Dr Sarah Gubara (Host): This is Transformational Pediatrics with Children's Mercy, Kansas City. I'm Dr. Sarah g Barra, and today we are discussing STEMI with Dr. Lindsay Malloy, Walton Associate Division Director for the heart Center and Medical director for inpatient cardiology, Laura Martis, pediatric Electrophysiology nurse practitioner, and Dr. Jennifer Flint. Pediatric cardiac intensivist And the medical director for pediatric Critical Care transport.
Welcome in everyone. We're so excited to talk to you about this new innovation.
Laura Martis: Thanks for having us.
Dr. Lindsey Malloy-Walton: Thank you for having us.
Dr Jennifer Flint: Yes. Thank you, Dr.
Dr Sarah Gubara (Host): Of course. So let's set the background. What makes STEMI in pediatric patient's unique compared to adults?
Laura Martis: Well, it is unique because pediatric STEMI is a completely different disease than adult stemi. The reason for That is the underlying mechanism is just very different than with adult stemi, and it can make the diagnosis really challenging. So adult stemi, as we know, it's almost always caused by plaque rupture And then acute coronary thrombosis.
But in children, that mechanism is pretty much non-existent. we recently did a study, that covered the last 10 years of our facility as well as an adult facility in our city, And we screened almost a thousand patient's. That presented with symptoms of myocardial infarction, but really only 13 pediatric patient's truly met the MI criteria, and none of them had the classic plaque rupture type one stemi.
What we know is that pediatric stemi, instead of being the typical type one stemi, it's usually tied to structural issues like congenital heart disease, coronary anomalies that may be related to congenital heart disease or other coronary abnormalities that may be present. like the ones that we see after Kawasaki disease.
Patient's, with MI or signs of mi, like chest pain and st. Segment elevation may actually not have anything ischemic but may have something like pericarditis, myocarditis, or even drug intoxication.
Dr Sarah Gubara (Host): Wow, a thousand patient's. What are some of the underlying conditions and how does this rarity create diagnostic challenges?
Laura Martis: Yeah, so the rarity of it And the fact that a lot of the patient's that, are under 18 that truly are meeting criteria for mi, those patient's just. Often have a different cardiac physiology, meaning they may have congenital heart disease or undiagnosed, coronary anomalies like an Al Kappa or, other coronary anomalies.
So just because the physiology of it is so different than what we see in adults, it can make the diagnosis really challenging.
Dr Sarah Gubara (Host): thank you for sharing that. So, when children and adolescents present with suspected stemi, what symptoms or atypical signs should clinicians look for?
Laura Martis: I think the biggest thing to recognize is that the signs in children aren't always the typical signs that we associate with stemi, especially in adults. So chest pain in adults is really concerning because it can be a sign of mi, but only about, three fourths of the patient's that we s.
Saw in our study, came in with chest pain. We also saw, patient's present with syncope or shortness of breath or nausea that was associated with the pediatric patient's having a true mi. But it was interesting that cardiac arrest was really the first presenting symptom in patient's that we saw with, congenital coronary anomalies that were undiagnosed.
Dr Sarah Gubara (Host): So how should diagnostics like ECGs, biomarkers, and imaging be interpreted differently in this population?
Laura Martis: Every patient in our cohort had st segment abnormalities on their EKG, but these patterns really weren't reliable indicators of, coronary occlusion. So we saw pretty much all types of st segment elevations, including lateral inferior interseptal, as well as diffused. In some kids, these changes were really just due to pericarditis and not ischemia at all.
it's also important to know that, repolarization patterns vary with age and are different in the pediatric population. So while the EKG can point you towards ischemia, it really shouldn't be the only deciding factor in pediatrics. it was also interesting that troponins were elevated in every patient that we had in this cohort, but really that doesn't equal, MI because kids can have an elevated troponin with things like myocarditis, arrhythmias, after resuscitation, trauma, sepsis, all of those things.
It can tell you that there's myocardial injury, but they're not necessarily having a stemi. So really it's important in the pediatric population to think about advanced imaging like a cardiac MRI or a ct, because this may identify previously unknown congenital heart disease.
