Dr Shelby Kutty is an endowed professor at Johns Hopkins University. He directs the Taussig Heart Center and chairs the Cardiovascular Analytic Intelligence Initiative at Johns Hopkins Hospital. Kutty has a Master’s degree in health care management from Harvard University, and is trained in medical artificial intelligence from the Massachusetts Institute of Technology.
With so much expertise, Kutty is a name to reckon with in paediatric cardiology. He leads a team at Johns Hopkins that has developed various clinical programmes in cardiac care and was awarded major grants from the National Institutes of Health to lead data science approaches to manage Covid-19. Kutty, a prolific author who has published over 400 peer-reviewed articles in leading medical journals, says cardiac complications from Covid-19 are rare in children. Excerpts from an interview:
We have been facing high levels of pollution in cities. What is its impact on children?
Air pollution is linked to many adverse health effects in children, affecting a multitude of systems. From a cardiac standpoint, chronic exposure to auto emissions and poor air quality as a child is linked to heart attacks, strokes, and atherosclerotic disease in early adulthood. There are many theories as to the potential cause, with some studies suggesting that increased inflammation from chronic exposure to pollution leads to changes in how we process cholesterol and fat, and it makes our vessels more susceptible to injury. Even among healthy adolescents, there are reports of sudden cardiac arrest and arrhythmias in individuals exposed to poor air quality conditions; many of the affected individuals were healthy, with no pre-existing conditions.
In India, over a lakh children every year are born with congenital heart disease. What factors might be contributing to this?
Congenital heart disease, as it is in the rest of the world, is a major health issue for India. The cause of congenital heart disease in the general population is multifactorial―genetic and environmental. We know that there is a higher risk of CHD in children who have close relatives affected by CHD, as well as certain genetic conditions. Maternal factors during pregnancy, such as diabetes, obesity, and alcohol consumption/smoking, are also well-known risk factors for CHD. Certain medications, taken during pregnancy, are also linked to CHD. Though this is becoming less prevalent with more awareness and education.
What lifestyle changes should parents bring about in children to ensure they are not at risk for heart attacks in adulthood?
Research has shown that risk factors for developing heart disease during adulthood are present during childhood. Some risk factors are genetic and cannot be changed, whereas others are modifiable. The good news is that evidence shows that adopting a healthy lifestyle during childhood reduces the risk of cardiovascular disease in adulthood. These include increased weight or obesity, elevated blood pressure, hyperlipidemia (high cholesterol or triglyceride levels), and smoking. They can develop at an early age, and progress until a child’s risk for heart attack in adulthood becomes substantial. Therefore, interventions to alter these factors should begin as early in childhood as possible.
Regular exercise, in addition to a diet low in sodium and saturated fat, should be a part of a child’s daily routine. Preventative care, with regular visits to the paediatrician, is important to detect modifiable coronary disease risk factors, counsel lifestyle changes and initiate medical therapy.
How often should one monitor blood pressure in children?
Blood pressure should be monitored annually in children over the age of three. Children with risk factors, such as those with kidney or heart disease, need to be monitored more closely at an earlier age. In healthy individuals, high blood pressure, or hypertension, is linked to stroke and heart failure early in adulthood. Poorly controlled hypertension can lead to heart attacks and even seizures.
Can family history of high cholesterol or premature heart disease put children at risk for developing cardiovascular disease?
Yes, very much so. There are certain genetic conditions that affect the way one metabolises cholesterol. Even with a good diet and regular exercise, these individuals are at a greater risk of high cholesterol and triglycerides (or fat in the blood), and require medicines to prevent early heart attacks, strokes, and sudden cardiac death.
Children don’t usually show signs or symptoms of heart disease, but the buildup of fatty deposits in the arteries, known as atherosclerosis, starts in childhood, especially when there is a family history. Obesity, elevated blood sugars, and diabetes also increase the risk of the development of heart disease.
Have you observed geographical disparities in cardiac health of children? How do you rate heart health of children in countries in South America, North America, and Asia?
Cardiovascular disease is the leading cause of death worldwide, but is more prevalent in some locations than in others. Many disparities in cardiac health are linked to lifestyle and diet. In North America, there is a higher incidence of risk factors like obesity, type 2 diabetes, and hypertension at a younger age. This is mainly due to a sedentary lifestyle and consumption of readily available cheap junk food, high in saturated fat and sodium. Diets rich in fat, sugar, and carbohydrates are common in many Asian households, contributing to a higher incidence of cardiac disease in certain South Asian groups. In Japan, however, where the population is physically active and the diet is high in fish and vegetables, there is a lower mortality rate from heart disease.
There are broad geographical disparities in availability of cardiac care services. In less affluent countries, the advanced surgical and medical interventions required for survival in childhood CHD are not available.
Have there been unusual observations among children admitted in the past two to three years?
Cardiac complications from Covid-19 are rare in children, and are often treatable. They can develop a condition called multisystem inflammatory syndrome (MIS-C), which causes inflammation of the heart muscle and coronary arteries after a Covid-19 infection, which can be dangerous. In addition, mental health challenges have increased, with higher rates of depression and anxiety reported in all age groups.
Why do sudden cardiac arrests happen among young children? Is it because of environmental factors, or genetic reasons?
Sudden cardiac death (SCD) is typically caused by structural heart disease, which can have a genetic cause, or can occur just by chance. Hypertrophic cardiomyopathy, which is a thickening of the heart muscle, coronary artery abnormalities, and genetic syndromes associated with arrhythmias are common causes of SCD. Infections that affect the heart, like myocarditis, can also cause a sudden cardiac event. It is rare for environmental and lifestyle factors to cause a sudden cardiac arrest in children, but these can lead to adverse events in early adulthood.
What are the breakthroughs that are helping us in understanding heart disease among young children?
Improving technology has been a key factor in helping cardiologists diagnose and treat children with heart disease earlier, sometimes in foetal life. Imaging modalities have become more precise and accurate, allowing us to pinpoint a problem more effectively. Surgical techniques have advanced, and we are able to treat many common congenital heart conditions less invasively, via transcatheter procedures and devices. Ultimately, our patients are leading longer, more fulfilled lives.
On the horizon, there is great potential to take advantage of major advances in medical information management, artificial intelligence, and machine learning to personalise care for our paediatric cardiac patients. As we combine medical history with cardiac imaging, genetic, metabolic, environmental, and even socio-economic data, there is the deep phenotype, which emerges, upon which fully informed decisions about heart disease management for the individual can be made.
Many Indian hospitals have set up separate departments for paediatric cardiology in recent years. Your views.
While the number of hospitals with paediatric cardiology programmes is increasing in India, many more programmes and providers are needed, particularly to care for CHD in patients who are becoming adults. In the developed world, the number of adults with CHD has exceeded the number of children. Nevertheless, in the US there are approximately 480 adult CHD providers, and close to 3,000 paediatric cardiologists. These numbers are largely mirrored in the rest of the developed world, and in lower income countries the relative shortage of physicians with expertise in adult congenital heart disease is even greater. India faces a great need for more providers and programmes to meet the growing demands for specialised CHD care in children and adults.