Undiagnosed cardiac abnormalities among school-aged children/Okul cagi cocuklarda tani almamis kardiyak anomaliler.
Abstract: Introduction: The aim of this study was to assess the frequency of undiagnosed congenital and acquired heart diseases among school-aged children.

Materials and Method: The study population consisted of 4.370 children (2081 boys and 2289 girls) who were chosen from a total school-aged children population of 51,891 students (aged 7-15 years) (10.7 [+ or -] 2.4) (8.4%).

Results: In this population, a total of 11 (0.25%) children had been diagnosed and treated for structural cardiac abnormalities before the study. In the study period (after an assessment by a questionmaire), cardiac evaluation was needed in 405 (9.3%) children who were invited to the pediatric cardiology unit. Among them, a total of 153 (37.8%) children were admitted for further evaluation, and 21 (13.7%) were diagnosed as having undiagnosed congenital (12.4%) or acquired (1.3%) heart diseases. Five children with congenital heart diseases were treated by surgical or invasive techniques, and penicillin prophylaxis was begun in two patients with rheumatic heart disease. The most frequent congenital heart diseases were atrial septal defect and mitral valve prolapse among the admitted children.

Conclusions: Some children still reach school age with undiagnosed congenital or acquired heart diseases. All children should be examined carefully at the time of school registration in order to diagnose and treat congenital and acquired heart diseases in an effort to prevent the occurrence of undesirable events during sports or social activities.

Key words: School children, cardiac disease

Giris: Bu calismanin amaci, ilkogretim cagi okul cocuklarinda tani konulmamis dogumsal ve kazanilmis kalp hastaliklarinin sikligini belirlemektir.

Gerec ve Yontem: Calisma grubu ilkogretim okullarina devam eden 7-15 yas grubu, toplam 51.891 okul ogrencisi arasindan 4,370 ogrencinin (%8,4) secilmesi ile olusturuldu. Ogrencilerin 2.081'i erkek, 2.289'u kiz olup ortalama yaslari 10,7 [+ or -] 2,4 yil (6,8-15,4 y) idi.

Bulgular: Secilen calisma grubunda; calisma tarihinden once toplam 11 (%0,25) cocuk yapisal kalp hastaligi tanisi almis ve tedavi edilmisti. Calisma sirasinda (bir anket formu ile yapilan degerlendirme sonrasinda) 405 (%9,3) cocuk ileri kardiyolojik degerlendirmeye gerek duyularak Cocuk Kardiyoloji unitesine davet edildi. Davetimizi kabul edip unitemize basvuran 153 (%37,8) cocuk unitemizde degerlendirildi ve 21 cocukta (%13,7) dogumsal (%12,4) ve edinsel (%1,3) kalp hastaligi saptandi. Konjenital kalp hastaligi olan 5 cocuk cerrahi veya invaziv teknikler ile tedavi edildi, romatizmal kalp hastaligi olan iki hastaya penisilin proflaksisi baslandi. Basvuran hastalar arasinda en sik tespit edilen kalp hastaliklari atriyal septal defekt ve mitral valv prolapsusu idi.

Sonuc: Konjenital veya edinsel kalp hastaligi olan bazi cocuklar, hala tani almadan okul cagina kadar gelebilmektedir. Tum cocuklar okula kayit esnasinda dikkatli bir sekilde muayene edilmeli; konjenital ve edinsel kalp hastaligi olanlar tedavi edilmelidir. Boylece sportif faaliyetler ve sosyal aktiviteler esnasinda meydana gelebilecek istenmeyen olaylarin gelismesi onlenebilir.

Anahtar kelimeler: Okul cagi cocuklari, kalp hastaligi
Article Type: Report
Subject: Electrocardiography (Usage)
Congenital heart disease (Diagnosis)
Congenital heart disease (Demographic aspects)
Elementary school students (Health aspects)
Electrocardiogram (Usage)
Authors: Karacan, Mehmet
Olgun, Hasim
Orhan, Mehmet Fatih
Altay, Nilgun Demet
Ozturk, Candan Ferai
Karakelleoglu, Cahit
Ceviz, Naci
Pub Date: 08/01/2010
Publication: Name: The Journal of Current Pediatrics Publisher: Galenos Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Galenos Yayincilik ISSN: 1304-9054
Issue: Date: August, 2010
Product: Product Code: E197200 Students, Elementary
Geographic: Geographic Scope: Turkey Geographic Code: 7TURK Turkey
Accession Number: 240017340
Full Text: Introduction

Congenital heart diseases (CHD) are the most frequent of all major birth defects (1). Furthermore, rheumatic heart diseases are still important health problems in developing countries (2-4). Although most of the children with overt symptoms related to cardiac pathologies can be diagnosed, some children can reach adolescence and even adult life with asymptomatic or undiagnosed significant congenital and acquired heart diseases. These patients carry the risk of infective endocarditis and recurrence of rheumatic fever, which may cause severe problems. Cardiovascular screening during studies performed on large groups of students can facilitate identification of children with undiagnosed heart diseases.