Dr Sarah Gubara (Host): Thank you. Now, your study reviewed over 10 years of data. What prompted you to investigate suspected pediatric stemi And what surprised you the most about these cases?
Dr. Lindsey Malloy-Walton: So as in many cases there was a problem that we identified, we started to see at our institution, although rare, an increase in poor outcomes with patient's that we sent for a pediatric STEMI evaluation to our adult collaborating facility. When we reviewed the literature, there was limited published data available.
So recognizing that pediatric patient's are not just small adults, we began to question our diagnostic approach and pathway for these patient's at our institution. We found that over 10 years of data. Less than 2% of patient's, or 13 total with billing codes relating to a myocardial infarction met the widely used adult criteria of SC segment changes and elevated cardiac biomarkers.
What surprised us the most was that most patient's presenting with a STEMI concern had congenital heart disease with some patient's being underdiagnosed at the time of the initial presentation.
Dr Sarah Gubara (Host): Wow. Now, given the high rate of congenital heart disease, including undiagnosed cases, what does your research reveal about early recognition, risk stratification, and common diagnostic over calls. Especially ECGs.
Dr. Lindsey Malloy-Walton: Yeah, so for pediatric patient's presenting with. A STEMI concern. a high suspicion for congenital heart disease is absolutely essential. ECGs are a helpful tool for demonstrating a STEMI in adults that we know. In pediatrics, ECG findings can be really difficult as the cardiac structure changes with age and more common non-ischemic conditions may present with similar ST segment changes thorough, non-invasive diagnostic.
Evaluation with advanced imaging is really key to ensuring that these patient's are managed effectively. I would also point out that conducting a cardiac catheterization in a pediatric hospital may help address the unique complexities associated with pediatric myocardial infarction, really ensuring that congenital anomalies are adequately considered and appropriate. interventions are carried out in a timely manner at a facility with congenital heart disease expertise.
Dr Sarah Gubara (Host): So most catheterizations at the adult facility resulted in no interventions. What does this tell you about applying adult STEMI algorithms to pediatric patient's?
Dr Jennifer Flint: So This is really interesting. And as a, internal medicine and pediatrics, boarded physician, I think initially our, desire was to get these patient's to an adult facility for coronary catheterization, assuming that they were having a similar adult type stemi. but, as our other, guest, Dr. Moy Walton and, Laura Marti.
Described these. Patient's are presenting with things like congenital heart disease and other coronary anomalies that don't amend themselves well to adult algorithms. it tells us really the etiology of chest pain and EKG changes in children and adolescents is very different. and pediatric patient's need pediatric specific algorithms that are really geared towards evaluating congenital heart disease.
And we discovered that it should be formed by providers that are really familiar with diagnosing and managing congenital heart disease, and, especially at an institution such as a pediatric facility, where there's resources available to care for those pediatric patient's.
Dr Sarah Gubara (Host): Thank you for sharing that. And so as you're modifying, adult STEMI algorithms for pediatric patient's, what recommendations do you have for how these. Pathways should be adapted. I know you touched on it a little, but we'd love to hear more.
Dr Jennifer Flint: I think we just have to be really thoughtful about the underlying etiology. Based on our study, we know that plaque rupture And the need for percutaneous intervention with a stent, placement or balloon angiopathy is not what any of our pediatric patient's needed. And so really the pathways need to be adapted to plan for that.
We don't need to be rushing our pediatric patient's to an adult cath lab. similar to how we do it for adults. we need to be thinking differently.
Dr Sarah Gubara (Host): How did your collaboration with an adult level One Heart Attack Center influence your team's management decisions?
Dr Jennifer Flint: So this was really great to have a really, well-established relationship with our adult level one heart attack center. because we had started out with processes that involved taking our pediatric patient's to the cath lab, just like an adult. But after our study, we all learned that that was probably not the best, approach.
And so we have worked really closely with our collaborating facilities, both on data collection in the study, And then also amending our, protocols and processes to have our pediatric patient's. Brought directly to the pediatric facility with appropriate evaluation.
