How should cardiac evaluation and management be tailored for adults compared to children, including appropriate diagnostic tests, evidence‑based pharmacologic therapy, and referral pathways?

Cardiac Evaluation and Management: Adults vs. Children

The fundamental difference in cardiac evaluation between adults and children lies in the predominance of congenital lesions in pediatrics versus acquired disease in adults, requiring distinct diagnostic algorithms, age-specific normal values, and different intervention thresholds that prioritize growth and development in children.

Key Diagnostic Distinctions

Initial Evaluation Approach

Pediatric patients require:

• ECG and echocardiography as first-line screening for suspected cardiac disease, with ECG repeated every 5-10 years for follow-up of congenital lesions 1
• Recognition that diagnostic cardiac catheterization is NOT recommended for initial evaluation in adolescents and young adults with conditions like pulmonic stenosis 1
• Understanding that certain ECG findings are normal variants in children (e.g., rSr' pattern in V1-V2 with normal QRS duration) but would be pathological in adults 2

Adult patients require:

• Standard cardiovascular risk assessment focused on acquired atherosclerotic disease 3
• Different thresholds for intervention based on accumulated disease burden rather than developmental considerations 1

Age-Specific Normal Values

Critical differences in heart rate interpretation:

• Sinus bradycardia (<60 bpm) is physiologically normal in young athletes and trained adolescents due to increased vagal tone 4
• Heart rates as low as 30 bpm can be normal in trained adolescents and young adults 4
• A heart rate of 45 bpm may be normal in an adolescent but pathological in an infant 4
• Asymptomatic bradycardia ≥30 bpm requires no further evaluation in young individuals 4

Condition-Specific Management Differences

Valvular Heart Disease

Adolescents and young adults with aortic stenosis:

• Balloon valvotomy is the preferred intervention (Class I) when peak LV-to-aortic gradient ≥50 mmHg with symptoms OR ≥60 mmHg without symptoms 1
• This contrasts sharply with older adults where balloon valvotomy provides only short-term palliation due to calcific disease 1
• Doppler echocardiography should be performed yearly if mean gradient >30 mmHg or peak velocity >3.5 m/s, and every 2 years if below these thresholds 1

Pulmonic stenosis management:

• Balloon valvotomy is recommended (Class I) when RV-to-pulmonary artery gradient >40 mmHg in asymptomatic patients or >30 mmHg with symptoms 1
• Symptoms are unusual in children even with severe stenosis, unlike adults who develop dyspnea and fatigue 1

Heart Failure Pharmacotherapy

Pediatric heart failure:

• Sacubitril/valsartan is FDA-approved for children ≥1 year old with symptomatic heart failure due to systemic left ventricular systolic dysfunction (LVEF ≤45% or fractional shortening ≤22.5%) 5
• Dosing is weight-based and differs substantially from adult regimens 5
• NT-proBNP reductions in pediatric patients (65%) are larger than those seen in adults, though between-group differences with enalapril were not statistically significant 5

Adult heart failure:

• Sacubitril/valsartan reduces risk of death and hospitalization in chronic heart failure, with greater benefit in patients with lower LVEF 5
• Standard adult dosing and titration protocols apply 5

Referral Pathways

When to Refer Pediatric Patients to Cardiology

Immediate referral required for:

• Symptoms: palpitations causing distress, chest pain, syncope, exercise intolerance, or dyspnea 2
• Family history: sudden cardiac death, inherited channelopathies (long QT, Brugada), or cardiomyopathies in first-degree relatives 2
• High ectopic burden: PVCs occurring in 5-10% of beats or complex ectopy 2
• Any murmur with clinical features suggesting congenital heart disease 1

Routine cardiology follow-up intervals for known conditions:

• Infancy to 1 year: If arrhythmias present, 24-hour Holter monitoring 1
• Childhood/adolescence (up to 20 years): Repeat echocardiogram every 2-3 years if no cardiac disease initially found; blood pressure at each visit 1
• Adulthood (>20 years): Echocardiogram every 3-5 years if no previous heart disease; blood pressure at each visit 1

Transition of Care

Critical infrastructure needs:

• Regional ACHD (Adult Congenital Heart Disease) centers should coordinate care for patients transitioning from pediatric to adult services 1
• Every pediatric cardiology program should identify the ACHD center for patient transfer 1
• Medical "passport" documenting complete cardiac history should be maintained by all ACHD patients 1

Special Populations

Neuromuscular Disease

Pediatric patients with Duchenne/Becker muscular dystrophy:

• Cardiac evaluation should begin at diagnosis regardless of symptoms 1, 6
• Risk of LV dysfunction increases dramatically with age: <5% before age 10, >75% after age 20 in DMD 1
• Referral to pediatric heart failure specialist is reasonable due to evolving diagnostic and management recommendations 1

Pre-anesthesia evaluation:

• Cardiac evaluation required before any anesthesia/sedation in NMD patients at risk for cardiac involvement 1
• For symptomatic patients, evaluation should occur within 3-6 months of the procedure 1

Cancer Survivors

Pediatric/young adult cancer survivors:

• Screening should begin 10 years after radiotherapy for those treated with combined chemotherapy and radiation 1
• ECG recommended at each cardiovascular screening visit to detect arrhythmias or conduction abnormalities 1
• Screening can be repeated every 5 years or with onset of symptoms 1
• Echocardiography is the primary modality for assessing LV structure, function, and diastolic parameters 1

Common Pitfalls to Avoid

Do not apply adult risk stratification to children - pediatric ectopy has different implications and natural history compared to adults 2

Do not over-investigate asymptomatic findings:

• Isolated PVCs occur in 20-35% of healthy teenagers and require no intervention if the child is asymptomatic with normal ventricular function 2
• Asymptomatic bradycardia ≥30 bpm in young athletes requires no evaluation 4

Do not delay intervention in symptomatic congenital lesions - unlike acquired adult disease, many congenital lesions benefit from earlier intervention with balloon techniques that are highly effective in young patients 1

Recognize that symptoms carry more weight than absolute values in young patients - the presence of symptoms with bradycardia or ectopy is the primary criterion for intervention 4, 2