Author + information
- Received March 27, 2018
- Revision received May 17, 2018
- Accepted May 24, 2018
- Published online October 15, 2018.
- Oliver M. Barry, MDa,b,∗ (, )
- Kimberlee Gauvreau, ScDa,b,
- Jonathan Rhodes, MDa,b,
- Jeffrey R. Reichman, BAa,
- Laura Bourette, MSa,
- Tracy Curran, MSa,
- Julieann O’Neill, MSa,
- Jennifer L. Pymm, MSa and
- Mark E. Alexander, MDa,b
- aDepartment of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- bDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Oliver M. Barry, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Farley Building, 2nd Floor, Boston, Massachusetts 02115.
Objectives This study quantified the incidence of arrhythmias during pediatric exercise stress tests (ESTs) and evaluated criteria to identify patients at risk of clinically important arrhythmias.
Background The incidence of clinically important arrhythmias during pediatric ESTs and criteria for identifying high-risk patients are poorly characterized.
Methods A retrospective review of ESTs performed from 2013 to 2015 was studied. Arrhythmias were categorized into 4 classes based on need for test termination and intervention. Risk factors evaluated included having an implantable cardioverter-defibrillator (ICD), cardiomyopathy, severe ventricular dysfunction, complex arrhythmia history, coronary disease with concern for ischemia, pulmonary hypertension, select poorly palliated congenital heart disease (CHD), and concerning symptoms. Negative predictive values (NPVs) were calculated.
Results During the study period, 5307 ESTs were performed. Median age of the subjects was 16 years (interquartile range: 13 to 24 years); 20% had complex CHD. At least 1 high-risk criterion was present in 507 tests (10%); having an ICD (37%) and cardiomyopathy (36%) were the most common criteria. Some arrhythmias were seen in 46% of tests, but only 33 events (0.6%) required test termination. Three events (0.06%) required cardiopulmonary resuscitation, all with high-risk criteria. Absence of a high-risk criterion had a 99.7% (95% confidence interval [CI]: 99.5% to 99.8%) NPV for an arrhythmia that required test termination and a 99.96% (95% CI: 99.85% to 99.99%) NPV for an arrhythmia that required intervention beyond test termination.
Conclusions Although self-terminating arrhythmias are common, dangerous arrhythmias are rare during ESTs in a high-volume pediatric cardiology program. Pre-defined high-risk criteria identified all patients with the most serious events. The absence of any criteria predicted a low risk for arrhythmias that required test termination. These data permitted informed choices regarding supervision of ESTs.
Dr. Alexander has received royalties from Up-to-Date; and he has been an expert witness for medical malpractice cases of infant arrhythmia, amiodarone overdose in infant with CHD, alleged missed long QT syndrome, alleged delayed diagnosis of Lyme Disease, alleged missed diagnosis of myocarditis, as well as non-malpractice case involving assertion of latent long QT syndrome as cause for drowning. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received March 27, 2018.
- Revision received May 17, 2018.
- Accepted May 24, 2018.
- 2018 American College of Cardiology Foundation
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