Cardiopulmonary Function, Exercise Capacity, and Echocardiography Finding of Pediatric Patients With Kawasaki Disease: An Observational Study

When two Z-scores meet-analysis of exercise capacity of children and adolescents with Kawasaki disease by a new Z-score model of coronary artery and a new Z-score evaluating peak oxygen consumption : Coronary artery Z-score and peakVO2 Z-score in KD

BACKGROUND

Coronary artery (CA) Z-score system is widely used to define CA aneurysm (CAA). Children and adolescents after acute stage of Kawasaki disease (KD-CA) have a higher risk of developing CAAs if their CA Z-score ≥ 2.5. Z-score system of peak oxygen consumption (Peak VO2 Z-score) allows comparisons across ages and sex, regardless of body size and puberty. We aimed to compare the exercise capacity (EC) indicated by peak VO2 Z-score during cardiopulmonary exercise testing (CPET) directly between KD-CA with different CA Z-score.

METHODS

KD-CA after acute stage who received CPET in the last 5 years were retrospectively recruited. CA Z-score was based on Lambda-Mu-Sigma method. Max-Z was the maximum CA Z-score of different CAs. KD children with Max-Z < 2.5 and ≥ 2.5 were defined as KD-1 and KD-2 groups, respectively. Peak VO2 Z-score was calculated using the equation established based on Hong Kong Chinese children and adolescent database.

RESULTS

One hundred two KD-CA were recruited (mean age: 11.71 ± 2.57 years). The mean percent of measured peak VO2 to predicted value (peak PD%) was 90.11 ± 13.33. All basic characteristics and baseline pulmonary function indices were comparable between KD-1 (n = 87) and KD-2 (n = 15). KD-1 had significantly higher peak VO2 Z-score (p = .025), peak PD% (p = .008), peak metabolic equivalent (p = .027), and peak rate pressure product (p = .036) than KD-2.

CONCLUSIONS

KD-CA had slightly reduced EC than healthy peers. KD-CA with Max-Z ≥ 2.5 had significantly lower peak EC than those < 2.5. Max-Z is potentially useful follow-up indicator after acute stage of KD.

Physicians' Self-reported Exercise Testing and Physical Activity Recommendations in Kawasaki Patients

Recommendations for management of patients with Kawasaki disease (KD) and coronary artery aneurysms (CAA) include physical activity (PA) promotion. This study aimed to characterize self-reported practices of KD providers to evaluate practice variation in use of cardiopulmonary exercise testing (CPET) and PA recommendations. We developed a REDCap survey with different clinical scenarios of KD patients. It was completed by members of the International Kawasaki Disease Registry (IKDR) and community pediatric cardiologists. Twenty-eight physicians responded; 63% practiced in the US, 63% practiced in an academic setting, 48% were general pediatric cardiologists, and 55% were IKDR members. Most respondents (69%) followed < 50 KD patients. The great majority (93%) agreed that patients with no CAA do not require CPET and could be cleared for all PA. For patients with small CAA, 43% of respondents recommended CPET and 75% cleared for all PA if CAAs regressed completely, but only 32% cleared if CAA persisted. For patients with medium CAA, 66% respondents cleared for PA if CAA regressed, and only 7% if CAA persisted; with 66% and 75% recommending CPET, respectively. For patients with large/giant CAA, 81% of respondents recommended CPET. No respondents felt comfortable clearing their patients with persistent large/giant CAA for PA and 19% would restrict from the entire physical education program. There is practice variation in use of CPET in KD patients with CAAs. Providers are hesitant to promote PA in KD patients with CAA despite known benefits and current guidelines.

Coronary artery aneurysms caused by Kawasaki disease in an adult: A case report and literature review

BACKGROUND

Kawasaki disease (KD) is a self-limiting febrile illness and an acute vasculitis with an unknown origin. It predominantly affects children aged < 5 years. KD is the common cause of acquired heart disease in children. We here report a case of KD in an asymptomatic young female patient diagnosed with multiple coronary aneurysms with calcification.

CASE SUMMARY

A 29-year-old female patient admitted to Hangzhou First People's Hospital with coronary artery abnormality identified for 1 wk. The patient was asymptomatic; however, chest computed tomography occasionally revealed strip-like dense shadows in the coronal sulcus. After coronary angiography and Doppler echocardiography, the final diagnosis was coronary artery aneurysms (CAAs) caused by KD. Although the patient was asymptomatic with no history of KD in childhood, the definitive diagnosis was CAAs caused by KD. The patient was administered anticoagulant, and surgical treatment was recommended.

CONCLUSION

KD potentially causes CAAs in 25% of untreated cases, primarily occurring in the proximal portions of the coronary arteries.

