Cardiac conditions

Question 1

Cardiac failure

Causes (neonates, infants, children), signs and symptoms

Answer 1

Causes:

• Neonates: Left heart obstruction
  
  • Coarctation of the aorta
  • Hypoplastic left heart syndrome (failure of LV development)
  • Critical aortic valve stenosis
  • Interruption of the aortic arch
• Infants: High pulmonary blood flow (due to failure of blood to pass to the left side of the heart to be pumped into systemic circulation)
  
  • VSD
  • AVSD
  • Large persistent ductus arteriosus
• Older children and adolescents: Left or right sided heart failure
  
  • Eisenmenger syndrome (Right sided only)
    
    • Long standing L→ R shunt causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic R → L shunt)
  • Rheumatic heart disease
  • Cardiomyopathy (dilated/hypertrophic/restrictive)

Symptoms:

• Breathlessness (worsened by feeding and exertion)
• Sweating
• Poor feeding
• Recurrent chest infection

Signs:

• Poor weight gaiin/faltering growth
• Tachypnoea
• Tachycardia
• Heart murmur - gallop rhythm
• Cardiomegaly
• Hepatomegaly
• Cool peripheries

Question 2

Clinical presentation of congential heart disease

Signs and symptoms

Answer 2

• Antenatal cardiac USS diagnosis
• Detection of a heart murmur
• Heart failure
• Shock
• Cyanosis

Question 3

Risk factors for congenital heart disease

Answer 3

• Genetics
  
  • Down’s syndrome, Marfan’s
• External teratogens
  
  • Warfarin, alcohol
• Maternal conditions
  
  • Rubella, SLE, diabetes mellitus

Question 4

Heart murmurs

Features of innocent heart murmurs, presentation of VSD/patent ductus arteriosus

Answer 4

*The most common presentation of congenital heart disease*

Features of innocent heart murmurs:

• Soft
• Systolic
• aSymptomatic
• left Sternal edge
• No parasternal thrill, no radiation

Febrile illness and anaemia → increased cardiac output → murmur heard - requires examination post-resolution of these conditions to confirm whether the murmur is pathological

Presentation of VSD/patent ductus arteriosus

• No symptoms or murmur at birth as pulmonary vasculature resistance is still high
• May only become symptomatic at several weeks of age (when the pulmonary vasculature resistance decreases)

Question 5

Causes of heart failure in paedriatrics

Answer 5

Question 6

Acyanotic congenital heart disease

Question 7

Atrioventricular septal defect

Question 8

Coarctation of the aorta

Question 9

Duct-dependent lesions

Question 10

Patent ductus arteriosus

Question 11

SVT

Question 12

Tetralogy of Fallot

Question 13

Transposition of the Great Vessels

Question 14

Ventriculoseptal/atrioseptal defects

Question 15

Cardiac disease and association with other syndromes

Question 16

Hypoplastic left heart

Question 17

Myocarditis

Question 18

HBE

Question 19

Conditions causing left-to-right shunt

Answer 19

• Atrial septal defects
  
  • Secundum ASD: A defect in the center of the atrial septum, involving the foramen ovale
  • Partial atrioventricular septal defect (AVSD or prinum ASD)
• VSDs
• Persistent ductus arteriosus (PDA)

Question 20

Atrial septal defects

Causes/classification, signs and symptoms

Answer 20

Causes/classification:

• Secundum ASD: A defect in the center of the atrial septum, involving the foramen ovale
• Partial atrioventricular septal defect (AVSD or prinum ASD)

Symptoms:

• Commonly, NONE
• Recurrent chest infections/wheeze
• Arrhythmias (4^th decade onwards)

Signs:

• Ejection systolic murmur: Due to increased flow through the pulmonary valve, caused by the left to right shunt
• Fixed and widely split 2nd heart sound: Ventricular stroke volume is equivalent in both inspiration and expiration
• Partial AVSD → apical pansystolic murmur from AV valve regurgitation

Question 21

List the key features that distinguish innocent from pathologic murmur.

Answer 21

Question 22

Describe the features of a venous hum.

a.k.a. Nun’s murmur

Answer 22

!An innocent heart murmur!

• Best heard at the upper left sternal edge
  
  • Right side of the neck, just above the clavicle
• ‘Machinery’ quality sound
• Due to flow through the great venous vessels
  
  • Arises due to compression of the internal jugular vein by the clavicle. Causes the walls of the vessels to vibrate
• Distinguishing venous hum from PDA: Rotation/flexion of the neck or placing a finger on the jugular vein will abolish/change the murmur

Question 23

Following CVS examination, be able to diagnose common murmurs.

Answer 23

Question 24

Be able to describe the presenting features of cardiac failure

Answer 24

Usually related to poor tissue perfusion, rather than systemic congestion.

Related to increased compensatory sympathetic drive

Symptoms:

• Sweating (worsened by exertion/feeding)
• Dyspnoea
• Fatigue
• Cough
• Recurrent chest infections

Signs:

• Tachycardia
• Gallop rhythm
• Tachypnoea
• Auscultatory crackles (pulmonary oedema)
• Hepatomegaly
• Oedema

Question 25

Be able to consider the differential diagnosis of cardiac failure.

Answer 25

• Nephrotic syndrome
• PE
• Pneumonia
  *

Question 26

Outline the initial management of a child with cardiac failure.

Answer 26

Bed rest and nurse in an up-right position

Supplemental oxygen (not in L → R shunt)

Ensure adequate nutrition

Diuretics

ACEi

Question 27

List the epidemiology, features and management of common types of acyanotic heart disease e.g. VSD/ASD/AS/PS