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The pediatric electrocardiogram. Part I: Age-related interpretation (DOI:10.1016/j.ajem.2007.08.003)
Abstract
Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric population. The purpose of this 3-part review will be to review (1) age-related changes in the pediatric ECG, (2) common arrhythmias encountered in the pediatric population, and (3) ECG indicators of structural and congenital heart disease in the pediatric population.
... At birth, pulmonary circulation and the left heart become dominant, mainly through an increase in the size of the ventricle, modifying the vector orientation (heart axis). The electrocardiographic pattern begins to introduce adult features, starting with the decreased amplitude of P (right atrial depolarization) (Tudbury and Atkinson 1950;Bright 1995;O'Connor et al. 2008). ...
... The atrioventricular node is sensitive to changes in sympathetic activity, leading to tachycardia and increased speed of electric conduction (Keunen et al. 2000). The delay in conduction of the electrical stimulation of the atria to the ventricles is also due to the lower myocardial mass in relation to adults (Chan et al. 2008;O'Connor et al. 2008). Ventricular contraction is represented by the R wave amplitude and decreased between birth and 35 days of age (0.190-0.087 mV). ...
... The present study observed an increase in QT intervals, whereas the frequency decreased over the course of weeks (0.168-0.209 s). Studies with lambs from two to five months and 10 to 12 months (Tudbury and Atkinson 1950;Bright 1995;Keunen et al. 2000;Mir et al. 2000;Ker and Webb 2005;Hamlin 2007;O'Connor et al. 2008;Mendes et al. 2010;Nunes et al. 2014) presented more QT intervals with lower frequencies (105 and 150 bpm), indicating a negative correlation. In adult animals, between one to two years (Atmaca et al. 2014) and two to seven years (Torío et al. 1997), the QT exhibits high values, with frequencies close to 100 bpm. ...
The cardiovascular system in newborns has unique features; the system differs from that of foetuses due to the onset of pulmonary respiration and the closure of shunts and differs from that of adults due to heart and autonomic system immaturity. Twenty Ile de France lambs were evaluated during the first 35 days of life to describe changes in the electrical conduction of the heart and in the sympathetic and parasympathetic system during the neonatal period. Electrocardiographic evaluation and the sympathovagal balance was assessed by heart rate variability (HRV) were performed, and ambulatory electrocardiography was performed with a Holter system from birth and at 7, 14, 21, 28 and 35 days of age. There was a significant difference in the duration of the PR and QT intervals and the T wave, as well as a decrease in the amplitude of the P, R and T waves for the evaluated moments. The heart rate and total QRS decreased progressively until 35 days, whereas the HRV indexes increased during the same period. The neonatal period requires care and attention, as several adaptations for neonate survival in the extrauterine environment occur during this period.
Abbreviations: HRV: heart rate variability; PR, QT: electrocardiographic intervals; P, R and T: electrocardiographic waves; QRS: electrocardiographic complexes; I, II, III, aVL, aVF and aVL: electrocardiographic member derivations; FP: frontal plane of electrocardiogram; HR: heart rate; RR or NN: interval between two R waves in Holter evaluation; NNmed: the average value of all normal cycles measured during the Holter evaluation; RMSSD: square root of the average of successive differences squared between normal RR intervals measured during the Holter evaluation; pNN50: successive differences between the percentage of RR intervals greater than 50 ms in Holter evaluation
... With advancing age, degenerative changes occur in heart muscle and its conduction system. Some of the pathways of pacemaker system may develop fibrous tissue and fat deposits (O'Connor et al., 2008). Furthermore, many of the changes that occur in the electrocardiogram reflect the anatomical dominance of the right ventricle during early months of life. ...
... This change can be accounted for by the gradual increase in vagal tone that accompanies aging. Younger animals also may be anxious during ECG acquisition, causing an artifactual decrease in the R-R interval (O'Connor et al., 2008). ...
... The QRS duration in young animals is shorter than that of adults, once again, because of smaller cardiac muscle mass. In children, a mild prolongation of the QRS interval may occur without clinical correlate, which labelled as intraventricular conduction delay (O'Connor et al., 2008). The Q-T interval, measured from the beginning of the QRS complex to the termination of the T wave, represents ventricular activity. ...
... The results of the present study showed that some of the electrocardiographic parameters were changed during neonatal period of the calves. Other researchers mentioned that several changes occur in cardiac muscle and its conduction system after birth (O'Connor et al., 2008). Furthermore, many of the changes that occur in the ECG reflect the anatomical dominance of the right ventricle during neonatal period. ...
... This change can be accounted for by the gradual increase in vagal tone that accompanies aging. Younger animals also may be anxious during ECG acquisition, causing an artifactual decrease in the R-R interval (O'Connor et al., 2008). ...
... The QRS duration in young animals is shorter than that of adults, once again, because of smaller cardiac muscle mass (O'Connor et al., 2008). The Q-T interval, measured from the beginning of the QRS complex to the termination of the T wave, represents ventricular activity. ...
Several physiological alterations may occur in cardiovascular system during fetal life to the neonatal period. Electrocardiographic studies in neonatal period may assist veterinarians to evaluate cardiovascular system in this period. Five multiparous high producing Holstein dairy cows were monitored at close-up dry period to calving. Electrocardiograms were recorded from their calves immediately and 5, 10, 15, 20, 25, 30 and 35 days after birth and all electrocardiographic parameters were evaluated. Durations of P, R and T waves were increased significantly from birth to the end of neonatal period (P
... Although the basic principles of interpretation of the electrocardiogram (ECG) are identical in children and adults, the paediatric ECG differs significantly from the adult ECG. 1 Interpretation of the paediatric ECG depends on patient age, reflecting the developmental changes in anatomy and physiology that occur in the growing infant or child. 2,3 In order to avoid errors in interpretation, anaesthesiologists, paediatricians, emergency physicians, etc should be familiar with the normal paediatric ECG and should be aware of the common ECG abnormalities occurring in children. 2 ...
... Factors contributing to the dynamic nature of the paediatric ECG include: (1) the anatomical dominance of the right ventricle during the neonatal period due to high pulmonary vascular resistance in utero; 2,3 (2) increase in vagal tone with ageing; 2,3 (3) reduced cardiac muscle mass; 2 (4) developmental changes in body size, position and size of the heart relative to the body, and of the cardiac chambers relative to each other; 3 and (5) the presence of maternal autoimmune disease and transplacentally acquired maternal antibodies. 2,3 The electrocardiographic variables influenced by the above-mentioned factors include the heart rate, P wave morphology, PR interval, mean frontal plane QRS axis, QRS duration, R and S wave amplitudes and progression, QT interval, T wave morphology and atrioventricular conduction, all demonstrating age-related changes. [1][2][3][4] Another major factor complicating interpretation of the paediatric ECG is congenital heart disease, which affects approximately 1% of newborns. ...