Dr Sarah Gubara (Host): Tell me more about some of these protocol changes. Um, what did your institution change as a result of the study?
Dr Jennifer Flint: So, as we mentioned before, none of our pediatric patient's who went to the adult facilities required any sort of coronary intervention in the cath lab. And we unfortunately had a couple of patient's in our study who had, cardiac arrest in, unfortunate outcomes at those adult facilities. So we worked with our adult partners and.
We have decided to divert all ambulances and transported patient's directly to our pediatric facility, where we have an emergent cardiology consultation and an echocardiogram followed by CT or angiography of the coronaries here at the pediatric facility, depending on the clinical situation. And then our adult colleagues continue to remain available for additional consultation.
So if we have a, pediatric patient, especially an older adolescent with some EKG findings, that are concerning and maybe they need to be transferred to the adult facility, we still have that established relationship And we can easily facilitate that transfer if needed.
Dr Sarah Gubara (Host): Wonderful. What are some of the key takeaways for clinicians managing high-risk pediatric patient's, particularly those with structural coronary anomalies?
Laura Martis: one of the biggest takeaways is that if a pediatric patient, comes in and they have signs of a STEMI and ST segment changes, really the chances of them needing an emergent, percutaneous intervention in a cardiac cath lab that's really low. And we didn't see any of that. Over 10 years.
But what these patient's need is pediatric cardiology involvement. So I think, a key takeaway is that they just need more imaging and, they need to be evaluated for congenital heart disease because we did have a few patient's in this cohort that did have undiagnosed coronary anomalies that, didn't need to go to the cath lab at all, but actually ended up needing surgery.
Dr. Lindsey Malloy-Walton: I think my biggest takeaway is we do it best, right? I think STEMI is often thought of. As an adult disease process and more common in the adult world. And I think that's very true when compared to the pediatric world. But when we really think about our pediatric patient's, where they're really served best is evaluation in a pediatric center with resources, available to really rule out congenital heart disease.
Dr Jennifer Flint: One of the things I took away from this study, was really an awareness, and getting out education to our first responders and our adult, ER colleagues, because they are used to, diagnosing these. Uh, adult STEMIs in the field And activating their adult processes, and really getting out the awareness and education that children are different and they should be evaluated as soon as possible at a pediatric facility that's capable of evaluating children for especially coronary anomalies and congenital heart disease is, is important.
Dr Sarah Gubara (Host): You're right. That's so important, and I'm gonna extend this final question out to all three of you. So pie in the sky, what future research or multicenter efforts do you. All think are most needed.
Laura Martis: So, even though we were able to screen a lot of patient's over several years, this study was still pretty small in the grand scheme of things. So I think that, pediatric hospitals all over the country should really look at their data and see how many pediatric, type one STEMIs they had.
That way, we can all come together and maybe create some standardized guidelines because there really just aren't any out there.
Dr Jennifer Flint: Yeah. Laura, I'm with you. I would love it if we could have, multi-institutional data inputted from all of the large pediatric cardiac centers to evaluate stem and. Children. 'cause I agree. This study was so small, it's really hard to draw conclusions at a big level. but if we had more data And we had a better idea of pediatric STEMI across the nation, we could definitely help come up with standardized processes.
Dr. Lindsey Malloy-Walton: I absolutely agree, a standardized guideline to really ensure that we have consistent and effective management of these patient's in a multi-center. Means would be the best. Although it's really challenging 'cause this patient population is so small. I do think it is essential and it, can be life-threatening and I think it's essential that we continue to try to standardize this process over time.
Dr Sarah Gubara (Host): Thank you all for educating us on pediatric STEMI and your incredible work in this research. It has been wonderful to learn and really gets us thinking about what our pediatric patient's need the most. lots of thanks to Dr. Lindsay Malloy Walton. Laura Marti and Dr. Jennifer Flynn. Thank you all for being here today.
Dr Jennifer Flint: Thank you.
