Imperative for long-term management and surveillance in Kawasaki disease

Abstract

Kawasaki disease (KD) is a significant pediatric vasculitis known for its potential to cause severe coronary artery complications. Despite the effectiveness of initial treatments, such as intravenous immunoglobulin, KD patients can experience long-term cardiovascular issues, as evidenced by a recent case report of an adult who suffered a ST-segment elevation myocardial infarction due to previous KD in the World Journal of Clinical Cases. This editorial emphasizes the critical need for long-term management and regular surveillance to prevent such complications. By drawing on recent research and case studies, we advocate for a structured approach to follow-up care that includes routine cardiac evaluations and preventive measures.

Key Words: Kawasaki disease; Long-term management; Coronary artery aneurysm; Surveillance; Preventive care

Core Tip: Kawasaki disease management requires ongoing surveillance due to the risk of severe coronary artery complications. Consistent follow-up and preventive care are essential for reducing the risk of adverse cardiovascular events in Kawasaki disease patients.

TO THE EDITOR

Kawasaki disease (KD) is a systemic vasculitis predominantly affecting children under the age of five[1]. The disease is characterized by a prolonged fever, rash, conjunctivitis, oral mucosal changes, and extremity swelling. Despite the acute nature of KD, which often resolves with appropriate treatment, the long-term prognosis can be complex due to potential cardiovascular complications[2]. To optimize patient outcomes, it is crucial to clearly define which patients should be selected for long-term surveillance. Evidence suggests that all patients with coronary artery aneurysms, regardless of size, should be considered for monitoring, but the criteria should be refined further, particularly for those with specific coronary artery aneurysms diameters or additional risk factors. KD can lead to the formation of coronary artery aneurysms, which may result in serious sequelae if not properly managed.

Recent case reports have illuminated the long-term risks associated with KD, particularly highlighting the cardiovascular consequences that may persist into adulthood. One such case involves a 35-year-old man who suffered a ST-segment elevation myocardial infarction (MI) as a result of longstanding coronary artery aneurysms from a previous KD diagnosis[3]. This case serves as a poignant reminder of the critical need for continuous monitoring and preventive care beyond the initial treatment phase. Furthermore, it is important to establish whether surveillance should include patients already on thromboprophylaxis or even those not on thromboprophylaxis. This needs to be clearly defined based on data, as patients on thromboprophylaxis are at higher risk and require closer follow-up. Maintaining compliance with thromboprophylaxis is crucial, particularly as follow-up may be lost during the transition to adulthood.

The transition from pediatric to adult care for KD patients is a significant period that requires careful management to address ongoing cardiovascular risks. This editorial underscores the necessity of establishing robust follow-up protocols and integrating preventive measures into long-term care plans. This includes determining when surveillance should begin, how frequently it should occur, and which modalities should be used, such as echocardiography, electrocardiogram, cardiac computed tomography, magnetic resonance imaging, intravascular ultrasound, or biomarkers of coronary or myocardial injury. The surveillance duration is also important to define, likely requiring lifelong monitoring. Moreover, other preventive strategies, such as managing hyperlipidemia, controlling blood pressure, and promoting lifelong healthy lifestyle choices, should not be overlooked. Effective management of KD involves not only addressing acute symptoms but also implementing strategies to monitor and mitigate long-term risks associated with the disease.

CASE ANALYSIS

The case report by Lee et al[3] sheds light on the severe implications of inadequate long-term management for KD patients. The patient, a 35-year-old man with a history of KD, presented with ST-segment elevation MI due to significant coronary artery aneurysms and thrombi. This case highlights a critical gap in the management of KD patients, as the individual had not received sufficient long-term follow-up after the acute phase of his illness.

The development of coronary artery aneurysms in KD patients is a well-documented complication that can lead to serious cardiovascular issues. While intravenous immunoglobulin therapy during the acute phase of KD is effective in reducing the risk of aneurysm formation, it does not negate the need for ongoing surveillance. The patient’s presentation with MI underscores the necessity of continuous cardiac evaluation and the implementation of preventive therapies, such as antithrombotic treatment, to manage and reduce the risk of coronary events. Additionally, it is critical to emphasize other preventive strategies, such as managing hyperlipidemia, controlling blood pressure, and ensuring lifelong lifestyle modifications. These strategies should be incorporated into the care of all KD patients to reduce long-term cardiovascular risk.

The case also highlights the importance of transitioning KD patients to adult care, particularly those with significant coronary artery involvement. Adult cardiologists and healthcare providers must be aware of the patient’s KD history and implement a comprehensive follow-up strategy that includes regular cardiac assessments and appropriate preventive measures. Ensuring continuity of care from childhood to adulthood is vital to successfully implementing these recommendations. National public health efforts should be directed towards increasing awareness among pediatric and adult clinicians, establishing strong transition programs, and educating families on the importance of ongoing surveillance.

CONCLUSION

The management of KD extends well beyond the acute phase of the illness. Long-term follow-up and preventive care are critical components of KD management to prevent severe cardiovascular complications[4]. The recent case of ST-segment elevation MI in an adult with a history of KD highlights the significant risks associated with inadequate long-term management and underscores the need for structured follow-up protocols. However, specific recommendations need to be established regarding which patients should be selected for surveillance, when it should begin, the frequency of monitoring, and the modalities used. Surveillance should likely be lifelong and include patients on thromboprophylaxis or those with specific risk factors. Additionally, preventive strategies such as managing hyperlipidemia, blood pressure control, and promoting healthy lifestyle choices should not be overlooked. Healthcare providers must prioritize long-term surveillance for KD patients, incorporating regular cardiac evaluations and preventive measures into their care plans. Future research should focus on optimizing long-term care guidelines, improving surveillance practices, and exploring strategies to reduce the incidence of adverse cardiovascular events in KD patients. By enhancing our understanding of the long-term implications of KD and refining management practices, we can improve patient outcomes and ensure better cardiovascular health for individuals affected by this complex disease.