Decision-making in pediatric cardiology: searching for the evidence

Abstract

The goal of evidence-based decision-making in pediatric cardiology and cardiac surgery may be difficult if not impossible to attain. This is due to the rarity, complexity and variability in the morphology and physiology of congenital heart disease. Nevertheless, constant attention to the process of searching for the evidence maximizes flexibility in decision-making and limits adherence to unproven management regimens. The long-term acceptance of prolonged bed rest for the treatment of acute rheumatic fever without significant evidence of benefit illustrates this principle. The result was unnecessary hospitalizations and restrictions on children as well as high medical cost. Much of the ‘conventional wisdom’ for medical and surgical treatment of congenital heart disease in the 1960s–1980s is no longer relevant. Without constant attention to evolving evidence gleaned from basic and clinical research, many of today's management pathways will not be appropriately altered and new pathways will not emerge. Analyses of treatment principles related to ventricular septal defect and discrete subvalvar aortic stenosis are presented, and questions are raised concerning other pediatric cardiac conditions where evidence-based outcome data are limited. The challenge to pediatric cardiologists and cardiac surgeons will always be to ‘search for the evidence’ in order to constantly reassess and adjust management pathways for children with heart disease.