Differences Between Pediatric and Adult Guidelines for Classifying Left Ventricular Dilation

Columbus, OH — February 2018

The American Society of Echocardiography has separate echocardiogram assessment guidelines for children and adults; the pediatric guidelines account for childhood development, while adult values tend to be less variable.

Those two sets of guidelines eventually meet when children transition into adult care, or when adult patients continue treatment in pediatric settings. In those cases, should clinicians use the adult or pediatric guidelines? Do they agree?

A recent study from The Heart Center at Nationwide Children’s Hospital suggests that at least in assessing left ventricular dilation, the guidelines don’t align, particularly in female patients. The paper was published in Pediatric Cardiology.

“I think this study shows that adult and pediatric cardiologists need to come to a mutual understanding on which guidelines we should follow for pediatric patients that are adult size or adult patients still being followed in pediatric institutions,” says Clifford Cua, MD, clinical cardiologist at The Heart Center and senior author of the study. “In doing the research, I saw some of my own reports that I had read as normal size that I would now read as abnormal with the adult guidelines in mind.”

The study evaluated left ventricular size in 1,489 echocardiograms from patients approximately 12 to 27 years of age. A total of 835 of the echocardiograms had been performed for females and 654 for males. Left ventricular dilation was graded normal, mild, moderate or severe based on adult guidelines and pediatric guidelines. The authors also noted grades from pediatric echocardiographic readers.

The adult and pediatric guidelines only agreed 14.49 percent of the time in left ventricular grades of female patients and 41.44 percent of the time in male patients. The agreement was even worse between pediatric echocardiographic readers and the adult guidelines. Pediatric echocardiographic readers and pediatric guidelines had better, but not perfect, agreement with one another. 

Another way of reading the results, the authors note, is that a minimum of 68.74 percent of echocardiograms performed on females and 32.24 percent of those on males were read as normal by pediatric standards but abnormal by adult ones. Because left ventricular dilation is just one factor in treatment decisions, it’s not clear whether the different guidelines would have led to different treatments, says Dr. Cua, who is also an associate professor of Clinical Pediatrics at The Ohio State University College of Medicine.

There are several limitations to the study, including differences in the ways left ventricular end-diastolic diameters were obtained, but the authors believe they are unlikely to completely account for the poor guideline agreement.

“We hope this study starts a conversation,” says Dr. Cua.

Harmon J, Sisco K, Dutro M, Cua CL.  Left ventricular dilation: when pediatric meet adult guidelines. Pediatric Cardiology. 2018 Jan: 39(1): 26-32.