Dr. Lindsey Malloy-Walton: Thank you.
Dr Sarah Gubara (Host): Of course, this has been Transformational Pediatrics with Children's Mercy, Kansas City. To refer your patient or for more information, please visit children's mercy.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other Children's Mercy podcast.
Welcome in everyone. We're so excited to talk to you about this new innovation.
Laura Martis: Thanks for having us.
Dr. Lindsey Malloy-Walton: Thank you for having us.
Dr Jennifer Flint: Yes. Thank you, Dr.
Dr Sarah Gubara (Host): Of course. So let's set the background. What makes STEMI in pediatric patient's unique compared to adults?
Laura Martis: Well, it is unique because pediatric STEMI is a completely different disease than adult stemi. The reason for That is the underlying mechanism is just very different than with adult stemi, and it can make the diagnosis really challenging. So adult stemi, as we know, it's almost always caused by plaque rupture And then acute coronary thrombosis.
But in children, that mechanism is pretty much non-existent. we recently did a study, that covered the last 10 years of our facility as well as an adult facility in our city, And we screened almost a thousand patient's. That presented with symptoms of myocardial infarction, but really only 13 pediatric patient's truly met the MI criteria, and none of them had the classic plaque rupture type one stemi.
What we know is that pediatric stemi, instead of being the typical type one stemi, it's usually tied to structural issues like congenital heart disease, coronary anomalies that may be related to congenital heart disease or other coronary abnormalities that may be present. like the ones that we see after Kawasaki disease.
Patient's, with MI or signs of mi, like chest pain and st. Segment elevation may actually not have anything ischemic but may have something like pericarditis, myocarditis, or even drug intoxication.
Dr Sarah Gubara (Host): Wow, a thousand patient's. What are some of the underlying conditions and how does this rarity create diagnostic challenges?
Laura Martis: Yeah, so the rarity of it And the fact that a lot of the patient's that, are under 18 that truly are meeting criteria for mi, those patient's just. Often have a different cardiac physiology, meaning they may have congenital heart disease or undiagnosed, coronary anomalies like an Al Kappa or, other coronary anomalies.
So just because the physiology of it is so different than what we see in adults, it can make the diagnosis really challenging.
Dr Sarah Gubara (Host): thank you for sharing that. So, when children and adolescents present with suspected stemi, what symptoms or atypical signs should clinicians look for?
Laura Martis: I think the biggest thing to recognize is that the signs in children aren't always the typical signs that we associate with stemi, especially in adults. So chest pain in adults is really concerning because it can be a sign of mi, but only about, three fourths of the patient's that we s.
Saw in our study, came in with chest pain. We also saw, patient's present with syncope or shortness of breath or nausea that was associated with the pediatric patient's having a true mi. But it was interesting that cardiac arrest was really the first presenting symptom in patient's that we saw with, congenital coronary anomalies that were undiagnosed.
Dr Sarah Gubara (Host): So how should diagnostics like ECGs, biomarkers, and imaging be interpreted differently in this population?
Laura Martis: Every patient in our cohort had st segment abnormalities on their EKG, but these patterns really weren't reliable indicators of, coronary occlusion. So we saw pretty much all types of st segment elevations, including lateral inferior interseptal, as well as diffused. In some kids, these changes were really just due to pericarditis and not ischemia at all.
it's also important to know that, repolarization patterns vary with age and are different in the pediatric population. So while the EKG can point you towards ischemia, it really shouldn't be the only deciding factor in pediatrics. it was also interesting that troponins were elevated in every patient that we had in this cohort, but really that doesn't equal, MI because kids can have an elevated troponin with things like myocarditis, arrhythmias, after resuscitation, trauma, sepsis, all of those things.
It can tell you that there's myocardial injury, but they're not necessarily having a stemi. So really it's important in the pediatric population to think about advanced imaging like a cardiac MRI or a ct, because this may identify previously unknown congenital heart disease.
Dr Sarah Gubara (Host): Thank you. Now, your study reviewed over 10 years of data. What prompted you to investigate suspected pediatric stemi And what surprised you the most about these cases?