... 2,3 The electrocardiographic variables influenced by the above-mentioned factors include the heart rate, P wave morphology, PR interval, mean frontal plane QRS axis, QRS duration, R and S wave amplitudes and progression, QT interval, T wave morphology and atrioventricular conduction, all demonstrating age-related changes. [1][2][3][4] Another major factor complicating interpretation of the paediatric ECG is congenital heart disease, which affects approximately 1% of newborns. 5 As the number of infants, children and adults with surgically corrected congenital heart disease is growing -a population that is particularly prone to develop cardiac arrhythmiasknowledge of the arrhythmias commonly associated with congenital heart disease becomes essential. ...
... P-R interval is longer in adults than children and in men than women due to a larger body surface area and heart size, and is prolonged in hypothyroidism (6,22,27). P-R interval is also longer in older people due to changes related to ageing (4,28), in patients with a slower heart rate (19), and in athletes in comparison to sedentary men. Genetic factors also have an influence on the P-R interval duration (9,10,16). ...
... It results in alterations in refractoriness, conductance, or automaticity. The most known form of electrical remodelling is occurring in atrial myocardium during atrial fibrillation, which relies on shortening of action potential, loss of physiological rate adaptation of the action potential, and a decline in conduction velocity (18,19,23,24,29,30). However, remodelling may also affect other than atrial cardiac cells (7,8,31). ...
The aim of the study was to assess the atrioventricular conduction in the model of porcine pacing induced tachycardiomyopathy. Fifty-one swine were examined: 27 were paced and 24 served as a control group. Every 4 weeks, the animals were anaesthetised for 1 h and an ECG Holter was performed. Thirty minutes after the onset of anaesthesia, P-R and R-R intervals were measured. Each result was assigned to the subgroup according to the animal's weight and the presence or absence of previous pacing. P-R interval was longer in animals after at least 4 weeks of rapid ventricular stimulation than in adjusted group of the animals according to the body mass. Multivariate analysis has showed that longer P-R interval was related to male gender, higher body mass, slower heart rate, and history of previous pacing. Chronic ventricular pacing led to the slowing of atrioventricular conduction. The presence of differences in the duration of R-R intervals between groups was only found in swine weighing 120-139 kg. The R-R interval was shorter in paced animals, whereas PR interval was longer in that group, indicating that PR prolongation is related to electrical or structural remodelling of the cardiac conductive tissue but not increased sympathetic nervous system activity, which is expected to produce corresponding changes in PR and R-R intervals.
... Electrocardiography: Incidental findings of a short PR interval without a d wave (below the lower limit for age in children 15,16 and Ͻ120 ms in adults 17 ) in subjects who undergo electrocardiography for cardiac or noncardiac reasons (presurgery evaluation, sport suitability, etc.) should be considered with caution as early potential markers of a myocardial storage disease 18 (Figure 2). A short PR interval is seen in 21% to 40% of adult patients with AFD 17,19 -21 and in about 28% of pediatric patients. ...
... The product is calculated as the sum of the total QRS amplitudes in the 12 ECG leads (mm) multiplied by the QRS duration, choosing the longest QRS duration in lead I, II, or III. 27 The Sokolow-Lyon product shows a good relation with the LV mass estimated by echocardiography 16 and is calculated from the Sokolow-Lyon index (the sum of SV 1 and RV 5 voltages) when it is multiplied by the longest QRS duration in lead I, II, or III 25,27 ; a cut-off value Ͼ297 (sensitivity Ͼ80%) has 46% specificity. 25 The Cornell product shows similar results. ...
Anderson-Fabry disease is a lysosomal storage disorder caused by α-galactosidase defects and progressive intracellular accumulation of globotriaosylceramide. The disease can be specifically treated with enzyme replacement therapy. Hemizygous men and heterozygous women can develop cardiac disease. Whereas men experience the most severe clinical phenotype, clinical presentation in women varies from asymptomatic to severely symptomatic. The characteristic cardiac phenotype is left ventricular hypertrophy mimicking sarcomeric hypertrophic cardiomyopathy or hypertensive heart disease. Early or prehypertrophy cardiac involvement may escape detection, unless electrocardiographic clues are present. The cardiac markers that raise suspicion of Anderson-Fabry disease include a short PR interval without a δ wave and a prolonged QRS interval, supraventricular and ventricular arrhythmias, and concentric left ventricular hypertrophy. Extracardiac features include renal failure, corneal deposits, and nervous, gastrointestinal, and cutaneous manifestations. Useful family data include cardiac and extracardiac traits in relatives and absence of male-to-male transmission. Symptoms are subtle, and the interval between the onset of symptoms and diagnosis may be as long as 20 years. As such, the diagnosis is typically late. Endomyocardial biopsy shows optically empty myocytes on light microscopy and dense osmiophilic bodies constituted of globotriaosylceramide on electron microscopy. Alpha-galactosidase A activity is reduced in hemizygous men but not in heterozygous women. Genetic testing is the gold standard for the diagnosis. In conclusion, a correct and timely diagnosis offers the possibility of disease-specific treatment that leads to sustained clinical benefits for cardiac and noncardiac signs and symptoms.
... [5][6][7] However, in view of the physiological maturation during pediatric age, many of these findings including short PR interval and RVH-like pattern can be found in normal children as well. [8][9][10] Ideally, to delineate ECG abnormalities, especially across different age groups of boys with DMD, comparison with age-matched controls is desirable. Besides, normative values for ECG parameters depend on the population being studied, and hence, distinguishing between pathological and nonpathological ECG Background: Electrocardiography (ECG) remains an excellent screening tool for cardiac assessment in Duchenne muscular dystrophy (DMD), but an accurate interpretation requires comparison with age-matched healthy controls. ...
Background
Electrocardiography (ECG) remains an excellent screening tool for cardiac assessment in Duchenne muscular dystrophy (DMD), but an accurate interpretation requires comparison with age-matched healthy controls.
Objective
We examined various ECG parameters in children with DMD, in comparison with age-matched controls.
Methods
Standard 12-lead ECG tracings of serial patients were screened for quality and selected. Controls were healthy, age-matched school-going children. Both quantitative and qualitative ECG parameters were analyzed.
