Outpatient pediatric cardiology consultations in a tertiary academic hospital

ABSTRACT

Objectives:

Cardiac diseases in the pediatric population can be congenital or acquired. If the diagnosis and treatment are early, the chance for survival increases. Thus, this study aimed to determine the indications for pediatric cardiology consultations in a single tertiary hospital in Jeddah, Saudi Arabia.

Materials and Methods:

This study was conducted in 2020–2021 at a tertiary center in Jeddah, Saudi Arabia. Patients younger than 14 years of age who were referred by outpatient clinics or those who presented to the emergency department and needed outpatient cardiac evaluation were included in this study. Inpatient referrals were excluded. The Statistical Package for the Social Sciences version 21 was used for statistical analyses.

Results:

A total of 416 referred patients were included in this study. New patients accounted for 74% of the referrals, while known patients accounted for 26%. The median age was 2.728 years, with 56.3% being male participants. The three most common reasons for referral were: evaluation of cardiac function (21.6%), follow-up evaluation of fetal/neonatal diagnosis (19.5%), and heart murmurs (16.8%).

Conclusion:

Most of the referrals were new patients. Of those who underwent echocardiography, 48.2% had abnormal results. We recommend further studies to help guide the direction of the residents’ education and to provide better patient healthcare services.

Introduction

Cardiac diseases in the pediatric population are either congenital or acquired. Congenital heart diseases (CHDs) are present at birth, while acquired cardiac diseases develop later in life. Examples of the latter are rheumatic heart disease and pericardial diseases.[1] The estimated birth prevalence of CHD is 8–12 per 1000 live births.[2]

Undiagnosed CHD is accompanied by a severe risk of mortality and morbidity. While this risk is potentially preventable,[3] delayed identification is still observed in more than 10% of patients with severe CHD.[4] Therefore, careful clinical examination is essential to rule out CHD.[5] If access to early diagnosis and treatment is available, infants have a 95% chance of survival to adult life with good long-term outcomes.[6]

The role of referrals is to link primary and specialty care.[7] Physicians seek specialists’ opinions for guidance regarding diagnosis, management, reassurance about the correct course of action, and education on current therapeutic modalities or rare conditions.[8] A study conducted in the United States reported that pediatricians referred patients to other specialists and found that heart murmurs, CHD, and cardiovascular signs or symptoms accounted for more than 50% of referrals to pediatric cardiologists.[8] In addition, the study also reported that while cardiologists received a high proportion of referred health problems, 68.8% were characterized as signs or symptoms rather than a diagnosis.[8]

The Future of Pediatric Education II task force report showed that 34% of pediatric cardiologists believed that there was an increase in the volume of referrals. This corresponded to a heavier workload.[9] This increase in referrals was attributed to various causes, including fear concerning the legal consequences of medical omissions and reluctance to take responsibility for excluding cardiovascular diseases.[10,11]

This study aimed to determine the indications for pediatric cardiology consultations in a single tertiary academic hospital in Jeddah, Saudi Arabia, as we could not find such a study in our geographical area to compare to what had been published.

Materials and Methods

Study type and duration

This retrospective record review study was conducted in 2020–2021 at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, Saudi Arabia. This study was supervised by the Department of Pediatrics and was approved by the Research Ethics Committee.

Study design

A review of the hospital information system was conducted. This review included the data of patients referred to pediatric cardiologists between 2015 and 2020. Patients of both sexes younger than 14 years of age who were referred by outpatient clinics and those that presented to the emergency department requiring outpatient cardiac evaluation were included in this study. Inpatient referrals were excluded.

Data collection

Information obtained from the hospital information system included sex, date of birth, and date of diagnosis. Additionally, if the patient was a known case of cardiac disease, the department from which the patient was referred, the reasons for consultation, and echocardiogram results, if there were any, were collected. The primary objective of this study was to determine the indications for pediatric cardiology consultations in a single tertiary hospital in Jeddah, Saudi Arabia.

Data analysis

The Statistical Package for the Social Sciences version 21 from IBM was used for statistical analyses. The means and standard deviations were calculated to describe continuous variables. Numbers are used for categorical variables. The Chi-square test was used to evaluate differences between categorical variables. A P value < 0.05 was considered statistically significant.

Results

A total of 416 referred patients were included in this study. New patients accounted for 74% (308/416) of the referrals, while known patients made up the remaining 26% (108/416). The median age was 2.7 years of age. There were 56% male and 43% female participants. Most of the participants were aged ≥1 year (66%). Patients <1 year accounted for 26%, while neonates (<30 days old) accounted for 7% of the referrals.

