Evo Terra (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland. Medical System. This is an episode in a series of podcasts answering frequently asked questions about what is normal in childhood development and when parents may need to seek a specialist.

I'm Evo Terra. And with me today is Dr. Thomas Chin, Professor and Chief of Pediatric Cardiology at the University of Maryland School of Medicine, as we help you understand which heart-related symptoms in kids are usually harmless and when it's time to see a specialist. Dr. Chin, thank you much for joining me.

Thomas Chin, MD: Thank you for inviting me.

Host: So, what are the most common reasons a child gets referred to a pediatric cardiologist like yourself?

Thomas Chin, MD: So, the patients that we most frequently see are those that are referred for heart murmurs, people who have chest pain, and also patients who have palpitations.

Host: Understood. Let's talk about that heart murmur for a moment. I've carried one for 58 years. When is it normal and when does someone need to be seen for more evaluation?

Thomas Chin, MD: Yeah. So, the term heart murmur is fairly general. And people with heart murmurs can either have a completely normal heart or, some of them, the murmur may be a sign of something more ominous. So in other words, it could be related to something such as a defect that is present since birth. It could be result something that's happened that's acquired, like some type of heart disease, rheumatic heart disease, Kawasaki's disease. It's difficult at times to tell whether it's a so-called innocent murmur, which means that it's associated with a completely normal heart versus a murmur that's related to something like a heart defect or some form of disease.

Host: Understood. Yeah, again, I've had mine since birth, and every time I see a new dentist and every time I see aesthetician, they want to look and then make sure it's A-okay. But it is. So, that's good news. Okay, enough about me. Chest pain in kids is frequently not heart-related, we know. So, what warning signs do make you worry?

Thomas Chin, MD: Chest pain, there's been a lot of concern that's occurred recently because the publicity that's surrounding these unfortunate athletes who have sudden cardiac death. So, I think it's important for somebody with chest pain to take that finding seriously. But having said that, certain types of chest pain are less worrisome than others. So for example, you can have a chest discomfort related to some sort of a skeletal or muscular type abnormality.

So for example, if you've been overworking your muscles, you've strained yourself, and you feel some tenderness at some place in your chest, that's most typically a benign finding. The things that are most concerning for us are people who have so-called exertional chest pain. So, it's reproducible and occurs every time that they push themselves, like some of the high-level athletes who are really pushing themselves 110% every day. And when they feel that get to a certain point and they feel sort of a chest pressure or aching pain, and that this is relieved when they stop exercising, that's usually potentially concerning. And so, it deserves some further and more formal evaluation.

Some people also will describe chest pain or chest discomfort when they sense palpitations. So in other words, when they feel like their heart's beating irregularly, very hard, irregular, or very, very fast, some people, especially the younger people will sense this and say that there's something wrong with their chest, something wrong with their heart, and often will describe palpitations as a form of chest pain. And palpitations themselves are also something that we should consider being evaluated talking a a little bit more about palpitations then.

It's normal for the heart to speed up when you're exercising or when you're excited. But people have abnormal heart rhythm problems, essentially related to the electrical system of the heart that drives the heart rate and coordinates the contractions of the different chambers of the heart. Some people may suddenly feel very, very fast heart rates, just that are unrelated to exercise or anxiety. And so, that's a little bit of a tip-off that something may be abnormal. If somebody has a heart rate where they're beating 70, 80 times a minute, and suddenly just in one beat, they're beating at 200 plus beats per minute. And that's often described as looking like the heart's beating outside of the chest, and often can be sensed by the child who's having the the palpitations. And also, if it's associated with dizziness or fainting, those are all concerning findings as well.

Host: You mentioned sports and professional athletes that are in the news, but I've got a couple nephews right now, I think they're semi-professional athletes and they're still in school, right? Because the intensity of kids's sports today is much greater than it was when I was a kid. So, let's talk about some of the signs that might present themselves while a child is either exercising or doing these sports that parents should really be aware of.

Thomas Chin, MD: So basically, the whole purpose of the pre-participation screens for athletes and also there certain red flags that have been listed by a Joint Commission from the American College of Cardiology and the American Heart Association are to help prevent the sudden cardiac death. So by definition, sudden cardiac death is something where somebody who doesn't know that they have a heart defect or heart abnormality suddenly keels over and dies from their heart defect. And many of these people may have been athletes that have been exerting themselves and not aware that they had any heart problems in the past. And typically, there are certain conditions that make up the majority of patients who have sudden cardiac death.

One of them is cardiomyopathy, where the heart itself may have the normal number of chambers, the valves may be normal. But on other hand, the muscle itself is abnormal and is prone to causing arrhythmias, which can cause a sudden cardiac death.

Another relatively common cause of sudden cardiac death is coronary artery abnormalities. So in other words, those blood vessels that are affected when somebody at an older age has heart attack may actually be coming off the wrong side of the heart and not be getting a full head of blood pressure. So, that for normal day-to-day activities, the heart and the blood supplying the heart may be normal. When they exert themselves, it's inadequate, and that could also trigger arrhythmias and sudden cardiac death.

