prognosis is excellent and the child should have no activity restrictions or longterm medications It is important that this information be communicated to families and that parents are encouraged to treat their children as normal and healthy It is reasonable to provide general cardiac risk assessment and counseling—including assessment of risk factors, such as fasting lipid profile, blood pressure, body mass index, and dietary and activity assessment—at least 1 year after the illness and then as indicated by general pediatric guidelines Counseling regarding a healthy lifestyle, the avoidance of obesity, encouragement of exercise, and, for older children, discouragement of smoking, should be provided at every visit Preventive cardiology assessments can be provided by primary care providers Additional Teaching for Patients With Coronary Aneurysms The long-term prognosis in Kawasaki disease depends on whether a child develops coronary artery dilation and, if so, the extent of the coronary involvement In addition to the general discharge teaching already outlined, patients with coronary enlargement/coronary aneurysms should receive additional patient-specific information Children with coronary dilation are at risk for thrombus formation due to interruption of laminar flow through the enlarged vessels For this reason, children with aneurysms are maintained on longer-term therapy These regimens place the child at a greater risk of bleeding In addition, children with significant coronary involvement may receive additional medications, such as a β blocker The nurse must make sure prior to discharge that the parents understand the rationale and are able to administer their child's medications accurately In particular for children on injections of low-molecular-weight heparin or those using INR machines at home, teaching should begin several days prior to discharge to ensure the parent's comfort level Patients receiving aspirin and clopidogrel or aspirin and anticoagulants should be restricted from high-impact sports to minimize the risk of bleeding In addition, the most severely affected children may need to be restricted from highly aerobic, highly competitive team sports as they get older.183 However, regular aerobic activity should be encouraged for overall cardiac health, and families should encourage diverse activities For children in day care, school, or camp, letters must be provided to caretakers outlining specific activity recommendations Cardiopulmonary resuscitation teaching to the parents of any child with coronary artery aneurysms should be considered prior to discharge In addition, caretakers of children with coronary aneurysms should be educated regarding the possible signs and symptoms of angina and myocardial infarction These may include chest pain, chest pressure or tightness, left arm pain, sudden pallor, diaphoresis, or nausea More subtle signs may occur in younger infants and children and may include left ear or neck pain, vomiting, or inconsolability If these symptoms develop in a child with coronary aneurysms, the child should be evaluated promptly at a local emergency room, typically including an electrocardiogram and serum troponin level Last, parents and caregivers should demonstrate a clear understanding of whom to call for questions after discharge In addition, it is helpful to review a plan of when and where to seek medical attention A written list of specific instructions, symptoms of concern, and contact information is helpful Follow-up phone calls by nurses may provide additional support to these families, particularly during the transition home from the hospital It is understandably very difficult for parents of children with acquired heart disease to incorporate this new reality into their lives and still treat the child as normally as possible Nurses can provide emotional support to the patient and family during this time as well as anticipatory guidance for subsequent evaluations and testing Recommendations for Long-Term Follow-up The frequency of follow-up, types of testing, and specific recommendations regarding surveillance, cardiovascular risk factor assessment and management, medical therapy, thromboprophylaxis, physical activity, and reproductive counseling are summarized in Table 53.3 (see also Table 53.2).2 Recommendations are based on both worst and current coronary artery status.2 Table 53.3 Long-Term Assessment Algorithm Risk Level Frequency of Cardiology Assessmenta No involvement May discharge between 4 weeks and 12 months If regressed to normal, discharge between 4 weeks and 12 months; if persistent dilation, reassess every 2–5 years Assess at 6 months then yearly Dilation only 3.1 Small aneurysm – current or persistent 3.2 Small aneurysm; regressed to normal or dilation only 4.1 Medium aneurysm; current or persistent 4.2 Medium aneurysm; regressed to small aneurysm 4.3 Medium aneurysm; regressed to normal or dilation only 5.1 Large or giant aneurysm; current or persistent 5.2 Large or giant aneurysms; regressed to medium aneurysm 5.3 Large or giant aneurysm; regressed to small aneurysm Assessment for Inducible Myocardial Ischemiab None None Frequency and Type of Advanced Cardiac Imagingc None None Assess every 2–3 years Assess every 1–3 years (may omit echo) Assess every 3–5 years Assess at 3, 6, and 12 months, then every 6–12 months Assess yearly May consider every 3–5 years May consider if evidence for inducible ischemia or ventricular dysfunction Assess every 1–3 May consider every 2–5 years years Assess every 2–3 May consider every 3–5 years years Assess every 1–2 years (may omit echo) Assess every 2–4 Not indicated unless years inducible ischemia Assess at 3, 6, 9, and 12 months, then every 3–6 months Assess every 6– 12 months Baseline within 12 months; surveillance every 1–5 years May consider for surveillance every 2–5 years Assess every 6–12 months Assess yearly Assess every 6–12 months Assess every 1–2 May consider for years surveillance every 2–5 years ... Recommendations are based on both worst and current coronary artery status.2 Table 53.3 Long-Term Assessment Algorithm Risk Level Frequency of Cardiology Assessmenta No involvement May discharge between 4 weeks and 12 months If regressed to normal, discharge