The referred patients were identified from three sources: emergency department, pediatric outpatient clinics, and pediatric surgery outpatient clinic. Most referrals (71%, 296/416) were from the pediatric outpatient clinic. The majority (74.5%) were aged ≥ 1 year.

The three most common reasons for referral were: evaluation of cardiac function (21.6%, 90/416), follow-up evaluation of fetal/neonatal diagnosis (19.5%, 81/416), and murmur (16.8%, 70/416). Regarding follow-up evaluation of fetal/neonatal diagnosis was for either acyanotic (87.7%) or cyanotic CHD (12%). Meanwhile, syndromes were the cause of 9.6% of referrals [Table 1]. The results showed that trisomy 21 was the most common syndrome, followed by infants of diabetic mothers (10 and 2%, respectively; Table 2).

Table 1.

Reasons for referral

Reason of referral	No.	%
Evaluation of cardiac function	90	21.6
Follow-up evaluation of fetal/neonatal diagnosis	81	19.5
Murmur	70	16.8
Surgical clearance	50	12
Syndromes	40	9.6
Cyanosis	21	5
Palpitation	17	4.1
Hypertension	15	3.6
Rheumatic fever	13	3.1
Chest pain	11	2.6
Arrhythmia	11	2.6
Intercurrent illnesses among cardiac patients	11	2.6
Cardiomegaly	9	2.2
Syncope/Dizziness	7	1.7
Kawasaki disease	5	1.2
Abnormal ECG	5	1.2
CVA/TIA	1	0.2
Pericardial effusion	1	0.2
Thrombus	1	0.2

*ECG, electrocardiogram; CVA/TIA, cerebrovascular accident or transient ischemic attack.

Table 2.

Syndromes and their corresponding frequencies

Syndrome	Frequency
Trisomy 21	44 (10.6%)
Others	31 (7.45%)
Infant of diabetic mother	9 (2.2%)
Cleft palate	3 (0.7%)
VACTERL	2 (0.5%)
Duodenal atresia	1 (0.2%)
Turner syndrome	1 (0.2%)
Omphalocele	1 (0.2%)

^†VACTERL, vertebral anomalies, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, renal anomalies, limb defects.

It was observed that follow-up evaluation of fetal/neonatal diagnosis represented 60% of cardiac referrals of neonates and 47% of cardiac referrals of those younger than 1 year of age. Follow-up of cardiac function was the most common referral in patients older than 1 year of age [Table 3].

Table 3.

Reasons for referral classified according to age group

Reason for referral	Neonate (first 30 days of life)	First year of life	More than 1 year
Follow-up evaluation of fetal/neonatal diagnosis	60%	47.7%	21.8%
Evaluation of cardiac function	-	7.2%	29.8%
Murmur	26.7%	26.1%	12%
Surgical clearance	3.3%	10.8%	13.5%
Cyanosis	10%	9%	2.9%
Chest pain	-	-	4%
Palpitation	-	0.9%	5.8%
CVA/TIA	-	-	0.4%
Cardiomegaly	3.3%	3.6%	1.5%
Arrhythmias	3.3%	-	3.6%
Intercurrent illnesses among cardiac patients	-	3.6%	2.5%
Syncope/dizziness	-	-	2.5%
Pericardial effusion	-	0.9%	-
Thrombus	-	-	0.4%
Hypertension	-	0.9%	5.1%
Rheumatic fever	-	-	4.7%
Abnormal ECG	-	-	1.8%
Kawasaki disease	-	-	1.8%

^‡CVA/TIA, cerebrovascular accident or transient ischemic attack; ECG, electrocardiogram.

Cardiac function evaluation was mainly requested due to hematological diseases, such as sickle cell anemia or β-thalassemia, followed by renal failure at 47 and 23%, respectively. Although cardiac evaluation was the most common reason for referral, only 23% (57/245) underwent an echocardiogram. In total, echocardiograms were performed in 245 out of 416 patients and 48% showed abnormal results. Of these abnormal results, 70% were new patients and 29% were known patients.

