Pediatric Cardiology

Association of European Pediatric and Congenital Cardiology practical recommendations for surveillance and prevention of cardiac disease in childhood cancer survivors: the importance of physical activity and lifestyle changes From the Association of European Pediatric and Congenital Cardiology Working Group Sports Cardiology, Physical Activity and Prevention, Working Group Adult Congenital Heart Disease, Working Group Imaging and Working Group Heart Failure. Kesting S, Giordano U, Weil J, McMahon CJ, Albert DC, Berger C, Budts W, Fritsch P, Hidvégi EV, Oberhoffer-Fritz R, Milano GM, Wacker-Gußmann A, Herceg-Čavrak V. Cardiol Young. 2024 Feb;34(2):250-261. doi: 10.1017/S1047951123004213. Epub 2024 Jan 4. PMID: 38174736 Review.  Take home points: Regular cardiac screening is necessary in long-term pediatric cancer survivors Modifiable lifestyle factors should be addressed Exercise assessment and exercise training are underappreciated and likely very helpful for these patients Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch: With the improved survival of pediatric cancer patients, the long-term health effects are becoming increasingly important. Besides secondary malignancies, many known adverse cardiac issues can develop due to cardiotoxicity from chemotherapy and radiation therapy to the chest, such as cardiomyopathies, valve dysfunction, arrhythmias, peripheral vascular disease, pericardial disease, and early coronary artery disease. See Table 1. This article is a consensus guidelines statement from the European Paediatric and Congenital Cardiology Working group. Summary as follows: Primary prevention includes dexrazoxane, liposomal anthracyclines, and a longer duration of infusions. Secondary prevention was discussed in much more detail. Those with high and moderate risk should have lifelong surveillance, usually recommended every few years; see Table 4. Given that many patients may have subclinical dysfunction, standard testing may not detect changes. Global longitudinal strain should be added to echocardiography and MRI considered if there is insufficient information on myocardial performance. Additionally, provocative testing such as cardiopulmonary exercise testing (CPET) +/- stress imaging may be helpful in the detection of early myocardial changes. Hypertension and metabolic syndrome are also common. Decreased physical fitness is possibly a modifiable risk factor in long-term survivors. Many survivors likely have decreased peak VO2 and if they have subclinical cardiomyopathies, may not be able to increase cardiac output appropriately. Exercise therapy may be a critical component of long-term health and reductions in morbidity and mortality, but research is in its early stages. While physical activity recommendations are provided for the general population, those with a history of chronic illness and a higher risk of CVD may have greater benefits.

The Child Opportunity Index 2.0 and Disparities in Pediatric Cardiorespiratory Fitness. Wang AP, Griffith G, Otto-Meyer S, Ward K.J Pediatr. 2024 May;268:113964. doi: 10.1016/j.jpeds.2024.113964. Epub 2024 Feb 17.PMID: 38369240  Take home points: Cardiac Opportunity Index 2.0 (COI) is being increasingly used to assess neighborhood-level characteristics that may affect pediatric medical disparities Lower COI was associated with lower cardiorespiratory fitness (CRF) Racial differences were not significant when adjusting for COI Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch: CRF as measured by peak oxygen consumption (pVO2) on cardiopulmonary exercise testing (CPET) is a known predictor of morbidity and mortality in many adult and pediatric studies. There have been some studies suggesting a racial disparity, with some biologic factors that may have contributed (eg. less aerobic muscle fibers or lower Hg), along with higher sedentary time. However, CRF can also be influenced by community level factors such as access to safe exercise and nutrition and whether these factors may be more significant than racial differences have not been well studied. The COI is a publicly available index of 29 domains that include education, health, environment, and socioeconomic factors that may impact health and child development. This study attempted to determine if lower COI is associated with lower CRF. This was a retrospective review of CPET data from 2004-2022 in 1735 patients referred for cardiac symptoms that did not have any underlying congenital or acquired cardiac disease. All had maximal tests (defined as RER > 1.10). Demographic data and COI based on zip codes were collected. COI was categorized into quintiles. Table 1 shows the full demographics. CPET data showed statistically significantly lower peak VO2 and exercise duration in the lower COI groups. White and Latinx patients had a higher peak VO2 than black patients, but with multivariate analysis when COI was included, no difference in race was present. See Figure 1. Given the neighborhood and socioeconomic factors contributing to decreased CRF and likely other risk factors for adult cardiac disease, it will be important from a provider and system level to address the barriers to regular and safe physical activity.