Differences between Sexes in Cardiopulmonary Fitness among Children and Adolescents with Kawasaki Disease

It is known that children and adolescents with Kawasaki disease (KD) can maintain normal cardiopulmonary fitness (CPF) after the disease’s acute stage has subsided. This study aimed to investigate whether gender differences affect CPF in children and adolescents with KD. We retrospectively reviewed a cohort of 204 participants (120 boys and 84 girls) with KD. All participants were instructed to complete a symptom-limited cardiopulmonary exercise test (CPET) adapted to assess their CPF. Based on body mass index (BMI), boys and girls were categorized into groups of underweight (19 boys and 12 girls), normal (62 boys and 59 girls), and overweight (39 boys and 13 girls). Although a similarity in body composition was found among both genders for KD subjects and normal Taiwanese peers, the percentage of overweight subjects was higher in KD boys than the normal Taiwanese boys. When comparing CPF for different BMI groups, the whole KD group showed no discrepancy, but a significantly lower peak VO2 for the overweight KD boys group was observed, representing poorer CPF. In conclusion, girls with KD had better CPF than boys, and gender stereotypes affect sports participation as well as self-efficacy, and may be contributing to poorer CPF in KD boys.

Serial Exercise Testing and Echocardiography Findings of Patients With Kawasaki Disease

OBJECTIVE

Kawasaki disease (KD) is the most common form of pediatric vasculitis. We evaluated the influence of KD on cardiopulmonary function and analyzed the echocardiographic findings of patients with KD through serial follow-ups from childhood to adolescence.

METHODS

This was a retrospective study. We recruited patients with KD after the acute stage who underwent at least two (with >1-year interval between visits) cardiopulmonary exercise testing (CPET) and echocardiographic examinations in the last 10 years. Cardiopulmonary function was determined through CPET on a treadmill. The maximum Z score (Max-Z) of the proximal left anterior descending coronary artery or right coronary artery was determined using echocardiography. Healthy peers matched for age, sex, and body mass index with serial CPET and echocardiographic data were recruited as a control group.

RESULTS

Each group consisted of 30 participants with comparable basic characteristics. No significant differences in the variables of the first CPET were observed between the two groups. In the final CPET, the control group had a higher percentage of measured oxygen consumption (Vo₂) at the anaerobic threshold (AT) to the predicted peak Vo₂ (p = 0.016), higher percentage of measured peak Vo₂ to the predicted peak Vo₂ (p = 0.0004), and higher Vo₂ at AT (p < 0.0001) than those of the KD group. No significant difference in the percentage of distribution of Max-Z was observed between the first and final echocardiographic examinations.

CONCLUSIONS

Children with a history of KD had comparable exercise capacity to their healthy peers. However, in the follow-up, the aerobic metabolism and peak exercise load capacities of adolescents with KD were significantly lower than those of control adolescents.

Patients with Kawasaki Disease Have Significantly Low Aerobic Metabolism Capacity and Peak Exercise Load Capacity during Adolescence

Introduction: Kawasaki disease (KD) is a childhood illness causing blood vessel inflammation. Children with KD have similar cardiopulmonary function to healthy children, but lower moderate-to-vigorous activity and exercise self-efficacy—possibly harming their cardiopulmonary function in adolescence. The purpose of this study is to investigate the cardiopulmonary function, exercise behaviors, exercise motivations, and self-efficacy of adolescents who once had KD. Methods: adolescents who once had KD and adolescents matched to the KD group in age and sex were enrolled. The cardiopulmonary exercise test was used to assess cardiopulmonary function. Weekly exercise behavior, exercise motivation, and self-efficacy were assessed with questionnaires. Results: this study recruited 50 and 30 participants, respectively, to the KD and control groups. The KD group had a lower ratio of VO₂/kg at the anaerobic threshold and peak to the predicted VO₂/kg at the peak (p = 0.021 and 0.043, respectively). No significant differences were found in questionnaire scores. The correlations of weekly exercise behavior scores with exercise motivation and self-efficacy scores were stronger in the KD group. Conclusions: adolescents with KD history had significantly lower aerobic metabolism capacity and peak exercise load capacity than controls. The correlations of amount of weekly exercise with exercise motivation and self-efficacy were stronger in the KD group.

Arterial stiffness late after Kawasaki disease in children: Assessment by performing brachial-ankle pulse wave velocity

BACKGROUND

Whether low-risk Kawasaki disease (KD) patients are at increased risk of cardiovascular disease later in life remains controversial. The purpose of this study is to examine the arterial stiffness and exercise performance of KD patients in chronic stage.