Discussion

A large body of literature has suggested that outpatient pediatric cardiology referrals have been increasing over time. This can be explained by the widespread reluctance of nonspecialists to take the decision and responsibility for diagnosing cardiac issues and due to the common belief that any child in need of a cardiac evaluation should be evaluated by a specialized cardiologist.[12]

This study examined a total of 416 patient referrals over the study period; 74% of whom were new patients. A previous study assessed new referrals to the pediatric cardiac unit in Leeds, United Kingdom, which covered outpatient services and outreach clinics in 19 surrounding hospitals, with a total of 526 referrals over 3 months.[12] Another study conducted in the Izaak Walton Killam Health Centre in Canada examined 620 new referrals within a period of 1 year.[13] The difference in participant numbers could be explained by the fact that other institutions included all referrals from outpatient services and different outreach clinics during the study period. This option was not available in our institute. The pediatric patient population in our hospital was mostly referred from various centers for specific subspeciality treatment, which might have limited the referrals to other specialties.

The assessment of cardiac function was the most common cause of referral in our study (21.6%), of which hematological diseases (sickle cell disease and β-thalassemia) were the most frequent. In contrast, Geggel[14] found that 12.7% of cardiology consultations included the evaluation of cardiac function. Saudi Arabia has a high prevalence of hereditary hemoglobinopathies.[15,16] Therefore, it is not surprising that evaluation of cardiac function among those with hematological diseases accounted for most of the referrals. Cardiomegaly, heart murmurs, and electrocardiographic abnormalities are common in children with these diseases; therefore, they require further assessment by cardiologists.[17]

Although the incidence of structural CHD has been estimated to be < 1% of all live births, it is still considered a major cause of perinatal morbidity and mortality.[18,19] The follow-up evaluation of fetal or neonatal diagnosis accounted for 19.5% of all referrals in our hospital and represented 4.3% in Boston Children’s Hospital, a tertiary academic hospital in Boston.[14] The fact that our hospital was one of the major referral centers for fetal echocardiography, pediatric cardiac catheterization, and neonatal cardiac surgeries that received patients from four major regions in the Kingdom of Saudi Arabia with a total population nearly 13 million could explain this difference.

Syndromes accounted for 8.5% of patients with CHD.[20] Early recognition of syndromes allows a thorough evaluation of cardiac and extracardiac manifestations.[21,22] The assessment of cardiac involvement among patients with specific syndromes represented 9.6% of all referrals, with trisomy 21 being the most common cause, followed by being an infant of a diabetic mother with 10.6% and 2.2%, respectively. A previous study reported that vertebral anomalies, anal atresia, cardiac defects, tracheoesophageal fistula, renal abnormality, limb anomalies association (VACTERL association), trisomy 21, and being an infant of a diabetic mother were the most commonly evaluated syndromes.[14]

Although most heart murmurs are not pathologic, a murmur may be the sole manifestation of serious heart disease.[23] In the current study, referral for heart murmur evaluation was the third most common cause among all referrals. However, two studies conducted in tertiary cardiac centers reported that auscultation of a cardiac murmur was the most common reason for referral.[12,14] This difference could be explained by two factors. The first factor was the difficulty of differentiating between an innocent and pathological heart murmur because cardiac auscultation skills in various residency training programs, including pediatrics, were documented as poor.[24,25,26] In fact, there was one study that found that pediatric residents’ auscultation skills were suboptimal.[26] Previous studies suggested that clinical assessment by a pediatric cardiologist was usually sufficient to distinguish pathological from innocent murmurs.[27] The second factor was the fact that the institution where the study was conducted was a tertiary center. Hence, most patients were visiting healthcare providers with a certain subspecialty, or they were following up due to a health-related issue, such as heart murmur, which was diagnosed at their primary or secondary hospital.

Limitations

The long-term implications of the current study affect future practice and help enhance pediatric residency programs. However, this study had some limitations. The main limitation was the study’s retrospective nature, which might have caused some important information to be missed. Since not all patients underwent echocardiography, minor cardiac defects might have been overlooked, and the true incidence rates might have differed. Additionally, since our hospital was a tertiary center, patients were referred to specific specialties; therefore, their cardiac evaluations were done at their original referring centers.

Conclusion

This study aimed to determine the indications for pediatric cardiology consultations at our center. Most of the referrals were new patients, and almost half of those who underwent echocardiography had significant findings. The most common referral indications were evaluation of cardiac function, followed by follow-up evaluation of fetal/neonatal diagnosis, and finally, heart murmurs. We recommend conducting multicenter studies across Saudi Arabia to determine the prevalence of different reasons for referrals and whether further evaluation by a Cardiologist was indicated or not. This can help direct the residents’ education while also working as a guide for primary care physicians – who are often the first to see the patient – regarding the most frequent conditions that necessitate Cardiology referral which would significantly affect the quality of patient’s care for the better.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.