We performed a previous study to determine the normal ECG limits in children aged 7-15 years living at a moderately high altitude (5). Cardiovascular system examination was performed in all children comprising the study population. The children with any symptoms and/or signs indicating a cardiovascular problem were invited for further examination. In the present study, we evaluated the results of these further evaluations and attempted to accumulate information about the prevalence of asymptomatic or undiagnosed significant heart diseases among school-aged children in our region.

Materials and Method

The original study aimed to obtain 12-lead surface ECG from a group of school-aged children living at a moderately high altitude (1850 meters). For this purpose, a total of 4.370 children were chosen from the total population of 51.891 students aged 7-15 years (8.4%). Selection was performed by using random systematic sampling method, which facilitates selection of a sample population that can represent the whole.

A questionnaire was used to investigate the presence of any previously diagnosed heart disease or signs of any heart disease. All children (n=4.370) were examined by the same investigator, a fellow in pediatric cardiology.

It was ascertained that 11 of the children had a previous diagnosis of heart disease from birth for which they were being monitored and/or had already undergone a surgical procedure for correction. These patients were observed as a separate group. In 405 (9.3%) children with no history of heart disease, further cardiac evaluation was needed because of a positive family history or physical examination finding. These children comprised the cohort of the present study.


The mean age of the 4.370 children was 10.7 [+ or -] 2.4 years (range 6.8-15.4 y), and 2.081 of them were male. Among them, 11 children were determined to have previously diagnosed structural cardiac abnormalities (Table 1).

After initial evaluation, a total of 405 children were invited to our center for further investigation. The indications for further evaluations are given in Table 2. Cardiac complaints were chest pain (n=3), easy fatigability (n=3), palpitation (n=2), and chest pain with palpitation (n=1). The extracardiac anomalies were cataract (n=1), polydactyly (n=1), amelia (n=1), and multiple congenital malformations (n=1). Only 153 (37.8%) children were admitted to the clinic. Table 3 gives the results of the cardiac investigations in these children. The number of diagnosed congenital and acquired pathologies and their relative frequencies are summarized in Table 4.

Aortic and/or mitral insufficiency were detected in 2 children and accepted as rheumatic heart disease. In these children, penicillin prophylaxis was started. In 19 patients, a CHD was detected; in 5 of them the detected CHDs were hemodynamically significant and were treated surgically (n=3) (atrial septal defect [ASD], ventricular septal defect [VSD], coarctation of aorta) or interventionally (n=2) (patent ductus arteriosus [PDA] coil embolization, ASD closure).


Recent advances in techniques and widespread availability of health services have made it possible to diagnose most children with CHDs in early life. In developing countries, however, some children even with severe CHDs may not be diagnosed until adolescence. There are many studies reporting the prevalence of CHDs in live birth infants (6-11). In developing countries, it is hard to give this ratio for various reasons (1). Thus, many authors have attempted to determine the frequency of CHDs among school-aged children (1,12-14). The prevalence had been reported between 0.07 and 0.2% in these studies (1,12-14). In our country, the same ratio was reported, ranging from 0.1-0.44% in different regions, between 1986 and 1998 (15-20).

Acquired heart diseases, especially rheumatic heart diseases, are still prevalent in developing countries (2-4). Their diagnosis is important to prevent recurrences and hence surgeries for severe valvular heart diseases.

In our region, Ozkan et al. (21) evaluated 2,547 schoolchildren in terms of cardiac murmurs and reported a frequency of undiagnosed CHD of 0.3% and of rheumatic heart disease of 0.11%. The examinations in that study were done by a pediatrician and echocardiographies by adult cardiologists. In the current study, 405 out of 4,370 children were invited for further evaluation, but only 153 presented. Congenital heart disease was determined in 19 (12.4%) of these children, and rheumatic heart disease in 2 (1.3%). Since we were unable to reach an important portion of the group that needed to be studied, we are not able to report a true prevalence of heart diseases among school-aged children. Nevertheless, when our incidence rates are compared with those of Ozkan et al. (21), it can be seen that the presence of a pediatric cardiology clinic in the region facilitated the diagnosis and monitoring of more patients, and more children with undiagnosed congenital or acquired heart disease were thus discovered during checkups. In the present study, hemodynamically important heart diseases were revealed and treated. These children are of course at risk for natural and harmful results of the heart defects (sudden cardiac death during sportive activities, infective endocarditis, pulmonary vascular disease, etc.) and for recurrence of rheumatic carditis. Therefore, it is important that children who reach school age without a diagnosis are diagnosed appropriately as soon as possible. An important means for this would be in conjunction with the required check-ups at the time of registration for elementary school. Even though the check-up is a requirement for admission to elementary school in Turkey, the results of the current study show that the implementation of this policy is inadequate.

