In search for optimal image quality in pediatric cardiac ct angiogram

“There can be no keener revelation of a society’s soul than the way in which it treats its children”. Years after his death, these Nelson Mandela’s prolific words still resonate universally with our moral and ethical foundations and, as researchers ourselves, we are very happy to know that Science walks on the right path of history. There are a number of methodological and ethical challenges of performing research in children. However, there can be no progress in pediatric clinical care without research in this population, whose findings may also otherwise be relevant to adult medicine. Given that approximately 1% of born children will have some kind of significant heart disease,1 it is of crucial importance to maximize the safety and efficacy profile of diagnostic and therapeutic interventions. Computed tomography cardiac angiography (CTCA) is being increasingly used, but its diagnostic accuracy in children is highly dependent on optimal image quality while minimizing radiation exposure as much as possible. Even with modern scanners, image quality in CTCA is still highly dependent on a stable and relatively slow heart rate (HR).2 To achieve optimal pre-scan conditions, beta-blocker administration is often advocated and a number of societal documents have been published providing guidance for patient selection and administration.3,4 Nevertheless, the different pharmacokinetic behavior of beta-blockers in pediatric patients (in addition to the higher baseline HR, body movement and smaller coronary arteries) cast a shadow regarding the optimal strategy and dosage to obtain high quality images without incurring in the risk of bradyarrhythmias.5 Beta-blockers should be given at an appropriate dose given the potential side effects, but doses and protocols typically vary among facilities. De Oliveira Nunes et al.6 share an elegant study that sheds a much needed and awaited light on this uncertainty. The aim of this study was to clarify the safety and efficacy of a metoprolol protocol in a series of pediatric outpatients.