559 - Outcomes of Abnormal ECGs in a Pediatric Emergency Department

Publication Number: 559.5626

Leon Chen, The Children's Hospital at Montefiore, New York, NY, United States; In Hye Park, Children's National Health System, Fairfax, VA, United States; Rittal Mehta, Children's National Health System, Washington, DC, United States; Andy S. Huang, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, United States; Niti Dham, Children's National Health System, Washington, DC, United States; James Chamberlain, Children's National Health System, Washington, DC, United States

Background: Electrocardiograms (ECG) are frequently performed in pediatric emergency departments (ED), however the outcomes for patients with abnormal ECGs have not been well delineated.

Objective: To describe the outcomes of patients with abnormal ECGs and to measure the associations of ED findings with a final diagnosis of clinically significant cardiac disease.

Design/Methods: Patients ≤21 years-old presenting to an academic children’s hospital in 2019 were included in this retrospective study. At our institution, ECGs are overread by a pediatric cardiologist, and abnormal ECGs are automatically referred to outpatient cardiology. Cases were identified by an abnormal ECG performed in the ED with subsequent follow up with outpatient cardiology. Demographic information, history, physical exam, laboratory and imaging studies, and interventions were analyzed to measure associations with cardiac diagnoses. Bivariable and multivariable logistic regression were used to estimate odds ratios (ORs) with 95% confidence Intervals (CI).

Results: 324 patients had an abnormal ECG, of whom 100 (31%) had a cardiology follow-up appointment. Of these, 25 (25%) had any cardiac diagnosis, 14 (14%) with a clinically significant cardiac diagnosis including ectopic atrial tachycardia, brugada pattern, and atrial septal defect, and 11 (11%) with a clinically insignificant cardiac diagnosis including POTS, PFO, and murmur.

Patients who were recommended cardiology follow up were more likely to be diagnosed with clinically significant cardiac disease (aOR 13.333, 95% CI 1.805-281.063, P=0.028). Multivariable analysis revealed cardiology consultation had a strong positive relationship with clinically significant cardiac disease (aOR 5.968, 95% CI 1.728-20.611, P=0.004). There were no associations between cardiac diagnosis and specific cardiac symptomatology, abnormal vital signs, or cardiac murmur. Specifically, syncope, dizziness, shortness of breath, and chest pain were not associated with a final diagnosis of clinically significant cardiac disease.

Conclusion(s): Compared to children with an incidentally abnormal ECG, those diagnosed with a clinically significant cardiac disease were more likely to have been identified in the ED as requiring cardiology follow up and cardiology consultation. These results suggest that ED providers are appropriately recognizing high-risk patients. However, since the incidental ECG abnormalities requiring automatic cardiology follow up have a low yield, further criteria for this population may need to be developed in conjunction with cardiologists to avoid the automatic referral.

Descriptive Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: ED, Emergency Department; HR, Heart Rate; IQR, Interquartile Range, NA, Not Available; NICU, Neonatal Intensive Care Unit; PE, Physical Examination; ROS, Review of Systems; RR, Respiratory Rate; SOB, Shortness of Breath. The presence of an ED recommended outpatient cardiology follow up, ED cardiology consult, and discharge vs admission disposition were associated with clinically significant cardiac disease. Specific cardiac symptoms, vital sign changes, murmur, and ECG analysis did not demonstrate associations with clinically significant cardiac disease.

Bivariable Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: CI, Confidence Interval; ED, Emergency Department; HR, Heart Rate; NA, Not Available; NICU, Neonatal Intensive Care Unit; PE, Physical Examination; ROS, Review of Systems; RR, Respiratory Rate; SOB, Shortness of Breath. Only the presence of an ED recommended outpatient cardiology follow up was positively associated with clinically significant cardiac disease.

Multivariable Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: CI, Confidence Interval; ROS, Review of Systems. Multivariable analysis assessed the relationship of dizziness and/or syncope, age, and cardiology consultation to clinically significant cardiac disease while controlling for other factors. Only cardiology consultation was positively associated with the likelihood of a clinically significant cardiac disease.

Descriptive Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: ED, Emergency Department; HR, Heart Rate; IQR, Interquartile Range, NA, Not Available; NICU, Neonatal Intensive Care Unit; PE, Physical Examination; ROS, Review of Systems; RR, Respiratory Rate; SOB, Shortness of Breath. The presence of an ED recommended outpatient cardiology follow up, ED cardiology consult, and discharge vs admission disposition were associated with clinically significant cardiac disease. Specific cardiac symptoms, vital sign changes, murmur, and ECG analysis did not demonstrate associations with clinically significant cardiac disease.

Bivariable Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: CI, Confidence Interval; ED, Emergency Department; HR, Heart Rate; NA, Not Available; NICU, Neonatal Intensive Care Unit; PE, Physical Examination; ROS, Review of Systems; RR, Respiratory Rate; SOB, Shortness of Breath. Only the presence of an ED recommended outpatient cardiology follow up was positively associated with clinically significant cardiac disease.

Multivariable Analysis of Risk Factors for Abnormal ECGs with Clinically Significant Cardiac Disease
Abbreviations: CI, Confidence Interval; ROS, Review of Systems. Multivariable analysis assessed the relationship of dizziness and/or syncope, age, and cardiology consultation to clinically significant cardiac disease while controlling for other factors. Only cardiology consultation was positively associated with the likelihood of a clinically significant cardiac disease.