Look for Warning Signs of Sudden Death in Kids

By Nancy Walsh, Staff Writer, MedPage Today

Published: March 26, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.

·         Awareness of warning signs and family history are crucial for the prevention of sudden cardiac arrest in young people.

·         Note that the statement recommends that clinicians recognize the warning signs and symptoms of sudden cardiac arrest, including those that may be incorrectly attributed to noncardiac diseases and, thus, delay correct diagnosis.

Awareness of warning signs and family history are crucial for the prevention of sudden cardiac arrest in young people, according to a new policy statement from the American Academy of Pediatrics.

Pediatric sudden cardiac arrest can be lethal within minutes if unrecognized and untreated, and some 2,000 related deaths are thought to occur in the U.S. each year, according to the statement, which was published online ahead of print in the April issue of Pediatrics.

“Although [sudden cardiac arrest] may be the sentinel event, symptoms in patients with structural-functional or primary electrical disorders may, in fact, be relatively common,” the statement reads.

Symptoms can include chest pain, dizziness, exercise-induced syncope, and dyspnea, which may have bee n disregarded by the patient and family; a detailed history also may reveal the sudden, unexplained death of a young relative.

In fact, estimates suggest these warning signs may be present in up to half of cases of sudden cardiac arrest in children.

The most common underlying causes of sudden cardiac arrest in this age group are structural or functional disorders such as hypertrophic cardiomyopathy and coronary artery anomalies, and primary cardiac electrical disorders such as familial long QT syndrome and Wolff-Parkinson-White syndrome.

The most frequent immediate event is a ventricular tachyarrhythmia, the statement authors noted.

Some types of arrhythmias, such as torsades de pointes, can be transient and may appear similar to seizures, which highlights the importance of accurate diagnosis.

The statement recommends that clinicians recognize the warning signs and symptoms of sudden cardiac arrest, including those that may incorrectly be attributed to noncardiac diseases and, thus, delay correct diagnosis.

For example, if the patient is thought to be experiencing a seizure, the likely referral may be to a neurologist, which could delay the diagnosis — with potentially disastrous results.

Similarly, if dyspnea is the presenting symptom, the workup may focus on a respiratory etiology, so a lack of response to initial treatment should trigger a reconsideration of potential cardiac causes, they suggested.

The statement also addressed the issue of screening young athletes before permitting sports participation.

A variety of risk-assessment tools have been used, and although these have not been validated or assessed for sensitivity or specificity, expert opinion currently emphasizes the importance of these “ominous” findings on a preparticipation screen:

·         A history of fainting or having a seizure, especially during exercise

·          Past episodes of chest pain or shortness of breath with exercise

·          A family member with unexpected sudden death or a condition such as hypertrophic cardiomyopathy or Brugada syndrome

The academy also considered the role of ECG screening for young athletes and referred to earlier American Heart Association guidelines that did not endorse widespread use of this test, citing the possibilities of false-positive and false-negative results, cost, and medicolegal problems.

“Wide-scale E CG screening would require a major infrastructure enhancement not currently available in the U.S.,” the statement pointed out, and called for additional data and debate on the subject.

Another recommendation was regarding the “molecular autopsy,” which would include a postmortem genetic analysis aimed at detecting cardiac channel abnormalities in any child with sudden cardiac death. This currently is primarily a research tool, but could provide valuable information to survivors.

As to secondary prevention of sudden death following an episode of cardiac arrest, the authors of the statement acknowledged that identification, treatment, and appropriate activity restriction ca n’t be successful in every case.

They therefore recommended extensive placement of automated external defibrillators in schools, along with cardiopulmonary resuscitation training of staff and others.

The statement also argued in favor of the establishment of a central registry for pediatric sudden cardiac arrest.

Other groups that have endorsed the statement include the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society.

One of the authors of the statement disclosed receiving fees, honoraria, and royalties from Biotronik, Boston Scientific, Medtronic, St. Jude Medical, and Transgenomic.