Cost-effective use of echocardiography in children with Kawasaki disease

Objective. To determine whether a third echocardiogram, performed 6 months to 1 year after the onset of Kawasaki disease (KD), as recommended by curre nt American Heart Association guidelines, identified any case of coronary a rtery abnormalities when previous echocardiograms were normal. Methods. Children diagnosed with KD were identified by searching our instit ution's database. Cases were included in the study if diagnosed between Jun e 1988 and December 1996 and if at least two echocardiograms were documente d, including at least one study between 2 weeks and 2 months from the onset of KD and another in follow-up. The patients' charts were reviewed and vid eotapes of the echocardiograms were reviewed if reports were unclear or con tradictory. McNemar's test for discordant pairs was used for statistical an alysis. Additionally, a complete review was performed in all other cases of KD in the database in which a coronary artery abnormality had been identif ied. Results. There were 203 patients diagnosed during the study period who had 2 or more echocardiograms performed, and 67 had the requisite studies in th e subacute period and later follow-up. The median age at onset of KD was 3. 0 years (range: 0.2-16), the median duration of follow-up was 12.5 months ( range: 1.7-100), and the median number of echocardiograms performed was 3 ( range: 2-8). Intravenous immunoglobulin was given in 62 cases, and high-dos e aspirin was given in 63. There were 35 children with no echocardiographic abnormalities at any point, and 15 other children had early abnormalities (including coronary ectasia, perivascular brightness, pericardial effusion, and ventricular dysfunction) but had a normal echocardiogram between 2 wee ks and 2 months. Of these 50 children, none were noted to have abnormalitie s on later studies. Three children had effusion and/or perivascular brightn ess after 2 weeks; follow- up studies were normal in each. Six children had coronary ectasia after 2 weeks; it persisted on follow-up in 1 child and h ad resolved in 5 children. Eight children had coronary aneurysms on studies after 2 weeks; in 3 children, the aneurysm resolved on later follow- up. N o coronary abnormalities were demonstrated on a late follow- up echocardiog ram in any child with normal coronaries between 2 weeks and 2 months. Conclusions. All children with KD should have an echocardiogram at the time of diagnosis with a follow-up study 4 to 6 weeks after the onset of fever. In the current environment of cost-containment, additional echocardiograph ic studies are justified only if abnormalities are present at 4 to 6 weeks.