Results
After screening, ECGs from 252 patients with DMD (8.32 ± 3.12 years, 2–21 years) and ECGs from 151 age-matched healthy controls (9.72 ± 2.23, 4–19 years) were included. A significantly higher heart rate, shorter R–R interval, and taller R wave in V1 were seen across all age group of DMD in comparison to controls, with the difference increasing with age. While QT prolongation was seen in all age groups of DMD, QTc prolongation was seen only at 10 years or more. Incomplete right bundle branch block (RBBB) and pathological Q waves in inferolateral leads were exclusive in DMD, with the latter declining with age. Evidence for left ventricular (LV) pathology, such as tall R in V5/V6, increase in SV1 + RV6 height, and QRS complex duration, were seen only in the age group of 10 years or more.
Conclusion
Stratification based on age and comparison with age-matched healthy subjects showed that several ECG parameters were influenced by age, and it also identified age-dependent evidence for LV pathology and QTc prolongation in DMD.
... 10 Although no signifi cant difference exists between adults and children related to P-wave amplitude, it does between adults and children, 10 with 120 ms and 140 ms in adults and 100 ms and 50 ms in pediatric and children younger than 1 year. 11 Age and sex varia-signifi cant distance percentage between both genders in our country. ...
Background: There are significant differences in electrocardiographic parameters between males and females. However, there is a lack of data regarding the gender-related differences in indications and findings of ambulatory electrocardiographic monitoring (AEM) especially in Middle Eastern population. Purpose: We sought to investigate the gender-related differences in the baseline ECG findings, indications, and findings of AEM in an Iraqi cohort of patients referred for AEM. Methods: Baseline ECG was analyzed for each patient, indications, and findings of AEM for each patient was documented. Results: n = 100 (53% were males and 47% were females). Patients were either referred for 24-hour or 48-hour AEM. Women were referred more for 48 hours AEM than male counterparts (19.1% vs 18.9%). Main indications for AEM referral in males were palpitation (26.41%), bradycardia (16.98%) and presyncope (13.2%) while main indications for AEM referral in females were palpitation (34.04%), presyncope (23.4%), and syncope (14.89%). Baseline ECG was normal in females more than in males (36.17% vs 20.75%). Premature atrial contractions (PAC), atrial fibrillation (AF), supraventricular tachycardia (SVT), ventricular tachycardia (VT) and significant pauses were detected more frequently in females while PVC and first degree heart block were detected more frequently in males. Conclusion: There are some gender-related differences in baseline ECG, indications, and findings of AEM. Further work is warranted to detect the impact of these changes on management and outcomes.
... All tracings were acquired digitally, and intervals, amplitudes, areas, vectors, QRS axis, etc., were automatically analysed and stored in the MUSE software (Version 8, GE Healthcare, Milwaukee, USA). QRS axis was defined as "adult normal" (+ 1 to + 90°), left axis deviation (LAD; 0 to − 90°), right axis deviation (RAD; + 91 to + 180°), or extreme axis deviation (EAD; + 181 to + 270°) [11,12]. ...
Ventricular septal defects (VSD) represent the most common congenital heart defect in newborns. We assessed the electrocardiographic characteristics of newborns with VSDs in a general population sample. The Copenhagen Baby Heart Study is a prospective population–based cohort study offering cardiac evaluation of newborns. Echocardiograms and electrocardiograms were obtained within 30 days after birth and systematically analysed. A VSD was identified in 530 newborns (mean age 11 ± 7 days, 42% boys). Newborns with VSDs had a more left-shifted QRS axis (116 ± 34 vs. 120 ± 3°, p = 0.02), and a higher S-wave amplitude in V1 (721 ± 584 vs. 636 ± 549 µV, p = 0.001) than controls. The largest differences were found in newborns with large or perimembraneous VSDs with a higher frequency of left axis deviation, higher S-wave amplitudes in V1, and higher R- and S-wave amplitudes in V6 compared with controls. R-waves in V1 and V6 were significantly associated to left ventricular mass, whereas S-waves in V1 and V6 were dependent on left ventricular end-diastolic diameter on echocardiography.
Conclusion: Newborns with VSDs showed significant differences in QRS axis, and R- and S-wave precordial amplitudes compared to matched controls. Perimembranous and large VSDs had the greatest effect on the neonatal ECG. What is Known:
• Ventricular septal defects in newborns are prevalent and may affect cardiac function and structure.
What is New:
• The Copenhagen Baby Heart Study is the largest study including a cohort of unselected newborns undergoing postnatal cardiac examination.
• We found that newborns with VSD showed significant electrocardiographic differences depending on size and type of VSD compared with healthy newborns.
... The pediatric electrocardiogram (ECG) demonstrates agerelated changes, most of which are due to a change in ventricular dominance by age [1]. Similar changes are seen with pediatric T waves which include T-wave inversions (TWI) in the anterior leads (V1, V2, V3) [2,3]. These inversions are common between 7 days and 10-15 years of age with a reported prevalence of 55% to 60% at 3 years of age [4]. ...
T-wave inversions (TWI) in inferolateral electrocardiogram (ECG) leads (II, III, aVF, V5–V6) are often suggestive of cardiac pathology in adult patients. They are a common reason of additional testing in pediatric patients. The goal of the study is to determine correlation of exercise stress test T-wave response with diagnosis of cardiac pathology. This is a retrospective review of pediatric patients < 21 years with the finding of baseline TWI in inferior (II, III, avF) and/or lateral (V5–V6) leads on 12-lead ECG. All patients underwent treadmill exercise stress test (EST) and an echocardiogram within 1 year of each other. Demographics, baseline ECG findings, echocardiogram results, and EST data were recorded. T-wave reversion was considered complete if T waves demonstrated normalization during exercise, partial if there was minimal improvement, and no response if there was no change or worsening of inversions. In our cohort of 72 patients with a mean age 14.6 (± 2.9) years and 61% males, 59 (82%) had a structurally normal heart. Thirteen patients had evidence of structural or functional heart disease. Of the 59 patients, 83% had either complete or partial T-wave response. Among the 13 patients with heart disease, two patients had genetic testing consistent with risk for hypertrophic cardiomyopathy and had complete and partial response on EST. Exercise stress testing for TWI in pediatric patients has low sensitivity and specificity for the diagnosis of cardiac disease and routine use in this patient population may not be indicated.
... Amplitudes higher than the above limits may indicate ventricular hypertrophy. 4 Boxes 1 and 2 describe the criteria for left and right ventricular hypertrophy, respectively. It is important to note that the diagnosis of left ventricular hypertrophy (LVH) and right ventricular hypertrophy (RVH) (figure 2 and box 2) should not be based on voltage criteria alone. ...