So, those are examples of things which could very easily be mixed. And so, when we look at some of these red flags that are listed by the American College of Cardiology and American Heart Association, for example, the chest pain, history of fainting with exercise, a heart murmur that hasn't previously been evaluated, and then also a family history of somebody who has cardiomyopathy because cardiomyopathies can be inherited within families. And so, if there's some family history of somebody else who had a heart attack at a very young age or had sudden cardiac death, these are some of the things that we're really focusing on to identify to protect some of these children who are participating in sports.

Host: So if a parent takes their child in to see a pediatric cardiologist like yourself, what should they expect? What's the visit like?

Thomas Chin, MD: Yeah. So, first, we'll be talking to the child and their family about what are their concerns, why do they suspect that there's some type of a heart problem. And sometimes, it'll just be something where, by the history from their pediatrician or from their coaches, they feel that more evaluation is warranted.

So beyond sort of a history, learning about other people in the family, we'll do a physical exam where we listen to hear if there's heart murmurs that were undetected in the past. We'll often do some screening procedures. An electrocardiogram or EKG is something where we can look at the rhythm of the heart and also get some idea by the voltages if some of the chambers or the muscle thickness in the heart is abnormal.

And then, finally, a portion these based on their physical exam and their EKG will go on to get an echocardiogram. And this is an ultrasound of the heart where we can actually look at the different structures directly, measure thicknesses of muscle, look at the chamber sizes, and then detect structural abnormalities or functional abnormalities of the heart. And the echocardiogram is a painless procedure. We basically use sound waves to look at the heart. And for a complete study, maybe somewhere in the order of 20 to 30 minutes. So, it's often something we can just do as an outpatient in the office.

So based on those things, then we'll pull all the information together, and we can very easily determine from that if somebody, you know, based on their symptoms and their findings are at risk for sudden cardiac death or unlikely to have any problems with that.

Host: I know that a lot of parents, and know I would be this way if someone said you need your kid to a heart doctor, that causes panic. So, what reassurances do you have for patients and also their parents?

Thomas Chin, MD: Yeah. So, different people have different access to medical care. One thing and I'll speak to, you know, regarding the University of Maryland, just because I'm most familiar with that system. There's some urgency in terms of the evaluation, and especially somebody who wants to participate in sports. They feel uncomfortable about some of the things that have been going on with their own body, and they want to perform an evaluation. We have a policy at the University of Maryland that with our large system of outreach clinics and things, we can essentially get anybody in within 48 hours to get an evaluation. So, we need a referral from their physician so that it'll be covered by the insurance. And so, that's something that we can do and facilitate for the patient so we can ease their minds.

Fortunately, as much as there's a huge need for people to be screened, only a small percentage of the people will have something that's actually dangerous. So, everything that you hear about nationwide with a sudden cardiac death, there's about one child who dies about every three days so from a sudden cardiac death event. In terms of of the incidence of sudden cardiac death compared to trauma, auto accidents, suicide, it's a small percentage. But of course, since it's preventable, then every single death is very tragic for the entire family and community.

So, also going through and talking about another activity that I'm involved with and in the Maryland region then, I work together with a number of different health centers and also with a group called the Bailey Bullock Heart and Soul Foundation, who was instrumental after they suffered a sudden cardiac death event in their own child several years ago in instituting some legislation where parents understand that there's availability of cardiac screening.

And what we've been doing together is working with the community systems and offering some events where we do free cardiac screenings. So, in other words, at the same time somebody comes in and has a pre-sports physical, those who have concerning findings of the heart will be sent over to a group of us, and we'll do an exam, do an EKG and, in some cases, an echocardiogram if needed. And that information is posted. And we've tried to cover all the different areas in the Baltimore region. Some in inner city Baltimore, some in Baltimore County. A number of screens up in Harford County. So, you know, some of these things are posted publicly. And if you don't have access through your private physician insurance or your school, then there's another mechanism where you can get your child screened.

But as much as there's a huge need for this, the number of people who can get a free screen, we probably only reach about 10% of the people who need a screening. So, this is a large public health issue that we're hoping to address and, you know, improve on across the country.

Host: Well, hopefully podcast episodes like this one will help us do that. We've covered a lot of ground during this conversation. It's been wonderful. Any key takeaways you'd like the listeners to have?

Thomas Chin, MD: Yeah. Let me touch back a little bit on the cardiac murmurs. We talked about earlier on and, basically, I had said there are some people who have, you know, innocent heart murmurs versus those that have things that really need to be followed long term. And again, I think it's important just based on what that child is feeling, if they have chest pain, they tire out with exercise. And many of the pediatricians are skillful in identifying which heart murmurs are more unusual and more likely to be associated with some abnormality. So, in terms of getting appropriate referrals to us as cardiologists, your family practitioner, your pediatrician, are great people to go to as a first step, and then they'll be able to guide you in terms of getting the subspecialty care within pediatric cardiology.

Host: Dr. Chin, thank you very much for joining me today.

Thomas Chin, MD: Thank you.

Host: And you can listen to more at umms.org/podcast on YouTube or your favorite podcast platform. Thank you for listening to Live Greater, a health and wellness podcast brought to by the University Maryland Medical System. And don't forget to check out the other topics on A Parent's Guide to What is Normal. We look forward to you joining us again, and please this on your social media.