Dr. Lindsey Malloy-Walton: So as in many cases there was a problem that we identified, we started to see at our institution, although rare, an increase in poor outcomes with patient's that we sent for a pediatric STEMI evaluation to our adult collaborating facility. When we reviewed the literature, there was limited published data available.
So recognizing that pediatric patient's are not just small adults, we began to question our diagnostic approach and pathway for these patient's at our institution. We found that over 10 years of data. Less than 2% of patient's, or 13 total with billing codes relating to a myocardial infarction met the widely used adult criteria of SC segment changes and elevated cardiac biomarkers.
What surprised us the most was that most patient's presenting with a STEMI concern had congenital heart disease with some patient's being underdiagnosed at the time of the initial presentation.
Dr Sarah Gubara (Host): Wow. Now, given the high rate of congenital heart disease, including undiagnosed cases, what does your research reveal about early recognition, risk stratification, and common diagnostic over calls. Especially ECGs.
Dr. Lindsey Malloy-Walton: Yeah, so for pediatric patient's presenting with. A STEMI concern. a high suspicion for congenital heart disease is absolutely essential. ECGs are a helpful tool for demonstrating a STEMI in adults that we know. In pediatrics, ECG findings can be really difficult as the cardiac structure changes with age and more common non-ischemic conditions may present with similar ST segment changes thorough, non-invasive diagnostic.
Evaluation with advanced imaging is really key to ensuring that these patient's are managed effectively. I would also point out that conducting a cardiac catheterization in a pediatric hospital may help address the unique complexities associated with pediatric myocardial infarction, really ensuring that congenital anomalies are adequately considered and appropriate. interventions are carried out in a timely manner at a facility with congenital heart disease expertise.
Dr Sarah Gubara (Host): So most catheterizations at the adult facility resulted in no interventions. What does this tell you about applying adult STEMI algorithms to pediatric patient's?
Dr Jennifer Flint: So This is really interesting. And as a, internal medicine and pediatrics, boarded physician, I think initially our, desire was to get these patient's to an adult facility for coronary catheterization, assuming that they were having a similar adult type stemi. but, as our other, guest, Dr. Moy Walton and, Laura Marti.
Described these. Patient's are presenting with things like congenital heart disease and other coronary anomalies that don't amend themselves well to adult algorithms. it tells us really the etiology of chest pain and EKG changes in children and adolescents is very different. and pediatric patient's need pediatric specific algorithms that are really geared towards evaluating congenital heart disease.
And we discovered that it should be formed by providers that are really familiar with diagnosing and managing congenital heart disease, and, especially at an institution such as a pediatric facility, where there's resources available to care for those pediatric patient's.
Dr Sarah Gubara (Host): Thank you for sharing that. And so as you're modifying, adult STEMI algorithms for pediatric patient's, what recommendations do you have for how these. Pathways should be adapted. I know you touched on it a little, but we'd love to hear more.
Dr Jennifer Flint: I think we just have to be really thoughtful about the underlying etiology. Based on our study, we know that plaque rupture And the need for percutaneous intervention with a stent, placement or balloon angiopathy is not what any of our pediatric patient's needed. And so really the pathways need to be adapted to plan for that.
We don't need to be rushing our pediatric patient's to an adult cath lab. similar to how we do it for adults. we need to be thinking differently.
Dr Sarah Gubara (Host): How did your collaboration with an adult level One Heart Attack Center influence your team's management decisions?
Dr Jennifer Flint: So this was really great to have a really, well-established relationship with our adult level one heart attack center. because we had started out with processes that involved taking our pediatric patient's to the cath lab, just like an adult. But after our study, we all learned that that was probably not the best, approach.
And so we have worked really closely with our collaborating facilities, both on data collection in the study, And then also amending our, protocols and processes to have our pediatric patient's. Brought directly to the pediatric facility with appropriate evaluation.
Dr Sarah Gubara (Host): Tell me more about some of these protocol changes. Um, what did your institution change as a result of the study?
