Pediatric cardiology update: office-based practice of pediatric cardiology for the primary care provider

Abstract

In the following article, selected topics are presented to provide an update on the practice of pediatric cardiology from the perspective of the primary care provider and outpatient-based subspecialist. The approach to the evaluation of very common presenting signs and symptoms are reviewed, including heart murmurs, chest pain, and palpitations. The role of the primary care provider in screening and clearing children for participation in sports activities is discussed. Finally, issues of insurability, employment, and pregnancy in the adolescent and young adult with congenital heart disease are presented. Heart Murmurs in Children A murmur in the child is quite common and, consequently, the evaluation of a murmur is the most frequent reason for outpatient referral to most pediatric cardiology practices. It is estimated that up to 72% of children will have a murmur noted at some time during their childhood. 1 Given the potential cardiac disease that could cause a murmur, this “diagnosis” is a source of concern for the primary care physician. The primary care physician’s comfort level of diagnosing innocent (or functional) murmurs depends on his or her clinical experience regarding innocent murmurs and any pathologic murmurs that they have detected in their training and practice. It is common to have a new community physician refer more patients for evaluation of a murmur in their first year after residency than it is during their fifth year. Which patient to refer for subspecialty evaluation can be influenced by other factors besides the murmur, including the anxiety level of the family. The family of a child referred to a pediatric cardiologist for murmur evaluation will come with many preconceived ideas and fears regarding their child’s murmur. 2 Family history of cardiac disease and patient symptoms will influence how the family approaches this evaluation. In addition, a murmur detected during a routine presports physical can result in significant anxiety for the family as well as the child because of concerns about sudden cardiac death in athletes, a rare occurrence, but one that is prominently reported by the media. However, the current medical community pressures of proper use of resources have to be balanced with the potential medical and legal issues surrounding the evaluation of murmurs and a possible missed diagnosis of congenital or acquired heart disease. Thus, the primary care physician must balance clinical skills, various testing modalities at his or her disposal, and the availability of subspecialty referral options. What follows is a framework for the evaluation of the new murmur. Topics such as diagnostic skills, levels of competency, variety of testing modalities, and a cost analysis will be discussed.