The Changing Landscape of Community Pediatric Cardiology: A Return to Traditional Medicine
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The practice of pediatric cardiology is evolving. Initial efforts at accurate diagnosis of congenital heart disease and advances in pre- and post-surgical care have impacted outcomes. Our combined success has resulted in the emergence of several congenital cardiology sub-specialties that include advanced imaging, electrophysiology, interventional cardiology, and advanced heart failure. Today, children born with complex congenital heart defects have significantly improved survival and outcomes.
Another emerging, less glamorous sub-specialty is the community based pediatric cardiology practice. Centers outside a tertiary medical center were developed to deliver high quality cardiac care and provide cardiology services closer to where patients reside. Advances in technology and lower equipment cost were instrumentally linked to their success.
Many cardiac tests, such as ECGs and echocardiograms, are now common-place. While pediatric cardiologists appreciate the benefits of expanded availability, they are also very much aware of their intrinsic limitations. For example, an EKG cannot exclude congenital heart defects, assess cardiac function, or definitively eliminate the risk for sudden death. A normal heart rhythm does not exclude previous arrhythmia. Misinterpretation or false-positive findings are not uncommon. Even the benefits of using ECG testing for sports "clearance" is debatable.1 Published guidelines were designed to curtail indiscriminate testing,2 but despite well intentioned efforts, the trend to perform more and more ECGs is increasing, and the benefits of doing so remain questionable.
For similar reasons, the use of echocardiography has become prevalent. "Why one should bother listening to a patient's heart, when one can see it?" is unfortunately becoming a growing mantra for some health care providers. "Ruling out" disease has become a common indication for expensive testing.3 Incidental findings and normal variants may result in confusion that may lead to even more tests. The use of prenatal echocardiography has also expanded. Technical limitations resulting in sub-optimal studies, the natural history of disease, and the intrinsic changes in fetal physiology make additional postnatal testing often a necessity. In this era of rising costs, we need to ask; "Are all of these truly a good use of our valuable time and limited resources?"
In many cases, symptoms of chest pain are non-cardiogenic.3 Often, a detailed history and exam may be sufficient to determine if additional testing is warranted. The increased incidence of obesity and use of ADHD medication have magnified anxiety about patients with heart disease.3 Unrealistic fear has been propagated by misinformation via the internet and from the media's dramatic accounts of tragic and sudden deaths in athletes. It is not surprising that many health care professionals feel obligated to perform more and more testing to accommodate requests from schools, coaches and family members who demand assurance that their child's heart is "normal."
As a result, community pediatric cardiology practices are now being inundated with referrals for many of these issues. Increased referrals may be due to heightened parental anxiety, time constraints in busy primary care offices that may not have adequate time and resources to address "cardiac" complaints, the increasing number of urgent care centers staffed with health care providers who may not be comfortable dealing with children with cardiac problems, and facilities that perform ECGs and echocardiograms but are unable to accurately interpret their results or worse, perform non-diagnostic studies of limited quality.
As a subspecialty, a community based pediatric cardiology practice can provide high quality care. However, proximity, availability, and easier access should not lead to frivolous overuse. The ramifications may not be immediate, but we must realize that all resources have limits. We need to provide a service and support families, schools, and pediatricians in our community that truly require a pediatric cardiologist's input. It is time to revert back to traditional medicine and obtain a detailed history and perform a thorough physical exam before ordering testing. A rational, common sense approach is pivotal. It would be wise for physicians to implement appropriate constraints before insurance companies or government health care organizations impose restrictions to our detriment.
- Preventing Athlete Deaths with ECG Screening. www.acc.org. Apr 26, 2016. Accessed Nov 28 2016. http://www.acc.org/latest-in-cardiology/articles/2013/04/26/14/16/preventing-athlete-deaths-with-ecg-screening.
- Maron BJ, Friedman RA, Kligfeld P, et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 2014;64:1479-514.
- Sachdeva R, Allen J, Benavidez OJ, et al. Pediatric appropriate use criteria implementation project: a multicenter outpatient echocardiography quality initiative. J Am Coll Cardiol 2015;66:1132-40.
Keywords: Arrhythmias, Cardiac, Attention Deficit Disorder with Hyperactivity, Cardiology, Chest Pain, Child, Echocardiography, Electrocardiography, Electrophysiology, Heart, Heart Failure, Heart Defects, Congenital, Medicine, Traditional, Pediatric Obesity, Primary Health Care, Sports
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