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February
1997
Are
chest radiographs and electrocardiograms still valuable in evaluating
new pediatric patients with heart murmurs or chest pain?
Swenson JM, Fischer DR, Miller SA, Boyle GJ, Ettedgui JA, Beerman LB;
Pediatrics 99: 1-3, 1997.
[ see
abstract below ]
The purpose of this
study was to determine the usefulness of electrocardiography and chest
radiography in evaluation of patients referred to pediatric cardiologists
for evaluation of a heart murmur or chest pain. This prospective study
enrolled 106 consecutive outpatients who were evaluated by history and
physical examination by the cardiologist into three categories:
- no heart disease
- possible heart
disease
- definite heart
disease
The chest x-ray and
electrocardiogram were reviewed and the cardiologist was given the opportunity
to change the previous category and order an echocardiogram. Review of
the chest x-ray and electrocardiogram helped to make the diagnosis of
definitive heart disease in 4 patients (7%) where the diagnosis would
have been missed on clinical evaluation alone if the chest x-ray and electrocardiogram
had not been done.
The importance of this paper for the anesthesiologist is that even a board
certified cardiologist can miss clinically important heart disease if
the proper screening tests are not performed. This means that calling
the cardiologist to examine a child who is found to have a murmur just
before anesthesia is insufficient if all that is done is to listen to
the heart and take a history.
I believe that the take home message here is that this study emphasizes
the importance of not assuming a murmur is innocent despite a negative
history. This study also demonstrates the importance of setting up a system
whereby patients with a newly diagnosed heart murmur can be properly evaluated
on the day of their surgery with minimal delay.
Obviously this means having worked out the referral process in advance
so that the child may move smoothly from the preanesthesia area to the
electrocardiogram area, to x-ray and then to cardiology. This study confirms
a previous similar study whereby the diagnosis made by the referring pediatrician
was compared to the final diagnosis.
In that study, the referring pediatrician was incorrect in the category
of pathologic murmur in 3/12 and incorrect in 75% of possible pathologic
murmurs. The cardiologist was correct in 98% of the patients labeled as
innocent murmur but that also means they missed 2% with just a history
and physical examination.
Return
to the Current Literature Review Front Page,
or read the abstract:
ABSTRACT
Objectives: To determine the usefulness of electrocardiography (ECG)
and chest radiography (CXR) in evaluation of patients referred to the pediatric
cardiologist for the evaluation of heart murmur or chest pain.
Design: In this prospective study, 106 consecutive outpatients were
categorized with no heart disease, or definite heart disease based on history
and physical examination; they then underwent ECG and CXR. Studies were
reviewed and the examining cardiologist could change the diagnosis and order
an echocardiogram.
Setting: Academic pediatric cardiology practice.
Results: In patients thought to have no heart disease, the diagnosis
was changed to definite heart disease in four solely on the basis of abnormal
CXR or ECG. In 25 patients thought to have possible heart disease, the diagnosis
was changed to no heart disease (7) or definite heart disease (5) after
review of the CXR and ECG. All 25 patients diagnosed with definite heart
disease had this confirmed by abnormal CXR (2), ECG (3), both abnormal CXR
and ECG, or echocardiogram (18).
Conclusions: ECG and CXR helped diagnose heart disease in four patients
though to have no heart disease, helped to rule out lesions in seven patients
with possible heart disease, helped diagnose heart disease in five patients
thought to have possible heart disease, and helped confirm heart disease
in nine patients. In these days of cost containment, routine ECG and CXR
continue to be valuable tools for the pediatric cardiologist in evaluation
of patients with heart murmurs or chest pain.
Initial evaluation of heart murmurs: are laboratory tests necessary?
Smythe JF, Teixeira OHP, Vlad P, Demers PP, Feldman W;
Pediatrics 86:497-500, 1990)
Secondary Abstract: Heart murmurs, most of them innocent, are the most common
reason for referral to a pediatric cardiologist. In the evaluation of murmurs,
the electrocardiogram and echocardiogram are often included. The purpose
of this study was to determine the utility of these examinations in the
initial assessment of heart murmurs in children and adolescents.
In a prospective series of 161 patients, the clinical diagnosis of heart
murmurs by a pediatric cardiologist was compared with that obtained after
electrocardiogram and echocardiogram (two-dimensional, M-mode, Doppler,
and color-Doppler). On the basis of the clinical diagnosis the patients
were classified as having "innocent murmur," "pathologic murmur," or "possible
pathologic murmur." A total of 161 patients (51% males), aged 1 month to
17 years (median 3.2 years), were studied. After electrocardiogram, no diagnosis
was changed.
After echocardiogram, the clinical diagnosis of innocent murmur in 109 patients
changed in 2 to pathologic (small ventricular septal defect 1, small atrial
septal defect 1); pathologic murmur in 46 changed to innocent in 3 and possible
pathologic in 2; and possible pathologic in 6 changed to innocent in 3 and
to pathologic in 2. The clinical examination by an experienced pediatric
cardiologist is an accurate means of assessing newly referred patients with
murmurs.
The clinical examination had a sensitivity of 96%, specificity of 95%, positive
predictive value of 88%, and negative predictive value of 98%. The electrocardiogram,
unlikely to disclose any unsuspected heart disease, may assist in reaching
lesion-specific diagnosis when there is underlying pathology. Echocardiography,
although diagnostic when heart disease is suspected, is unnecessary in pediatric
patients with clinically diagnosed heart murmurs.
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