ECG interpretation is a core skill for any healthcare practitioner that looks after children. The article aims to educate the reader in basic interpretation of paediatric ECG in a succinct, interactive, organised manner in a way that it can be easily referenced and applied in everyday clinical practice. We include clinical examples as well as age and sex-related reference ranges for QT intervals, P-wave duration, Q-wave amplitude, QRS complex duration, R-wave and S-wave amplitude, R/S ratio and PR intervals.
... Furthermore, Kviesulaitis et al. (2018) the heart muscle and its conduction system. Some of the pathways of the pacemaker system may develop fibrous tissues and fat deposits (O'Connor et al., 2008). Furthermore, many of the changes occurring in the electrocardiogram reflect the anatomical dominance of the right ventricle during early months of life. ...
Short-term electrocardiography is one of the most suitable tools to study the electrical activity of the heart, but the use of a tool such as a Holter-monitor with the ability to assess the long-term of the heart electrical activity, can provide more accurate information about these activities by comparing the results. It is possible to understand the superiority of each over the other and the resulting differences. Therefore, 60 female Holstein cows in 10 age groups, including 1 day, 1, 3, 6 months, 1, 2, 3, 4, 6 and 8 years were included in the study (6 heads in each age group). Electrocardiography (for 5 min) and Holter-monitoring (for 24 hr) were performed from the entire study population. The Q, R and T amplitudes in electrocardiography were significantly higher than those in Holter-monitoring. The P, R and T durations and P-R, R-R, Q-T and S-T intervals at all ages were significantly longer in the Holter-monitoring than in the electrocardiographic method. The heart rate of animals was significantly lower in the 24-hr Holter-monitoring than in the short-term electrocardiography. The trend of changes of all parameters was significant during ageing. Cardiac arrhythmias included sinus arrhythmia and sino-atrial block, which were the most common cardiac arrhythmias in the 24-hr Holter-monitoring. It appears that long-term Holter-monitoring is a more reliable method than short-term electrocardiography to assess cardiac arrhythmias. Additionally, the indicators of electrical activity of the heart (waves) in the Holter-monitoring method are significantly different from short-term electrocardiography, which is probably due to the collection of information over a long period and in non-stressful situations. Furthermore, it appears that the use of the 24-hr Holter-monitoring method is preferable to the short-term electrocardiography method to evaluate the electrical activity of the heart of cows at all ages.
... Surprisingly, the prevalence of conduction abnormalities in NHS participants < 18 years old was also high (65.5%). However, since multiple diagnostic criteria are commonly used for pediatric ECGs and the criteria changes with age [10] [11] [12], we were unable to identify a suitable comparator cohort for the pediatric participants in the NHS. Physical examination as well as vitals taken at screening (diastolic blood pressure, systolic blood pressure, height, heart rate, knee to heel length, respiratory rate, temperature, and weight) were all within normal ranges and showed no correlations to ECG abnormalities. ...
Abstract Background Genetic contributors to cardiac arrhythmias are often found in cardiovascular conduction pathways and ion channel proteins. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare disease of massive heterotopic ossification caused by a highly recurrent R206H mutation in ACVR1/ALK2. This mutation causes abnormal activation of the bone morphogenetic protein (BMP) pathway in response to Activin A. Prior studies suggested increased risks of cardiopulmonary complications in FOP. We examined participants in a Natural History Study (NHS) of FOP (ClinicalTrials.gov #NCT02322255) to better understand their cardiovascular status. Methods The NHS is an ongoing 3 year international multi-center longitudinal study of 114 patients (ages 4–56 years) with genetically confirmed ACVR1/ALK2 R206H FOP. Patients were clinically assessed at baseline and 12 months. Electrocardiograms (ECGs) were reviewed in a central ECG laboratory. Conduction abnormalities were compared against clinical data collected in the NHS, and echocardiograms collected from NHS and non-NHS patients. Results Conduction abnormalities were present in 45.3% of baseline ECGs, with the majority of abnormalities classified as nonspecific intraventricular conduction delay (37.7%). More specifically, 22.2% of patients > 18 years old had conduction abnormalities, which was significantly higher than a prior published study of a healthy population (5.9%; n = 3978) (p
... It is also important to note that studies on healthy adults have reported that females' HRV and CC are usually greater than they are in males (Ryan et al., 1994;Koenig and Thayer, 2016). Since HR regulation changes throughout the lifespan (O'Connor et al., 2008;Moodithaya and Avadhany, 2012), further longitudinal research should focus on when these patterns invert along the course of development and why. Perhaps the higher HRV and CC in some adult females come from an effort to balance out anxiety or depression. ...
Background: The association between decreased heart rate variability (HRV) and increased internalizing symptoms is well documented. Adolescence is a critical period for the development of mental health problems, in particular internalizing symptoms. Previous research has illustrated sex differences in adolescent HRV, such that females have reduced short-term resting state HRV compared to males. Studies on long-term ecological recordings of HRV in adolescents are scarce. The aims of the present study were, (a) to test if adolescent females show decreased long-term HRV and cardiac complexity (CC) compared to males, and (b) to explore whether sex and HRV and CC measures, as well as their interaction, would predict internalizing symptoms.
Materials and Methods: HRV was recorded in n = 166 adolescents (86 girls), on a normal school day. HRV and CC measures were calculated on the interbeat interval time series.
Results: Females showed lower HRV and CC in most of the assessed indices. Internalizing symptoms were mainly predicted by HRV whereas sex only predicted symptoms of social anxiety. The interaction between sex and HRV did not predict internalizing symptoms.
Conclusions: Results suggest that reduced HRV should be considered as a potential contributor to exacerbating internalizing symptoms in adolescence. Girls with reduced HRV and CC might be prone to the development of internalizing disorders. HRV is a promising tool for the early identification of vulnerability.
... ECG was recorded as rhythm, conduction, and right ventricular hypertrophy (RVH) by age-related interpretation. 5 Complete echocardiography examination was performed using the Philips SONOS 7500 system (Philips, Andover, MA, USA). Data were collected using 2-dimensional images, M-mode transducer, pulse wave/continuous wave, and color flow Doppler. ...
Pupose:
To determine predictive factors of spontaneous closure or size reduction in large secundum-type atrial septal defects (ASD) diagnosed in infancy prior to catheterization or surgical intervention.
