Missed Diagnosis of New-Onset Systolic Heart Failure Common in Children

Among children with no known heart disease who are hospitalized with new-onset heart failure, almost half had a missed diagnosis of heart failure on first presentation, according to results published in The Journal of Pediatrics.

The results indicated that children who presented with gastrointestinal symptoms were more likely to have a missed diagnosis compared with children who had cardiovascular features of heart failure.

The study included participants <21 years old with no known heart disease who had been hospitalized with new-onset heart failure from 2003 to 2015 at a tertiary-quaternary care institution (N=191). The researchers reviewed medical records for missed diagnosis of heart failure (primary outcome), associated process breakdowns, and clinical outcomes.

The results indicated that 49% (n=94) of participants had a missed diagnosis of heart failure on first presentation. The most common incorrect diagnostic labels given to the conditions of these participants were bacterial infection (29%; n=27), viral illness (22%; n=21), and gastroenteritis/hepatitis (21%; n=20).

After multivariable analysis, the researchers found that presentation to a primary care provider, longer duration of symptoms (median 7 days), >2 symptoms of heart failure, and nausea/emesis were associated with a missed diagnosis of heart failure.

The researchers further broke down the examining process and found errors in history taking for 49% and no documentation of differential diagnosis in 50%.

Among participants in the missed diagnosis category, 18% underwent unnecessary noninvasive testing, and 4% underwent unnecessary invasive testing.

“Our findings suggest that children who present with [gastrointestinal] symptoms rather than cardiovascular features of heart failure are more likely to be missed,” the researchers wrote.

Reference

Puri K, Singh H, Denfield SW, et al. Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease [published online January 21, 2019]. J Pediatr. doi:10.1016/j.jpeds.2018.12.029