Association of Initially Normal Coronary Arteries With Normal Findings on Follow-up Echocardiography in Patients With Kawasaki Disease

Abstract

guidelines recommend echocardiography in Kawasaki disease at baseline, 1 to 2 weeks, and 4 to 6 weeks after treatment to detect coronary artery abnormalities. However, these examinations are expensive and may require sedation in young children, which is burdensome and carries some risk. OBJECTIVE To assess the benefit of additional echocardiographic imaging at 6 weeks in patients with uncomplicated Kawasaki disease who had previously normal coronary arteries. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective review of patients with Kawasaki disease who were cared for between 1995 and 2014 in 2 academic pediatric referral practices Eligibility criteria included receiving intravenous immunoglobulin treatment for acute Kawasaki disease at a center; the absence of significant congenital heart disease; available echocardiographic measurements of both the right and left anterior descending coronary arteries at 10 days or less after diagnosis (baseline), 2 (±1) weeks, and 6 (±3) weeks of illness; and normal coronary arteries at baseline and 2 weeks, defined as maximum coronary artery z scores less than 2.0 and no distal aneurysms. Data analysis was completed from March 2015 to November 2015. MAIN OUTCOMES AND MEASURES The number of patients with right coronary artery or left anterior descending coronary artery z scores of 2.0 or more at 6 weeks. RESULTS The median age of the 464 included patients was 3.3 years (interquartile range, 1.8-5.4 years); 264 (56.9%) were male, 351 of 414 for whom data were available (84.8%) had complete Kawasaki disease, and 66 (14.2%) received additional intravenous immunoglobulin treatment. At 6 weeks of illness, 456 patients (98.3%) who had had normal coronary artery z scores at baseline and 2 weeks continued to have normal z scores. Of the remaining 8 patients (1.7%), the maximum z score within 6 weeks was 2.0 to 2.4 in 5 patients (1.2%), 2.5 to 2.9 in 1 patient (0.2%), and 3.0 or more in 2 patients (0.4% [95% CI, 0.1%-1.5%]). Coronary artery dimensions ultimately normalized in all but 1 patient, who had minimal dilation at 6 weeks (right coronary artery z score, 2.1). Sensitivity analyses using less restrictive cut points (eg, a maximum z score <2.5) or less restrictive timing windows (eg, considering patients with incomplete echocardiographic data within 21 days) gave similar results; in these analyses, 454 to 463 of 464 patients (98% to 99.7%) had coronary artery z scores of less than 2.5 at 6 weeks. CONCLUSIONS AND RELEVANCE New abnormalities in coronary arteries are rarely detected at 6 weeks in patients with Kawasaki disease who have normal measurements at baseline and 2 weeks of illness, suggesting that the 6-week echocardiographic imaging may be unnecessary in patients with uncomplicated Kawasaki disease and z scores less than 2.0 in the first 2 weeks of illness.

Prognosis and Risk Factors of Coronary Artery Lesions before Treatment Among Patients with Kawasaki Disease

“…We also analyzed the factors that may affect the duration of CAL, and the results indicated that female sex was a protective factor for the prognosis of CAL, while overweight status, higher platelet count, lower albumin level and delayed IVIG treatment were independent risk factors for the prognosis of CAL. These findings are consistent with a previous report ( 9 ). However, the levels of alanine transaminase and hemoglobin had no association with the duration of CAL.…”

“…The proportion of patients with CAL before IVIG treatment was lower than previously reported. De Ferranti et al ( 9 ) found that about 31.6% (318/1203) of patients had CAL at baseline (within 10 days of onset), most children were younger than 3 years old, and the proportion of male children was 71.4%. In our study, the proportion of children younger than 36 months old was 83.50%, and the proportion of male children was 28.6%.…”

“…A study in our department showed that the proportion of children with CAL in acute-stage was about 20% ( 7 ). Left ventricular strain is impaired in patients with KD at a median follow-up of 57.5 months ( 8 ); however, 99.8% of children with maximum z scores of less than 2.5 at ≤10 days or 2 weeks would return to normal by the 6th week after illness onset ( 9 ). We found that many children developed CAL before IVIG treatment.…”

Multisystem inflammatory syndrome in children: Is there a linkage to Kawasaki disease?

“…The most concerning complication of KD is CAAs that can be detected within 2 weeks during the convalescent stage of KD [10] . These abnormalities are typically identified by echocardiography.…”

Utility of color Doppler echocardiography combined with clinical markers in diagnosis and prediction of prognosis of coronary artery lesions in Kawasaki disease

“…Based on the current recommendations, it is stated that echocardiography must be conducted during the diagnosis for complex KD cases without any obvious signs of coronary artery disease, then again at 1-2 weeks and 4-6 weeks following treatment. More frequent evaluation is required for patients with progressive abnormalities to detect thrombosis and aneurysms (14,15). The signs and symptoms, clinical data and echocardiographic results of 200 children with KD were analyzed in a previous study and it was identified that the signs and symptoms of KD in infants <3 months old were varied, and these patients were exposed to a higher risk of coronary artery anomalies; nevertheless, barring the patients suffering from giant coronary artery aneurysms, all other patients successfully recovered after an average follow-up period of 18 months with no complications (16).…”