Methods:
From June 2003 to October 2009, 59 infants diagnosed with secundum-type ASDs measuring ≥ 8 mm in the first year of life were retrospectively enrolled. We reviewed medical records, as well as electrocardiography and echocardiography findings. Patients were divided into 2 groups according to the last ASD size: group A (n = 23), ASD reduction in size to < 5 mm or spontaneous closure; group B (n = 36), size of ASD remained ≥ 5 mm.
Results:
The ASDs spontaneously closed in 10 (17%) patients at a median age of 26.0 ± 5.1 months (range, 15-58 months), or decreased to < 5 mm in 13 (22%) (range, 6-27 months) patients. There was a significant difference in age at diagnosis between the 2 groups (p = 0.014). Patients in group A were younger than those in group B at the time of diagnosis. Changes in ASD size (p < 0.001) and body weight percentile (p = 0.01) were also significantly different fromthe 6-month follow-up. ASD diameter of ≥ 10 mm was a negative predictive factor for size reduction (p = 0.017).
Conclusions:
Spontaneous closure or size reduction of large ASDs was not uncommon in patients diagnosed during infancy. Patients with initial ASD sizes between 8 and 10 mm who were younger at the time of diagnosis and showed better weight gain were more likely to have favorable outcomes.
Key words:
Infancy; Large secundum atrial septal defect; Natural course; Spontaneous closure.
... RVH was determined by electrocardiogram (ECG) and echocardiogram. 8,9 The diagnosis of RVH by ECG fulfilled at least three of the following criteria: right axis deviation, tall P waves (> 2.5 mm), an rsRЈ pattern in the right precordial leads with the second R wave taller than the initial one, a qR pattern in the right precordial leads, age-corrected increased voltage of the R wave in lead V 1 , increased voltage of the S wave in leads V 5 -V 6 , and a positive T wave in lead V 1 between the ages of 6 days and 6 years. On echocardiographic assessment, RVH was diagnosed by the demonstration of paradoxical motion of the interventricular septum on an M-mode study and/or the presence of a larger right ventricular volume than the left ventricular counterpart, as seen on the apical four-chamber view of a two-dimensional echocardiogram. ...
Pediatric patients with atrial septal defect (ASD) may have failure to thrive. This study aimed to investigate body weight changes in pediatric patients after transcatheter closure of ASD.
From June 2003 to September 2008, we enrolled 60 pediatric patients who underwent transcatheter closure of ASD. Changes in body weight percentile, heart rate, and resolution of right ventricular hypertrophy were compared before and after ASD closure. Patients were divided into two groups according to initial weight percentile: group A, <50(th) percentile (n = 39) and group B, ≥50(th) percentile (n = 21). Echocardiography and routine weight measurements were performed before the procedure and at 3, 6, and 12 months during follow-up. Clinical presentations, laboratory data, and outcomes were measured.
Increased body weight percentile (41±4 vs. 48±4, p<0.01), lower heart rate (100±2 beats/min vs. 89±2beats/min, p<0.01), and resolution of right ventricular hypertrophy (59/60 vs. 1/60, p<0.01) were achieved after ASD closure at the 12-month follow-up. Patients in group A were significantly younger (4.6±0.5 years vs. 7.0±0.9 years, p = 0.016), had a higher pulmonary/systemic blood flow ratio (2.2±0.1 vs. 1.8±0.l, p = 0.044), a largerratio of ASD diameter/body surface area (25.0±1.4 vs. 16.4±1.9, p<0.01), and higher percentage of weight gain increase ≥ 5 percentile compared with patients in group B (22/39 vs. 6/21, p = 0.039).
Transcatheter closure of ASD positively affects weight gain. An increase of 7 percentile weight was observed at 1 year of follow-up. Patients with a younger age, higher pulmonary/systemic blood flow ratio, and a larger ratio of ASD diameter/body surface area may have better weight gain after ASD closure.
The postnatal mammalian heart undergoes remarkable developmental changes, which are stimulated by the transition from the intrauterine to extrauterine environment. With birth, increased oxygen levels promote metabolic, structural and biophysical maturation of cardiomyocytes, resulting in mature muscle with increased efficiency, contractility and electrical conduction. In this Topical Review article, we highlight key studies that inform our current understanding of human cardiomyocyte maturation. Collectively, these studies suggest that human atrial and ventricular myocytes evolve quickly within the first year but might not reach a fully mature adult phenotype until nearly the first decade of life. However, it is important to note that fetal, neonatal and paediatric cardiac physiology studies are hindered by a number of limitations, including the scarcity of human tissue, small sample size and a heavy reliance on diseased tissue samples, often without age-matched healthy controls. Future developmental studies are warranted to expand our understanding of normal cardiac physiology/pathophysiology and inform age-appropriate treatment strategies for cardiac disease.
Although the basic principles of electrocardiogram (ECG) interpretation in children are identical to those in adults, pediatric ECGs are more challenging to read as compared to adult ECGs. These difficulties are mainly related to progressive changes in normal cardiac anatomy and physiology between birth and adolescence. Furthermore, structural and hemodynamic changes in congenital heart disease may affect nearly all aspects of the surface ECG. Therefore, the ability to clearly distinguish an abnormal ECG pattern from a normal variant is an essential skill for pediatric practitioners. The purpose of this chapter is to provide a systematic approach to ECG interpretation in pediatric patients. We also discussed all important ECG abnormalities such as chamber hypertrophy, conduction abnormalities, and common cardiac arrhythmias. In addition, we presented typical ECG features of common congenital heart diseases, cardiomyopathies, cardiac inflammatory conditions, and cardiac tumors in children. We hope that the readers will find this chapter a helpful synopsis and an enjoyable experience.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
The present study has been conducted to evaluate the changes in electrocardiogram (ECG) parameters among various age groups of apparently healthy Labrador retriever dogs. A total of 24 Labrador retriever dogs were included and were divided into four groups of six dogs in each group. Animals below one year-age were kept in group I, between one to eight year-age in group II, between eight to ten year-age in group III and above ten year-age in group IV. Significant (P<0.05) changes in P, R and T wave amplitude, QRS duration and PR interval were noticed with ageing. No significant difference was observed in Right lateral Vertebral heart Score (RLVHS) and Left lateral Vertebral heart Score (LLVHS) between various age groups of Labrador retriever dogs. Abnormal rhythm like arrhythmic patterns, sinus tachycardia and abnormal ECG morphology like P mitrale, low QRS voltage complexes and ST segment depression were also predominant in aged dogs. Amplitudes and duration of different ECG waves were affected by age.
