Echocardiography May be Unnecessary for Many Children with Supraventricular Tachycardia

PediatricsOnline 

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The first study to examine prevalence of congenital heart disease in children and adolescents with SVT reveals that echocardiography may not be required in most cases.

Because babies with supraventricular tachycardia (SVT) with or without ventricular preexcitation are known to have congenital heart disease in up to 30 percent of cases, they often receive screening echocardiography to assess for structural defects. Although the same rate of structural heart problems in older children has never been officially confirmed, most children presenting with SVT outside of infancy are evaluated using the same tests.

Now, research from clinicians at Nationwide Children’s Hospital suggests screening echocardiograms may not be required in many cases.

“I think a lot of physicians were extrapolating the data from infants, expecting that up to 30 percent of all patients presenting with SVT may have a structural heart lesion, but that appears to be specific to infants,” says Kaitlin L’Italien, MD, attending pediatric cardiologist in The Heart Center at Nationwide Children’s and lead author on the research, published in the Journal of the American Society of Echocardiography in October. “When we went to the literature to look for the prevalence of congenital heart disease in otherwise healthy, older children presenting with SVT, the data just weren’t there.”

Dr. L’Italien and her colleagues performed retrospective chart reviews of 290 patients presenting with SVT outside of infancy, of which 224 had received both EKGs and echocardiographic exams. Thirty children had abnormal EKG findings, of whom only one was found to have clinically significant congenital heart disease via echocardiography (a primum atrial septal defect requiring surgical closure). All 29 others had normal echocardiograms. Four patients who had normal EKGs were found to have minor (not clinically meaningful or likely to become meaningful) structural abnormalities on echocardiography.

The researchers concluded that SVT alone does not appear to confer additional relative risk for having congenital heart lesions in children and adolescents.

“In these children and teenagers, echocardiography is not necessary if their EKG and physical exam are normal,” says Dr. L’Italien, who is also an assistant professor of Clinical Pediatrics at The Ohio State University College of Medicine.

 The findings apply only to children who are otherwise healthy and who do not have the characteristic ventricular preexcitation form of SVT, also called Wolff-Parkinson-White (WPW) syndrome. EKGs and physical exams are still clearly indicated in all patients.

The research team hopes that their findings will impact future versions of pediatric appropriate use criteria (AUC) for clinical testing in cardiology. The current AUC guidelines list SVT as an “always appropriate” reason for echocardiography, but Dr. L’Italien would like the guidelines to be more nuanced to reflect that echocardiography is unlikely to identify structural heart disease in children with SVT who have normal EKG and physical exam findings.

Dr. L’Italien believes that refraining from echocardiography testing in these cases could offer significant cost savings while also reducing inconvenience and anxiety for families. However, she and her colleagues stress the importance of clinical judgment.

“If a patient were to have an abnormal cardiac physical exam finding, or EKG abnormalities suggestive of a structural heart issue, then of course getting an echocardiogram is always indicated,” says Dr. L’Italien. “If there are clinical concerns from the physician, they should be able to order any tests they feel are helpful or useful.”

For example, echocardiography can be extremely useful when a child is going to have an invasive cardiac procedure.

“But when there are no other concerns, they’re not necessarily missing anything significant if they opt not to obtain that additional testing,” says Dr. L’Italien. She expects that force of habit will make clinical practice slow to change, as will fear of missing a diagnosis. In time, however, she hopes that increased attention to the best strategies for utilizing certain tests will help change practice patterns and result in better health care.

“If you can define situations in which a diagnostic test is most likely to be useful and potentially impact patient care versus other situations when it’s not demonstrated to be as high yield,” Dr. L’Italien says, “there are real opportunities to help streamline and improve care.”

Reference:

L'Italien K, Conlon S, Kertesz N, Bezold L, Kamp A. Usefulness of echocardiography in children with new-onset supraventricular tachycardia. Journal of the American Society of Echocardiography. 2018 Oct; 31(10):1146-1150.