskeletal chest pain was the most frequent diagnosis made by providers (32.9%), with most undiagnosed (54.6%). Pulmonary disease was relatively frequent (6.3%).

43. Discussion This study has several implications for Quality improvement. –It affirms that chest pain in children is rarely due to cardiac disease. –It validates the SCAMP methodology for creating an efficient and cost-effective approach for evaluating a common complaint in a heterogeneous biologically variable population.

44. Discussion This SCAMP shows that the indication for diagnostic studies can be limited and keyed to presenting symptoms, focused history, cardiac physical findings, and ECG abnormalities. Exercise testing and rhythm monitoring, excluded from the algorithm based on previous study, provide no clear diagnostic benefit. Chest x-ray in the absence of febrile illness was not beneficial.

45. Discussion The great majority of patients can be seen, evaluated, and discharged with a single visit. – Patients returning after discharge because of persistent symptoms had additional testing but no change in diagnosis. The most common cause of chest pain in this population was musculoskeletal. –Pulmonary disease was relatively common by initial history and on final diagnosis.

46. Discussion Improving resource utilization while preserving beneficial clinical outcomes is a core benefit of SCAMPs. In this study, exercise testing,ambulatory monitoring, and repeated follow-up visits were greatly reduced.

47. Conclusions Using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources. The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers often limiting clinical practice guideline implementation

48. Commentary Translation of research into clinical care, however, has been poor, controversial, or at best highly variable. The reasons offered are diverse, and include behavioral and operational barriers to include decreased awareness, adoption, adherence, buy-in and supportive organizational culture. Even with awareness, providers will often use clinical judgment at the point of patient care rather than research based recommendations

49. Take away? Cardiac causes for chest pain are rare and are usually suggested by history, physical or ECG findings. No mention of dysrhythmias (SVT) –Should have abnormal VS SCAMP patients presented cardiology clinic –Applicable to our population? Diagnosing other causes for chest pain may require further testing