Although the basic principles of electrocardiogram (ECG) interpretation in children are identical to those in adults, pediatric ECGs are more challenging to read as compared to adult ECGs. These difficulties are mainly related to progressive changes in normal cardiac anatomy and physiology between birth and adolescence. Furthermore, structural and hemodynamic changes in congenital heart disease may affect nearly all aspect of the surface ECG. Therefore, the ability to clearly distinguish an abnormal ECG pattern from a normal variant is an essential skill for pediatric practitioners. The purpose of this chapter is to provide a systematic approach to ECG interpretation in pediatric patients. We also discussed all important ECG abnormalities such as chamber hypertrophy, conduction abnormalities, and common cardiac arrhythmias. In addition, we presented typical ECG features of common congenital heart diseases, cardiomyopathies, cardiac inflammatory conditions, and cardiac tumors in children. We hope that the readers will find this chapter a helpful synopsis and an enjoyable experience.
Assessing hypertrophy of cardiac chambers using electrocardiography (ECG) is a reliably screening tool and a frequent indication for performing this low-cost study with reasonable accuracy. The detection of hypertrophy of a cardiac chamber or combination of chambers is a valuable tool in arriving to diagnosis of heart disease even before more expensive investigative studies are used. Furthermore, monitoring chamber hypertrophy through ECG can be easily performed.
Pediatric exposures to xenobiotics are more frequent than in any other age group. In 2011, U.S. poison control centers dealt with 2,333,004 human exposures with major occurrences in children 19 years of age and under (62%). Children are more likely to be poisoned by substances that are readily available. While the majority are of low toxicity and result in no symptoms, there are toxins that can result in significant morbidity and mortality of children. A number of dramatic pharmacokinetic, pharmacodynamic, and psychosocial changes occur as preterm infants mature toward term, as infants mature through the first few years of life, and as children reach puberty and adolescence. Understanding normal cardiac development is essential prior to discussing the adverse effects that toxins can have on the developing heart. Embryology is important to pediatric cardiology because it helps to clarify the etiology and pathogenesis of cardiac malformations. Respiratory rate, heart rate, and blood pressure have age-specific normal values. Additionally, differences occur when comparing electrocardiogram waveforms between adults and children. Toxicology should be in the differential of every pediatric patient or a dangerous condition may be missed.
Electrocardiograms were recorded from 89 clinically healthy Holstein cattle divided into 10 age groups, comprising newborn calves (18 to 72 hours), 15 days, 1, 3, 6 and 9 months and 1, 3, 5, and 7 years of age. The electrocardiograms were recorded on a bipolar base apex lead, using limb lead I. Duration and amplitude of the P, QRS complexes, T waves and the PR, RR, QT and ST intervals were measured in traced electrocardiograms. The values of P-duration, P-R, R-R, Q-T and S-T intervals in adults were significantly higher than young cattle, but the amount of P and R-amplitudes in older animals were significantly lower than younger once (P<0.05). There were no significant changing patterns of T-duration, T, S and Q-amplitude among all age groups. With advancing age, degenerative changes such as developing fibrous tissue and fat deposits occured in heart muscle and its conduction system. Furthermore, the conductive properties of the body, cardiac mass and size, characteristics of Purkinje fibres in cardiac conductive system and changes of vagal tone during aging can explain the changing patterns of bovine electrocardiographic parameters at different ages. The present study, also, incorporated both calves and adult Holstein cows in a single wide study which can provide a good basis for judging the electrocardiograms in cattle. © 2015, Bulgarian Journal of Veterinary Medicine. All rights reserved.
Arrhythmias Pediatric arrhythmias are increasing in prevalence secondary to improved patient survival following cardiac surgery and more extensive use of ECG monitoring. Proper management includes accurate electrocardiographic diagnosis, careful clinical evaluation, and initiation of appropriate therapy. With all rhythm disturbances, the approach to the patient begins with a 12-lead ECG, but, if there is hemodynamic instability, a single-lead ECG will suffice. Cardiac arrhythmias requiring emergency therapy can be classified simply into tachycardias and bradycardias. The tachycardias can be further divided into narrow and wide QRS complex groups. Rhythms in the narrow complex group include atrial fibrillation, atrial flutter, and supraventricular tachycardia, although the most common is sinus tachycardia. Atrial fibrillation Atrial fibrillation is usually associated with dilatation of the right or left atrium. It most commonly occurs in patients with mitral valve disease, chronic atrioventricular (AV) valve insufficiency, Wolff-Parkinson-White syndrome, or following the Fontan procedure in patients with only one functional ventricle. Other associations include hyperthyroidism, Ebstein's anomaly, atrial septal defect, or atrial tumor. Atrial fibrillation suggests significant atrial conduction system disease and is usually a chronic problem. “Lone” atrial fibrillation, in the absence of other cardiac abnormalities, is rare in children. Clinical presentation and diagnosis Suspect atrial fibrillation when the pulse is “irregularly irregular.” Heart sounds may vary in intensity, a pulse deficit may be present, and the cardiac impulse is markedly variable. The ECG shows chaotic fibrillatory waves of varying amplitude, morphology, and duration, causing variation of the baseline. The RR interval is irregularly irregular.
This article presents an approach for identification of infants with congenital heart disorders. These disorders are difficult to diagnose because of the complexity and variety of cardiac malformations; additionally presentation can be complicated by age-dependent physiology. By compiling data from the history and the physical examination, the emergency physician can identify lesion category and initiate stabilization procedures. Critical congenital cardiac lesions can be classified as left-sided obstructive ductal dependent, right-sided obstructive ductal dependent, and shunting or mixing. The simplified approach categorizes infants with these lesions respectively as "pink," "blue," or "gray." The emergency provider can provide life-saving stabilization until specialized care can be obtained.
Copyright © 2015 Elsevier Inc. All rights reserved.
Objective:
T-wave inversion in lateral electrocardiogram (ECG) leads (II, III, aVF, V4 -V6 ) is suspicious of cardiac pathology in pediatric patients, though many are found to have structurally normal hearts. The purpose of this study is to evaluate T-wave response during exercise stress testing (EST) in pediatric patients with structurally normal hearts and lateral-lead T-wave inversion on resting ECG.
Design:
An IRB-approved, retrospective review of EST databases at two centers identified patients with lateral-lead T-wave inversion on resting ECG. Inclusion criteria were normal exam and echocardiogram, absence of anginal chest pain, and age <18 years. All patients underwent treadmill or cycle ergometer EST. Data recorded included demographics, echocardiogram results, baseline ECG, EST method, peak heart rate and metabolic equivalents (METs), and heart rate and METs at T-wave reversion. T-wave reversion was considered complete if T-waves reverted in all leads, partial if reversion occurred in only some leads, and none if no reversion occurred.
