Limited Utility of Exercise Stress Tests in the Evaluation of Children with Chest Pain

Kyle, W. Buck; Macicek, Scott L.; Lindle, Katherine A.; Kim, Jeffrey; Cannon, Bryan C.

doi:10.1111/j.1747-0803.2012.00702.x

Cited by 17 publications

(13 citation statements)

References 13 publications

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“…3,4,11 EST is extremely low yield in this population, as evidenced by 3 recent studies of more than 600 pediatric patients with chest pain in whom EST detected no cardiac disorders. 2,3,18 Ambulatory ECG also has extremely low yield in this population and has no role in evaluating chest pain in the absence of palpitations or syncope. 3,19 Echocardiography is also low yield and is considerably more likely to uncover incidental findings than the etiology of chest pain, 3,4 but nonetheless it remains the modality of choice for patients with concerning history, examination, or ECG findings given its ability to diagnosis most of the serious cardiac conditions that can present with chest pain, including anomalous coronary artery origin, cardiomyopathies, pulmonary HTN, pericardial effusion due to pericarditis, and left ventricular outflow tract obstruction.…”

Section: Chest Painmentioning

confidence: 99%

Chest Pain and Syncope in Children: A Practical Approach to the Diagnosis of Cardiac Disease

Friedman

Alexander

2013

The Journal of Pediatrics

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Section: Chest Painmentioning

confidence: 99%

Chest Pain and Syncope in Children: A Practical Approach to the Diagnosis of Cardiac Disease

Friedman

Alexander

2013

The Journal of Pediatrics

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“…23 In this setting, objective testing to elicit ischemic changes and especially to evaluate the severity of a given case of ACAOS has not been studied prospectively in large series, mainly because the initial general experience with this approach has been disappointing. 24 Electrocardiographic, nuclear or cardiac MRI, and echocardiographic stress testing for myocardial ischemic manifestations in the clinical laboratory setting have frustrated clinicians by producing both low numbers of true-positive and relatively high numbers of false-positive results. In fact, some CAAs have been fortuitous findings associated with (falsely) positive stress test results (which are reported to constitute 15-30% of the reasons for diagnostic heart catheterization).…”

Section: Clinical Evaluation: Symptoms and Objective Signs Of Ischemiamentioning

confidence: 99%

Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Angelini¹

2014

Circ: Cardiovascular Imaging

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Downloaded from Circ Cardiovasc ImagingJuly 2014 population with echocardiography or magnetic resonance angiography (MRA) have finally established the conditions for improving our knowledge of the denominator in the risk fraction (the number of cases of SCD divided by the number of persons with CAAs in the general population rather than only in autopsy series). 15,[19][20][21][22] Definitive data about CAA-associated mortality are still lacking, because of a lack of studies based on defined and controlled populations. 13This report attempts to clarify this matter by presenting an overview of more recent and precise approaches to CAA screening, pathophysiology, and clinical evaluation. Systematic Screening for CAAsBecause CAAs are potential causes of severe clinical events in young persons and cannot be identified on the basis of a history and physical examination, various imaging modalities are being tested for their detection. Magnetic Resonance ImagingAt our Center for Coronary Artery Anomalies, recent MRAbased screening of a continuous preliminary series of 1836 students (aged between 11 and 15 years) has finally presented credible data regarding the prevalence of ACAOS. These data are essential for discovering the risk of SCD. Our method is precise, extensive, and related to a general population (the denominator).19 It involves the use of an Achieva 1.5 T A-Series scanner with 32-channel coils (Philips, Amsterdam, the Netherlands) in a mobile unit that has been visiting several public middle schools in Houston. In this ongoing study, we do not use any sedation, contrast medium, or medication.We routinely acquire standard 2-chamber, 4-chamber, and left ventricular outflow tract gradient echo steady-state free precession cine images, followed by a stack of short-axis cine images from the left ventricle, with in-plane resolution of 1.8×1.8 mm and an 8-mm slice with a 2-mm gap for 30 cardiac phases. Coronary MRA images are obtained with a 3-dimensional steady-state free precession electrocardiography-gated echo-navigator sequence with T2 prepreparation. The aortic root and the left ventricular outflow tract are included to ensure identification of the coronary ostia and proximal segments. Acquisition takes a total of 15 to 25 minutes, making this method a much simplified version of cardiac MRI.One foundational finding of this study has been that CAAs are the most frequent high-risk cardiovascular condition for SCD in young persons: indeed, 40% of young people with a high-risk cardiovascular condition have a CAA. 19 Our basic plan was to screen ≈10 000 children for only the types of CAAs capable of causing ischemia and SCD. 13,19 The term ACAOS was refined to include only unusual coronary patterns involving an anomalous aortic origin that the literature suggested could result in a high-risk cardiovascular condition: patterns characterized by an intramural aortic course (previously "located between the aorta and pulmonary artery," or interarterial). 6,10,12,17 Unfortunately, this matter has not been totally resolv...

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“…Exercise stress test dropped drastically from pre‐SCAMP use, though was not eliminated as predicted. Recent and prior studies continue to show that exercise stress test does not detect cardiac pathology in young people complaining of chest pain . In the study by Basso et al, even in elite athletes who died of coronary anomalies, pre‐mortem stress testing did not demonstrate ischemia …”

Section: Discussionmentioning

confidence: 96%

“…An echocardiogram is the test of choice for further evaluation of patients with noteworthy findings. Additional testing, including exercise stress test and rhythm monitoring, is not recommended by the SCAMP given the low yield of positive findings related to chest pain . Clinicians using the SCAMP are unhindered in their medical choices and are only asked to provide reasoning if they choose to divert from the algorithm.…”

Section: Introductionmentioning

confidence: 99%

Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan

Saleeb

McLaughlin

Friedman

et al. 2017

Congenital Heart Disease

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Objective: Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain.Design: Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014.Results: Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%).Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. Conclusions:The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.chest pain, quality improvement, resource reduction, SCAMP | I NTR OD U CTI ONChest pain in the pediatric population is one of the most common complaints presenting to primary caregivers as well as cardiology specialists. The majority of chest pain in this young population represents a benign symptom, with a paucity related to serious organic disease. [1][2][3][4][5][6] A cardiac etiology to chest pain in children is exceedingly rare (0.1-1%) and determining which child could be among those affected remains a challenge.1,2,5,7-11 As detailed in prior publications, the Pediatric ChestPain Standardized Clinical Assessment and Management Plan (SCAMP) was developed and implemented at Boston Children's Hospital in 2010 as a quality improvement initiative. The goals of the SCAMP are to reduce unnecessary resource utilization for chest pain assessment in the cardiology clinic and to aid in the detection of rare cardiac disease by decreasing practice variation and directing resources to signs and symptoms most suggestive of cardiac disease. 2,8,12The Chest Pain SCAMP was developed based on review of the literature and analysis of a decade of patients presenting to BostonChildren's Hospital with serious cardiac disease and chest pain as a major complaint.

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Limited Utility of Exercise Stress Tests in the Evaluation of Children with Chest Pain

Abstract: In children referred to pediatric cardiology clinic for chest pain, EST has a low yield in identifying cardiac abnormalities.

Cited by 17 publications

References 13 publications

Chest Pain and Syncope in Children: A Practical Approach to the Diagnosis of Cardiac Disease

Chest Pain and Syncope in Children: A Practical Approach to the Diagnosis of Cardiac Disease

Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan

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