Pulmonary stenosis: defect-specific diagnostic accuracy of heart murmurs in children.

OBJECTIVE: To determine the accuracy of expert examination for pulmonary stenosis (PS) among children with murmur. STUDY DESIGN: Five hundred twenty-one consecutive, previously unevaluated, pediatric patients were enrolled. The investigators prospectively recorded their diagnosis and level of confidence, categorizing any PS suspected as mild or severe. After echocardiography, PS was categorized by severity with peak systolic flow velocity. Receiver operating characteristic curves described accuracy of clinical examination. RESULTS: Sixty-two patients had PS (mild, 29; moderate, 27; and severe, 6). Receiver operator characteristic curve areas were: total, 0.834 +/- 0.033; mild, 0.862 +/- 0.044; and moderate to severe, 0.809 +/- 0.046 (P =.20). Specific difficulties in discrimination of PS from small ventricular septal defect, aortic valve disease, atrial septal defect, and innocent murmur were identified. All cases of severe PS in which PS was suspected were thought possibly severe. CONCLUSIONS: Although expert clinical examination is highly accurate for distinguishing PS from non-PS cardiac murmurs in pediatric patients, it is imperfect.

Prospective study of the electrocardiographic effects of imipramine in children.

Because imipramine and desipramine have been implicated in sudden death in children, noninvasive electrophysiologic data were accumulated in 25 patients. Two children were excluded on the basis of resting electrocardiographic and Holter abnormalities. The remaining 23 patients received imipramine to a maximum dose of 5 mg/kg or a serum level of 150 to 250 ng/ml. Consistent but clinically insignificant resting electrocardiographic changes occurred during treatment. Ambulatory electrocardiographic monitoring may be useful when one is assessing the cardiovascular risks of imipramine therapy.