Results:
The search identified 14 patients: nine females and five males (10 Caucasians and four African Americans) and an average age of 16 (range 12-18) years. Complete T-wave reversion occurred in 11 (79%) patients, partial in two (14%), and none in one (7%). Reversion occurred in both genders, ethnicities, and EST methods. No complications occurred during EST; no adverse outcomes occurred during 2-year follow-up.
Conclusions:
EST in pediatric patients with lateral-lead T-wave inversion on resting ECG and structurally and functionally normal hearts resulted in either complete or partial T-wave reversion in the vast majority of patients.
Pre-partecipation screening is the systematic practice of medically evaluating large populations of athletes before participation in sport activities for the purpose of identifying abnormalities that could cause disease progression or sudden death. In order to prevent sudden cardiac death (SCD), cardiovascular screening should include a strategy for excluding high-risk subjects from athletic and vigorous exercise. There are two major screening programmes in the world. In the United States competitive athletes are screened by means of family and personal history and physical examination. In Italy there is a mandatory screening for competitive athletes, which includes a resting electrocardiogram (ECG) for the detection of cardiac abnormalities. The most important issue to be addressed is whether a screened subject is really guaranteed that she/he is not suffering from any cardiac disease or at risk for SCD. Conceivably, the introduction of echocardiogram during the pre-participation screening, could be reasonable, despite the discrete sensitivity of ECG, in raising clinical suspicions of severe cardiac alterations predisposing to SCD. It is clear that the cost-benefit ratio per saved lives of the ECG screening is a benchmark of the Public Health policy. On the contrary, the additional introduction of echocardiography in a large population screening programme seems to be too much expansive for the Public Health and for this reason not easily practicable, even if useful and not invasive. Even if we strongly believe that a saved life is more important than any cost-efficacy evaluation, the issue of the economical impact of this approach should be further assessed.
This article aims to provide a concise, structured approach to the child with chest pain. Chest pain is a common presenting symptom in children but, unlike in adults, the cause is rarely cardiac. We review the main causes of chest pain in children and discuss the important features that may alert those assessing paediatric chest pain to serious underlying pathology. In the vast majority of cases, reassurance is all that is required and a thorough initial consultation can exclude rare, serious disease and provide vital reassurance to children and families.
Objective:
Limited evidence is available about the early cardiac manifestation of Fabry disease (FD) in children. We aimed to evaluate cardiac involvement in children with FD by analysing serial structural and electrocardiographic changes.
Methods:
The data were acquired from 22 children with FD [11 males; median age 9.8 (ranging 2.5-16) years]. Seven patients (5 males) were on enzyme replacement therapy (ERT) with Agalasidase alpha. Echocardiography, ECG and 24-h ECG monitoring recordings were acquired during routine annual clinical controls. ECG data were compared to a group of age-and gender-matched controls.
Results:
At baseline, ECG and ECHO parameters of left ventricular mass were similar in both males and females. Three boys (all were on ERT) developed left ventricular hypertrophy (LVH) during two-year follow-up. The progression to LVH was accompanied by the appearance of frequent ventricular premature beats in two cases and supraventricular premature beats (SPBs) with T wave inversion in one case. T wave inversion and SPBs were detected in two younger relatives of a patient with LVH, in the absence of detectable LVH. Seven out of 22 patients had T wave abnormalities. Five of them were males (p = 0.03) all carrying the N215S mutation (p = 0.03). At baseline, median PR intervals were prolonged in FD subjects compared to controls [143 (122-177) vs. 122 (82-165) ms; p < 0.0001].
Conclusions:
Cardiac complications of FD become apparent in childhood as subtle changes with slow but detectable progression over time, with males more frequently affected than females. Progression of LVH was apparent in three children despite ERT.
To investigate fetal cardiac performance by abdominal fetal electrocardiography (ECG) in monochorionic diamniotic pregnancies with twin-to-twin transfusion syndrome (TTTS-MCDA).
Abdominal fetal ECG was attempted in 16 singleton, 21 non-TTTS-MCDA, and 14 TTTS-MCDA pregnancies at 16-27 weeks' gestation. Standard ECG parameters were compared across study groups and evaluated for their correlation with Doppler ultrasound indices.
Clear P-QRST complexes were recognized in all cases. In the TTTS-MCDA pregnancies, the QT interval and QTc were significantly longer than in both singletons and the non-TTTS-MCDA pregnancies (p = 0.002 and p = 0.0002, respectively), whereas in the recipient fetus, both the PR interval and PR/RR were significantly longer when compared with all other study groups (p = 0.019 and p = 0.012, respectively). Further comparison with Doppler ultrasound indices yielded significant reciprocal correlations between ductus venosus pulsatility index and the QT interval (r = 0.552, p = 0.041) and between umbilical artery pulsatility index and PR/RR (r = 0.654, p = 0.011) both demonstrated in recipient fetuses alone.
Abdominal fetal ECG is feasible in second-trimester twin pregnancies. In TTTS, there is evidence of a higher risk of cardiac dysfunction in the recipient twin. © 2012 John Wiley & Sons, Ltd.
Approximately 10% of infants admitted to a Neonatal Intensive Care Unit (NICU) are at risk for Neurological Impairment (NI). While we have limited knowledge on the influence of NI risk on pain responses, we have no knowledge of how these responses change over time.
To compare physiological and behavioural pain responses of infants at three levels of NI risk during the NICU neonatal period (Session 1) and at 6 months of age (Session 2).
Prospective observational design with 149 preterm and term infants at high (Cohort A, n=54), moderate (Cohort B, n=45) and mild (Cohort C, n=50) risks for NI from 3 Canadian tertiary level NICUs. Infants were observed in the NICU during 3 standardized phases of a heel lance: baseline, stick and return-to-baseline. At 6 months, infants were observed during the same three phases during an intramuscular immunization injection. Physiological (heart rate, oxygen saturation) and behavioural (9 facial actions, cry) responses were continuously recorded.
A significant interaction of Phase by Session was found with less total facial activity observed during Session 2 (all p values<0.04). A significant interaction for Session by Cohort was found, showing that infants in Cohort A had significantly more change from baseline-to-stick phase for brow bulge, eye squeeze, nasolabial furrow and open lips between sessions with less facial actions demonstrated at Session 2 (all p<0.02). There were significantly lower mean and minimum heart rate (all p<0.02) and higher minimum and maximum oxygen saturation (p<0.04) at Session 2. Significantly higher mean and minimum fundamental cry frequencies (pitch) in Cohort B (p<0.04) were found in Session 1. Cohort A had significantly longer cry durations, but no significant differences in cry dysphonation.