Dr Jennifer Flint: So, as we mentioned before, none of our pediatric patient's who went to the adult facilities required any sort of coronary intervention in the cath lab. And we unfortunately had a couple of patient's in our study who had, cardiac arrest in, unfortunate outcomes at those adult facilities. So we worked with our adult partners and.
We have decided to divert all ambulances and transported patient's directly to our pediatric facility, where we have an emergent cardiology consultation and an echocardiogram followed by CT or angiography of the coronaries here at the pediatric facility, depending on the clinical situation. And then our adult colleagues continue to remain available for additional consultation.
So if we have a, pediatric patient, especially an older adolescent with some EKG findings, that are concerning and maybe they need to be transferred to the adult facility, we still have that established relationship And we can easily facilitate that transfer if needed.
Dr Sarah Gubara (Host): Wonderful. What are some of the key takeaways for clinicians managing high-risk pediatric patient's, particularly those with structural coronary anomalies?
Laura Martis: one of the biggest takeaways is that if a pediatric patient, comes in and they have signs of a STEMI and ST segment changes, really the chances of them needing an emergent, percutaneous intervention in a cardiac cath lab that's really low. And we didn't see any of that. Over 10 years.
But what these patient's need is pediatric cardiology involvement. So I think, a key takeaway is that they just need more imaging and, they need to be evaluated for congenital heart disease because we did have a few patient's in this cohort that did have undiagnosed coronary anomalies that, didn't need to go to the cath lab at all, but actually ended up needing surgery.
Dr. Lindsey Malloy-Walton: I think my biggest takeaway is we do it best, right? I think STEMI is often thought of. As an adult disease process and more common in the adult world. And I think that's very true when compared to the pediatric world. But when we really think about our pediatric patient's, where they're really served best is evaluation in a pediatric center with resources, available to really rule out congenital heart disease.
Dr Jennifer Flint: One of the things I took away from this study, was really an awareness, and getting out education to our first responders and our adult, ER colleagues, because they are used to, diagnosing these. Uh, adult STEMIs in the field And activating their adult processes, and really getting out the awareness and education that children are different and they should be evaluated as soon as possible at a pediatric facility that's capable of evaluating children for especially coronary anomalies and congenital heart disease is, is important.
Dr Sarah Gubara (Host): You're right. That's so important, and I'm gonna extend this final question out to all three of you. So pie in the sky, what future research or multicenter efforts do you. All think are most needed.
Laura Martis: So, even though we were able to screen a lot of patient's over several years, this study was still pretty small in the grand scheme of things. So I think that, pediatric hospitals all over the country should really look at their data and see how many pediatric, type one STEMIs they had.
That way, we can all come together and maybe create some standardized guidelines because there really just aren't any out there.
Dr Jennifer Flint: Yeah. Laura, I'm with you. I would love it if we could have, multi-institutional data inputted from all of the large pediatric cardiac centers to evaluate stem and. Children. 'cause I agree. This study was so small, it's really hard to draw conclusions at a big level. but if we had more data And we had a better idea of pediatric STEMI across the nation, we could definitely help come up with standardized processes.
Dr. Lindsey Malloy-Walton: I absolutely agree, a standardized guideline to really ensure that we have consistent and effective management of these patient's in a multi-center. Means would be the best. Although it's really challenging 'cause this patient population is so small. I do think it is essential and it, can be life-threatening and I think it's essential that we continue to try to standardize this process over time.
Dr Sarah Gubara (Host): Thank you all for educating us on pediatric STEMI and your incredible work in this research. It has been wonderful to learn and really gets us thinking about what our pediatric patient's need the most. lots of thanks to Dr. Lindsay Malloy Walton. Laura Marti and Dr. Jennifer Flynn. Thank you all for being here today.
Dr Jennifer Flint: Thank you.
Dr. Lindsey Malloy-Walton: Thank you.
Dr Sarah Gubara (Host): Of course, this has been Transformational Pediatrics with Children's Mercy, Kansas City. To refer your patient or for more information, please visit children's mercy.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other Children's Mercy podcast.
