A Reflection on Pediatric Sudden Cardiac Arrest

Sudden cardiac arrest (SCA) in children is much less common than in the adult a population. However, this devastating event has a tremendous impact on families, the community, and all who are involved. Prevention of sudden cardiac arrest and death is the topic of ongoing discussion, and there are important strategies currently undertaken to improve the outcomes for out-of-hospital cardiac arrest for both children and adults.

The true incidence of “unexpected” pediatric SCA and sudden cardiac death (SCD) is not known, varying from one in 200,000 to one in 67,000 per year. The National Institutes of Health and Centers for Disease Control Sudden Death in the Young Registry, patterned after the sudden unexpected infant death (SUID) Registry,  will begin  collecting  comprehensive data from seven states that will include not only detailed cardiac autopsy anatomic information, but also selected molecular genetic studies in cases in which anatomic analysis is negative (autopsy negative sudden death). Channelopthies and associated known gene defects may thus be diagnosed, enabling life-saving identification of potentially affected family members. Ultimately, this registry will not only give us an opportunity to better understand the true incidence of sudden cardiac death and identify its etiologies, but will also allow follow-up evaluation of the data collected and enable analysis of specific questions based on that data.

Strategies for primary prevention of  SCA and SCD in the pediatric population emphasize a comprehensive personal and family history including a thorough cardiac physical examination. Although some children and adolescents  who have experienced SCD have had antecedent symptoms such as syncope and exercise-induced chest pain, many have been asymptomatic, with no positive family history. Therefore, not all children at risk for SCD may be identified before the sentinel event. There is also continued debate regarding the feasibility and utility of mass electrocardiogram (ECG) screening to identify children and adolescents at risk.

Further discussion and data collection are necessary before we arrive at a more definitive recommendation regarding this.

As the primary prevention of SCD cannot yet be universally achieved, strategies for its secondary prevention must be emphasized. These include optimization of cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED) education and the creation and implementation of emergency action plans in schools and other public areas. Currently, 19 states have passed legislation to mandate CPR and AED use instruction prior to high school graduation, and more states are  attempting to do so. These educational efforts will increase lay  recognition of cardiac arrest, making  it more likely that, when necessary, the general public will be willing and able to intervene, thus improving the outcomes of out-of-hospital cardiac arrest for both children and adults.

We have come a long way in the field of pediatric SCA, but there is much more to be done and learned. We are on a path to a better understanding of its true incidence and various etiologies. An accurate autopsy, including a molecular autopsy, will likely prove invaluable. It is the hope that we may eventually be able to define an optimal cardiac arrest primary prevention strategy. Until then, we need to continue to work hard to improve secondary prevention, emphasizing CPR/AED education and emergency action plan implementation. Perhaps at some point in the future, lay rescuer CPR will have a success rate close to 100%, improving the survival of pediatric, as well as adult, SCD.

References:

  1. Campbell R, Berger S, Ackerman M. Policy statement: pediatric sudden cardiac arrest. Pediatrics 2012;129:e1094-102.
  2. Wren C. Sudden cardiac death in children and adolescents. Heart 2002;88;426-31.
  3. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-55.
  4. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the "chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-47.
  5. Council on School Health. Medical emergencies occurring at school. Pediatrics 2008;122:887-94.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Quality Improvement

Keywords: Adolescent, Adult, Autopsy, Cardiopulmonary Resuscitation, Centers for Disease Control and Prevention (U.S.), Chest Pain, Child, Death, Sudden, Cardiac, Defibrillators, Electrocardiography, Follow-Up Studies, Heart Arrest, Incidence, National Institutes of Health (U.S.), Out-of-Hospital Cardiac Arrest, Pediatrics, Physical Examination, Primary Prevention, Registries, Secondary Prevention, Syncope, United States


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