Fainting freshmen and sinking sophomores: cardiovascular issues of the adolescent

The teenager with palpitations

Palpitations can result from cardiac awareness (increased conscious perception of the heart beating) or from a fast or irregular cardiac rhythm. Most causes for palpitations in the teenager can be diagnosed with minimal testing. Patients with an abnormal ECG, non-sinus tachycardia, abnormal cardiac examination, concerning family history, or palpitations associated with activity or syncope should be referred to a pediatric cardiologist. This article discusses the evaluation, testing, and management of teenagers with palpitations. It also provides a general guideline for referral for subspecialty evaluation.

Minimally invasive approach to the child with palpitations

Palpitations are a common reason for referral to a pediatric cardiologist. Although generally benign, palpitations are a significant cause for concern in the individual and their family. Similarly, palpitations may be the initial presentation of significant heart disease, resulting in heightened concern in the referring physician. Although emphasis is usually placed on excluding arrhythmia as the cause for palpitations, there are a variety of noncardiac causes for palpitations. The patient history and physical examination are the key components of the evaluation and guide subsequent investigations. In many cases, an immediate diagnosis cannot be made and additional testing may be required; this often includes further monitoring for episodes, cardiac imaging and ambulatory monitoring. Current technologies for ambulatory monitoring during symptoms include Holter monitoring and a variety of patient-activated event recorders, including implantable loop recorders. Each presents its own unique advantages and disadvantages to aid diagnosis in the management of a child with palpitations. The primary focus for the clinician is to determine whether the etiology is benign in nature or whether there is underlying heart disease that may carry a more serious prognosis.

Syncope and Near Syncope in Competitive Athletes

Syncope, although common among the general population, is rare among athletes. Syncope can result from any one of several causes. The majority of cases are due to neurocardiogenic syncope, without the potential for sudden death, and due to a sudden reduction in venous return. Cardiac syncope may be due to mechanical or structural factors. A thorough history and physical examination, along with an electrocardiogram, can usually distinguish benign cases from those due to more life-threatening conditions. Those at risk for sudden death need to be identified, so they can be appropriately restricted from further athletic activity.

Cardiac issues in the young athlete

Young athletes are disproportionately plagued with congenital cardiac disease. Many of these diseases predispose to sudden cardiac death (SCD), a dramatic and tragic outcome for any young athlete. In many cases, conditions that predispose to SCD do not cause symptoms or show signs on examination, making diagnosis of cardiac disease and prevention of SCD difficult. Clinicians should be familiar with common causes of SCD and their symptoms, perform careful evaluations, refer athletes in whom there are concerns, and make sure any concerning findings receive thorough evaluation. Clinicians should also be familiar with and follow recent guidelines on return to play. Unfortunately, most preparticipation examinations are inadequate, due in part to use of inadequate forms. Better forms are available and should replace inadequate ones.

Dental treatment of patients with long QT syndrome

BACKGROUND

Long QT syndrome (LQTS) is associated with life-threatening cardiac arrhythmias causing syncope and sudden cardiac death, frequently precipitated by physical or psychological stress.

TYPES OF STUDIES REVIEWED

The authors did a literature review of data published in peer-reviewed medical and dental journals. They also extracted epidemiologic information, correlations between genetic mutations and disease onset and progression, and data regarding outcomes of therapy from published peer-reviewed studies and the cohort population belonging to the International Long QT Syndrome Registry.

RESULTS

LQTS is diagnosed after an unexpected cardiac event or through QT interval prolongation on an electrocardiogram. Gene mutation identification in LQTS provides insight into respective proarrhythmogenic factors and indicated therapeutic regimens. beta-blockers are the initial treatment for two of the three major forms of LQTS. Patients refractory to beta-antiadrenergic therapy may benefit from one or more of the following: cardiac pacemakers, implanted cardioverter defibrillators and left cardiac sympathetic denervation.

CONCLUSIONS

Clinical studies are needed to investigate the safety of treating patients in an ambulatory setting.

CLINICAL IMPLICATIONS

Preventive measures are recommended, including evaluation by a cardiac specialist before any dental intervention, use of anxiolytic protocols, avoidance of drugs that prolong the QT interval, and provision of treatment in a setting in which medical emergencies can be managed expeditiously. Dental treatment in a hospital and use of a general anesthetic administered by anesthesiologists are recommended for procedures in which anxiety and adrenergic stimulation would not be suppressed sufficiently in an ambulatory environment.