Exercise testing in many forms is used diagnostically, prognostically, and to determine if interventions are needed and/or successful in pediatric cardiology patients. Exercise-based diagnostic testing is used in pediatric cardiology to assess exertional symptoms in children with and without known heart disease. For pediatric patients with arrhythmia syndromes, exercise testing is used to identify children at risk for life threatening arrhythmias/sudden death and to assess effectiveness of therapies aimed to prevent sudden cardiac death.
CPET is used in congenital heart disease (CHD) patients to evaluate morbidity and mortality risk and to evaluate physiologic changes during exercise that may signal an increased risk for a sudden or devastating event. For patients with congenital heart disease, CPET is critical to determine current functional level, abnormal responses to exercise, need for medical, procedural and/or surgical therapies, and to assess efficacy of medical or surgical interventions.
Patients with congenital heart disease tend to minimize exertional symptoms and overestimate their own exercise capacity. However, those who do report symptoms, tend to have moderate to severely reduced Ṿ̇O₂peak by the time they report symptoms to their provider, highlighting the need for surveillance CPET in patients with CHD rather than testing only when symptoms are described. While exercise testing in patients with congenital heart disease is generally considered safe, approximately 50% of pediatric and young adult patients tested in a busy pediatric exercise lab had arrhythmia associated with testing, thus it is critical to have an exercise medicine expert to determine individual risk and ensure appropriate preparation and supervision for potential exercise-related events. Low Ṿ̇O₂peak, in addition to several additional variables obtained via CPET, has repeatedly been shown to be predictive of poor outcomes in patients with CHD.
Exercise therapeutics are critical in the modern care of pediatric patients with congenital and acquired heart disease. With improvements in fetal, neonatal, surgical, and pediatric cardiac care, the great majority of children born with CHD can expect to live well into adulthood. Improved survival of patients with CHD has resulted in a shift in the care model from prolonging lifespan to improving health span of this complex patient population.
Within the lifespan model, exercise was typically discussed in terms of restrictions to decrease the risk for sudden cardiac death. The newer focus on health span calls for safe, appropriate exercise promotion. Adolescents and adults with CHD have lower cardiorespiratory metabolic fitness than the general population and this varies with lesion severity. As outlined above, poor CRMF is predictive of morbidity and mortality in the CHD patient population.
A scientific statement from the American Heart Association in 2013 recommended counseling patients with CHD about the importance of daily physical activity and decreasing sedentary time as a core component of caring for a patient with CHD. This statement proposed strong arguments in favor of appropriate exercise counseling and promotion within safe boundaries as determined by a thorough history and evaluation. However, also noted in this statement was that healthcare providers reported that they "do not have the knowledge, skill, resources or time needed to implement the extensive literature on physical activity promotion."
Countless researchers and papers have documented the beneficial effects of physical activity therapeutics for patients with CHD; however, this major component of standard of care health span promotion is not available to most CHD patients due to a lack of adequately trained clinicians with the time to appropriately assess, implement, and track safe physical activity. An ACGME-backed fellowship in EMD&T would provide an essential training opportunity for providers who wish to address this gap in patient care.