Impact of Z score system on the management of coronary artery lesions in Kawasaki disease

Z-score evaluation and inferences for management of aortopathy patients

Echocardiographic Z-score models play a crucial role in defining cardiac pathology in paediatric patients. There are multiple models that practitioners utilize in the United States without guiding principles to standardize their use. Discrepant interpretations can occur depending on the model chosen, even if standardized Z-score cutoffs are applied. In this study, a survey was developed to assess pediatric cardiologists' use of Z-score systems when evaluating and treating patients with isolated bicuspid aortic valve. The majority of respondents reported using Z-score cutoffs to evaluate the degree of aortic root and ascending aorta dilation. For the aortic root, mild, moderate, and severe dilation averaged at 2.13 (SD = 0.32), 3.59 (SD = 0.49), and 5.11 (SD = 0.84), respectively. Similar cutoffs were reported for determining ascending aorta dilation. A large proportion of respondents primarily used the Boston system (36%, 18/50) or Boston and Pediatric Heart Network systems together (36%, 18/50). There were also differences in management decisions, such as implementing competitive sports restrictions, based on Z-scores and the 2015 Task Force 7 Bethesda exercise guidelines. These survey results demonstrate variability that exists among paediatric cardiologists in their use of Z-scores for describing aortic root and ascending aorta dilation in patients with isolated bicuspid aortic valve and suggests the need for implementation of national guidelines for Z-score usage.

Novel multiple Z-score models for detection of coronary artery dilation: application in Kawasaki disease

BACKGROUND

This study aims to develop Z-Score models to normalize measurements of three coronary arteries and enhance the diagnosis of Kawasaki disease (KD) in children from newborns to 10 years old. Developing a reliable Z-Score model is challenging, as some existing models fail the normality test. Overcoming these challenges is crucial for improving KD diagnosis.

METHOD

Detailed measurements of the left main coronary artery (LCA), left anterior descending coronary artery (LAD), and right coronary artery (RCA) were collected, along with patient demographics such as age, height, weight, and body surface area (BSA). Several Z-Score models, named the Kuo Z-Score models, were proposed, with separate designs for different coronary arteries and different age groups, resulting in multiple Z-Score models. The Z-Score model for the RCA employs the Box-Cox method for data transformation. Finally, we tested various age group combinations, selecting models that passed the Anderson-Darling normality test and had higher R-square values for robustness and best data fit.

RESULTS

The study included 1180 participants free from coronary or heart diseases. The Kuo Z-Score models were optimized for LCA, LAD, and RCA across the five age groups 0-6 years, 6-7 years, 7-8 years, 8-9 years, and 9-10 years. Only the normality test for the RCA in the 7-8 year age group failed. The proposed model fitted to the normality assumption outperforming the other models.

CONCLUSION

The Kuo Z-Score models, applicable across a broad age range, provides robust identification of coronary artery dilatation and aneurysm in KD. The models' capability to normalize diverse data sets marks a significant advancement in KD diagnostic sensitivity, aiding in better clinical decision-making and potentially improving patient outcomes.

Update on Diagnosis and Management of Kawasaki Disease: A Scientific Statement From the American Heart Association

Kawasaki disease (KD), an acute self-limited febrile illness that primarily affects children <5 years old, is the leading cause of acquired heart disease in developed countries, with the potential of leading to coronary artery dilation and coronary artery aneurysms in 25% of untreated patients. This update summarizes relevant clinical data published since the 2017 American Heart Association scientific statement on KD related to diagnosis, cardiac imaging in acute KD treatment, and long-term management. Criteria defining North American patients at high risk for developing coronary artery aneurysms who may benefit from more intensive initial treatment have been published. Advances in cardiovascular imaging have improved the ability to identify coronary artery stenosis in patients with KD, yet knowledge gaps remain regarding optimal frequency of serial imaging and the best imaging modality to identify those at risk for inducible myocardial ischemia. Recent data have advanced the understanding of safety and dosing for several anti-inflammatory therapies in KD. New anticoagulation medication, myocardial infarction management, transition of health care for patients with KD, and future directions in research are discussed.

Diagnosis of coronary artery abnormalities in Kawasaki disease: recent guidelines and z score systems

Kawasaki disease, an acute systemic vasculitis affecting children, is the leading cause of acquired heart disease in developed countries. This vasculitis has a predilection for the coronary artery, and coronary artery abnormalities are the main criteria for its diagnosis. The diagnosis of coronary abnormalities has historically been based on dichotomous criteria, but recent guidelines have accepted the body surface area-adjusted z score system to define coronary abnormalities and classify coronary artery aneurysms. Z score systems have improved risk classifications of coronary aneurysms and improved correlations with clinical prognosis. However, the discrepancy of calculated z scores according to the formula has been noticed in the application of the z score system, which is possibly related to the diagnosis of coronary artery abnormalities. This variability was greater in larger coronary aneurysm dimensions. A careful choice of the z score formula and its consistent use is needed in clinical applications.

Practical Workflow for Cardiovascular Assessment and Follow-Up in Kawasaki Disease Based on Expert Opinion

BACKGROUND

Approximately 25% of the patients with a history of Kawasaki disease (KD) develop coronary artery pathology if left untreated, with coronary artery aneurysms (CAA) as an early hallmark. Depending on the severity of CAAs, these patients are at risk of myocardial ischemia, infarction and sudden death. In order to reduce cardiac complications it is crucial to accurately identify patients with coronary artery pathology by an integrated cardiovascular program, tailored to the severity of the existing coronary artery pathology.

METHODS

The development of this practical workflow for the cardiovascular assessment of KD patients involve expert opinions of pediatric cardiologists, infectious disease specialists and radiology experts with clinical experience in a tertiary KD reference center of more than 1000 KD patients. Literature was analyzed and an overview of the currently most used guidelines is given.

CONCLUSIONS

We present a patient-specific step-by-step, integrated cardiovascular follow-up approach based on expert opinion of a multidisciplinary panel with expertise in KD.