METHODS

This study included 158 subjects. They were divided into three groups: 37 KD patients with regressed coronary artery lesions (CALs) (M/F 23/14, 13.6 ± 6.5 years) (group I), 43 KD patients without CALs (M/F 26/17, 13.9 ± 6.2 years) (group II), and 78 age- and gender-matched normal controls (M/F 44/34, 13.2 ± 6.9 years) (group III). They all underwent brachial-ankle pulse wave velocity (baPWV), an exercise test, and blood sampling to measure the levels of high-sensitivity C-reactive protein (hs-CRP), triglycerides (TG), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and total cholesterol (TC). The differences among the groups were compared.

RESULTS

There were significant differences among the three groups in terms of right and left baPWV (p < 0.01 respectively), HDL level (p < 0.05), TC/HDL ratio (p < 0.05), and oxygen consumption (VO2) peak (p < 0.05). Moreover, group I subjects had significantly higher right and left baPWV (p < 0.05 respectively), lower HDL level (p < 0.05), and lower VO2 peak (p < 0.05) than group II subjects. Furthermore, baPWV was significantly correlated with TG level (r = 0.326, p < 0.05), TC/HDL ratio (r = 0.483, p < 0.01), LDL level (r = 0.386, p < 0.01), and VO2 peak (r = -0.385, p < 0.05) in group I subjects. Only the TC/HDL ratio was found to be a significant correlating factor for an increase of baPWV (beta = 0.68, p < 0.05) in KD patients after multiple linear regression.

CONCLUSION

Our results suggest that arterial stiffness is present late after KD and may adversely affect exercise performance, especially in patients with regressed CALs. Regular measurement of baPWV may be indicated in the long-term follow-up of KD patients.

Myocardial fibrosis after adrenergic stimulation as a long-term sequela in a mouse model of Kawasaki disease vasculitis

Kawasaki disease (KD), the leading cause of acquired cardiac disease among children, is often associated with myocarditis that may lead to long-term myocardial dysfunction and fibrosis. Although those myocardial changes develop during the acute phase, they may persist for decades and closely correlate with long-term myocardial sequelae. Using the Lactobacillus casei cell wall extract-induced (LCWE-induced) KD vasculitis murine model, we investigated long-term cardiovascular sequelae, such as myocardial dysfunction, fibrosis, and coronary microvascular lesions following adrenergic stimuli after established KD vasculitis. We found that adrenergic stimulation with isoproterenol following LCWE-induced KD vasculitis in mice was associated with increased risk of cardiac hypertrophy and myocardial fibrosis, diminished ejection fraction, and increased serum levels of brain natriuretic peptide. Myocardial fibrosis resulting from pharmacologic-induced exercise after KD development was IL-1 signaling dependent and was associated with a significant reduction in myocardial capillary CD31 expression, indicative of a rarefied myocardial capillary bed. These observations suggest that adrenergic stimulation after KD vasculitis may lead to cardiac hypertrophy and bridging fibrosis in the myocardium in the LCWE-induced KD vasculitis mouse model and that this process involves IL-1 signaling and diminished microvascular circulation in the myocardium.

Analysis of Exercise Capacity of Children with Kawasaki Disease by a Coronary Artery z Score Model (ZSP Version 4) Derived by the Lambda-Mu-Sigma Method

OBJECTIVE

To compare exercise capacity measured by direct cardiopulmonary exercise testing (CPET) of children with Kawasaki disease with different coronary artery diameter z scores (CA z score).

STUDY DESIGN

This was a retrospective study that recruited children with Kawasaki disease after the acute stage receiving CPETs determined by CPET with treadmill. CA z score was based on a model using the Lambda-Mu-Sigma method. Max-Z was defined as the maximum z score of the proximal left anterior descending CA (LCA) or right CA (RCA). Children with Kawasaki disease with a Max z <2.0 and ≥2.0 were defined as Kawasaki disease group 1 and Kawasaki disease group 2, respectively.

RESULTS

We recruited 32 boys and 17 girls with a mean age of 12.39 ± 3.61 years. Kawasaki disease group 1 (n = 36) had significantly higher peak metabolic equivalent (peak-MET) and peak rate pressure product (PRPP) than Kawasaki disease group 2 (n-13) (P = .046, P < .001). Max-Z correlated with peak-MET moderately and negatively (P < .001, Spearman rho= - .506). Max-Z correlated with PRPP modestly and negatively (P = .011, Spearman rho= - .360).

CONCLUSIONS

Children after Kawasaki disease with a coronary artery Max-Z ≥ 2.0 had significantly lower peak exercise capacity than those with a Max-Z < 2.0. Max-Z might be used as an indicator of CA reserve and exercise capacity during peak exercise after the acute stage of Kawasaki disease.