Behavioural and physiological infant pain responses were generally diminished at 6 months of age compared to those in the neonatal period with some differences between NI risk groups in cry responses. Future exploration into the explanation for these differences between sessions and cohorts is warranted.
Objective:
To ascertain the quality of electrocardiogram (ECG) use in a pediatric emergency department (PED).
Research Design:
Patient series.
Setting:
Pediatric emergency department in a university-based hospital.
Participants:
Seventy patients, aged 2 months to 22 years.
Measurements:
All ECGs obtained in the PED were received by the Division of Pediatric Cardiology during the 15-month study period. The charts of all patients were then reviewed to determine the (1) indications for obtaining an ECG; (2) accuracy of documentation; (3) impact of ECG results on the treatment of patients; and (4) concordance between PED and pediatric cardiologists in ECG interpretation.
Results:
Chest pain was the most commonly documented indication, accounting for 54% of the ECGs obtained. Other indications were suspected arrhythmias (11%), seizure and syncope (11%), drug exposure (8%), and miscellaneous (16%). Twelve charts (17%) lacked documentation of ECG results. Ten ECGs (14%) were performed improperly. Twenty three (32%) were interpreted differently by the pediatric cardiologists; 14 ECGs (20%) had potential clinical relevance. Thirty-seven (52%) ECGs were useful in patient care; this was significantly associated with the presence of a PED attending (P=.03 by Fisher's Exact Test).
Conclusion:
We recommend education of pediatric residents in ECG interpretation and subsequent review by a pediatric cardiologist of each ECG performed in the PED.(Arch Pediatr Adolesc Med. 1994;148:184-188)
Normal ECG values were determined using computer-assisted measurement of the ECGs of 2,141 white children aged 0 to 16 years divided into 12 age groups.
These values are plotted on graphs containing the second, fifth, 25th, 50th, 75th, 95th, and 98th percentiles for each age group. This provides a convenient, fast, and practical method for comparing the values found in a given ECG with those found in a normal population, taking into account the evolution of ECG patterns with age.
This report deals with the ramifications of the concept of left axis deviation. In early life, the leftward shift of the frontal plane QRS axis is determined chiefly, if not solely, by the relative weights of the ventricles. Once adult ventricular weight ratios are reached, there is a long period of axis stability, then a gradual leftward drift of the QRS, governed principally by left anterior fascicular conduction. Thus, the normal QRS axis is age-dependent, and left axis deviation must be considered accordingly.
To ascertain the quality of electrocardiogram (ECG) use in a pediatric emergency department (PED).
Patient series.
Pediatric emergency department in a university-based hospital.
Seventy patients, aged 2 months to 22 years.
All ECGs obtained in the PED were received by the Division of Pediatric Cardiology during the 15-month study period. The charts of all patients were then reviewed to determine the (1) indications for obtaining an ECG; (2) accuracy of documentation; (3) impact of ECG results on the treatment of patients; and (4) concordance between PED and pediatric cardiologists in ECG interpretation.
Chest pain was the most commonly documented indication, accounting for 54% of the ECGs obtained. Other indications were suspected arrhythmias (11%), seizure and syncope (11%), drug exposure (8%), and miscellaneous (16%). Twelve charts (17%) lacked documentation of ECG results. Ten ECGs (14%) were performed improperly. Twenty three (32%) were interpreted differently by the pediatric cardiologists; 14 ECGs (20%) had potential clinical relevance. Thirty-seven (52%) ECGs were useful in patient care; this was significantly associated with the presence of a PED attending (P = .03 by Fisher's Exact Test).
We recommend education of pediatric residents in ECG interpretation and subsequent review by a pediatric cardiologist of each ECG performed in the PED.
We compared the interpretation of an electrocardiogram (ECG) made by computer with that made by physicians in training, as well as with the diagnosis made by cardiologists. ECGs were collected from 1058 Japanese adults (812 men and 246 women, mean age 49 +/- 19 years). With the computer program, the incidence of false-negative reports was 10.5% while that of false-positive reports was 16.5%, when compared with the physician's diagnosis. The incidence of a false-positive diagnosis with the computer was 18 times higher than that found by the physicians in training. The results show the advantages and the limitations in the use of computers for analysis of ECGs.
We assess accuracy of ECG interpretation and indications for obtaining ECGs and develop a clinical classification system of ECG abnormalities.
Prospectively acquired ECG data on patients 0 to 21 years of age and presenting to our pediatric emergency department (ED) were obtained. Clinical indications were documented. The initial ECG interpretation (pediatric ED attending physician) was compared with the criterion standard (pediatric cardiologist). A blinded cardiology panel reviewed discrepancies, and a final concordance rate was determined. An ECG abnormality classification system was developed and used to categorize these abnormal ECGs.
One thousand six hundred fifty-three ECGs from 1,501 patients, aged 2 days to 21 years (median 10.0 years), were obtained during 3.5 years. Fifty-one percent were male patients. ECG indications included chest pain (21%), seizure or syncope (18%), arrhythmias (17%), apparent life-threatening event or respiratory symptoms (16%), ingestions (10%), cardiac abnormality (10%), and miscellaneous (8%). From 1,631 ECGs, 1,160 (71%) were normal (class 0), 259 (16%) were minimally abnormal (class I), 174 (11%) were moderately abnormal (class II), and 38 (2%) were severely abnormal (class III). Kendall's tau-b test showed concordance of 0.73 (95% confidence interval 0.70 to 0.77) between pediatric ED and cardiology interpretation. The sensitivity of pediatric ED interpretation was 75%, and the specificity was 98.5%. The positive predictive value of pediatric ED interpretation was 88.3%, and the negative predictive value was 96.3%.
We conclude that, overall, a high rate of concordance exists between the pediatric emergency physician's and the cardiologist's ECG interpretation. The majority of discordant ECGs are not clinically significant. However, among the clinically significant ECGs, there is a higher rate of discordance. These data suggest that review of pediatric ECGs by pediatric cardiologists may significantly reduce underdetection of clinically important ECG findings in children.
How to read pediatric ECGs. St Louis: Mosby
- Park Mk Gunteroth
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Park MK, Gunteroth WG. How to read pediatric ECGs. St Louis: Mosby; 1992.