Study Limitations

Since we could not perform echocardiographic examination in all 4,370 children, it is impossible to report a true prevalence for undiagnosed heart diseases in our cohort. In addition, the majority of the children who were invited for further evaluation did not admit to our unit. This hindered the determination of the number of children with undiagnosed heart disease among those with abnormal symptoms. Nevertheless, we believe that the high frequency of pathologies observed in the patients who presented to our department for advanced examinations is an indication that the frequency would also be quite high in the study group as a whole.

In conclusion, our results suggest that there are still important numbers of school-aged children with significant heart disease who require treatment and follow-up. A more detailed compulsory check-up before admission to elementary school for children in this age group will help to identify and properly treat children with important heart diseases. Furthermore, educational programs should be conducted among families to increase participation in these screening programs.


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Mehmet Karacan, Hasini Olgun, Mehmet Fatih Orhan *, Nilgun Demet Altay *, Candan Ferai Ozturk *, Cahit Karakelleoglu *, Naci Ceviz

Department of Pediatrics Division of Pediatric Cardiology Ataturk University Faculty of Medicine Erzurum, Turkey

* Department of Pediatrics Ataturk University Faculty of Medicine Erzurum, Turkey

Address for Correspondence/Yazisma Adresi

Mehmet Karacan

Ataturk Universitesi Tip Fakultesi, Yakutiye Arastirma Hastanesi Cocuk

Kardiyolojisi Bilim Dali 25070, Erzurum, Turkey

Tel: +90 442 231 68 50

Fax:+90 442 236 13 01

E-posta: mehmet.karacan@gmail.com

Received/Gelis Tarihi: 15.02.2010

Accepted/Kabul Tarihi: 21.05.2010
Table 1. Children with previously diagnosed cardiac
abnormalities among the whole study group (n=4,370)

Cardiac pathology                             n

Rheumatic heart disease                       3
Tetralogy of Fallot *                         2
Ventricular septal defect                     2
Transposition of the great arteries **        1
Atrial septal defect ***                      1
Aortic coarctation ****                       1
Patent ductus arteriosus *****
Total 11 (0.25%)

* Total correction had been performed

** Total cavo-pulmonary anastomosis had been performed

*** Surgically closed

**** Balloon angioplasty had been performed

***** Coil embolization had been performed

Table 2. Reasons for further investigations in 405 children

Cause                                                  n (%)

Murmur                                              342 (%84.4%)
History of syncope                                   13 (3.2%)
Cardiac complaints *                                  9 (2.2%)
Pectus excavatum                                       8 (2%)
Pectus carinatum                                       8 (2%)
[S.sub.2] hardness                                    7 (1.7%)
Hypertension                                          6 (1.5%)
History of acute rheumatic fever                      5 (1.2%)
Extracardiac anomalies **                              4 (1%)
Split [S.sub.2]                                       2 (0.5%)
Hypertension and weak femoral arterial pulsation      1 (0.3%)

* Chest pain, easy fatigability, palpitation and chest pain with

** Cataract, polydactyly, amelia and multiple congenital

Table 3. The reasons and results of cardiac investigations in 153
children admitted to our clinic

Cause of cardiac evaluation                        n

Cardiac murmur                                    133
  Normal                                          107
  Atrial septal defect                              4
  Mitral valve prolapse                             4
  Physiological mitral regurgitation                4
  Mitral valve abnormality                          2
  Patent foramen ovale                              2
  Patent ductus arteriosus                          2
  Ventricular septal defect                         2
  Parachute mitral valve                            1
  Pulmonary stenosis                                1
  Atrial septal defect + mitral valve prolapse      1
  Aortic stenosis                                   1
  Aortic insufficiency                              1
  Mitral and aortic insufficiency                   1
Syncope                                             3
  Normal                                            2
  Vasovagal syncope                                 1
Cardiac complaint                                   6
  Normal                                            6
Chest deformity                                     5
  Normal                                            4
  Physiological mitral regurgitation                1
Hypertension                                        3
  Normal                                            3
Split second heart sound                            1
  Normal                                            1
Extracardiac anomaly                                1
  Normal                                            1
Hypertension and weak femoral pulses                1
  Aortic coarctation                                1

Table 4. The detected congenital and acquired cardiac pathologies
and their relative frequencies

Number of school    Number of children with     Number of children
children examined     positive history or     admitted for evaluation
                       physical findings

4370                          405                       153

                                              Congenital HD *
                                              Acquired HD **

Number of school        Number of children
children examined    with cardiac abnormality

4370                         % of        % of
                     n     invited     admitted
                           children    children

                     19      4.7         12.4
                     2       0.5         1.3
                     21      5.2         13.7

* Congenital HD: Congenital heart disease.

** Acquired HD: Acquired heart disease.
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