Cardiac Disorders Flashcards
Hypertension
Blood pressure consistently above the 95th % for age, gender, and height.
- Measured on 3 separate occasions.
- Cuff size, measure after rest, check upper and lower extremities.
Essential Hypertension
Multifactorial, genetic, familiar, environmental, dietary factors.
Secondary Hypertension
Usually renal vascular in origin, systemic vascular with genetic syndrome, endocrine disorder, excess endogenous catecholamine.
HTN Assessment
BP evaluation, heart sounds.
PE: Dysmorphic features, abnormal retinal exam (papilledema), abnormal growth parameters.
HTN Diagnostics
CBC, UA, UCx, uric acid, BUN, creatinine, electrolytes, lipid panel, renal ultrasound, echocardiography.
HTN Management
Mild Essential HTN: dietary, exercise, weight loss.
Essential HTN: diuretics, vasodilators, beta-blockers, ACE inhibitors (NEVER first line).
Secondary HTN: find and treat underlying cause, referral to cardiology or nephrology.
Kawasaki Syndrome
Acute systemic vasculitis of unknown origin.
- Acute and subacute phases.
S/S: (PRIMARY) Prolonged fever, reddened and indurated palms/soles of feet, erythematous rash, bilateral conjunctival injection, red peeling lips, strawberry tongue, unilateral cervical lymphadenopathy, irritability.
(SECONDARY) May have evidence of vasculitis in other systems: murmur, diarrhea, vomiting, abdominal pain, proteinuria, cough, joint pain, swelling, seizures.
Dx: Based on 5 symptoms with fever > 5 days and 4 of 5 other primary symptoms OR fever > 5 days, 3 other symptoms and coronary aneurysm documented by imaging.
Tx: (Inpatient treatment) IVIG, high dose aspirin, chronic aspirin if indicated, cardiology and ID consults, long-term follow up with echocardiograms.
Rheumatic Fever
Collagen vascular disease of connective tissue resulting in vasculitis. Inflammation of joints and heart. Complication of Group A Streptococcal pharyngitis.
S/S: Presents as migratory polyarthritis with joint pain. Rash: erythema marginatum. Subcutaneous nodules found on elbows, knees, wrists, occiput, or vertebrae. 100% of cases have chorea.
Dx: Modified Jones criteria - 2 major criteria (carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) OR 1 major and 2 minor criteria (arthralgia, fever, elevated CRP, ESR, WBC), prolonged PR interval (EKG).
Tx: (Acute) PCN, aspirin therapy, bedrest until fever and symptoms resolve, cardiology and ID consults. PCN prophylaxis for prevention.
Cardiomyopathies
Acute or chronic sequelae of a typical viral disease. Dilated cardiomyopathy is most often seen.
S/S: Congestive heart failure and decreased cardiac output. SOB, CXR reveals cardiomegaly, ECHO reveals globally decreased function.
Dx: Workup for anatomic abnormalities, metabolic causes, infectious causes.
Tx: (Acute) support cardiac output with inotropes and vasodilators, diuretics, treat causes (IVIG, antivirals, surgery for ALCAPA - anomalous left coronary artery from the pulmonary artery)
Hypertrophic Obstructive Cardiomyopathy
50% familial, often found on autopsy.
S/S: Acute decompensation, may be with sports or activity.
Tx: Activity restriction, beta-blockers, avoidance of catecholamines.
Long QT Syndrome
Congenital disorder characterized by a prolongation of the QT interval on ECG and a propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death.
S/S: Usually not diagnosed until child/adolescent has a cardiac event, including syncope or cardiac arrest. Relatives of patients who have died of sudden death require evaluation.
Dx: Potassium, magnesium, and thyroid function. EKG and sometimes echocardiogram indicated.
Tx: Beta-blockade, implantable cardioverter/defibrillator may be needed. Patients should avoid other medications that will prolong the QT interval.
ASD
Opening in the atrial septum.
- Left to right shunting.
S/S: Usually asymptomatic, with soft, systolic ejection murmur with fixed S2.
Dx: EKG may show right axis deviation, RVH, echocardiogram.
Tx: May close spontaneously. Echocardiogram is routine monitoring. Surgery for large lesions.
VSD
Opening in the ventricular septum.
- Left to right shunting.
S/S: Findings are dependent on size of lesion and pulmonary vascular resistance. Signs of CHF, holosystolic murmur, pulmonary hypertension can occur.
Dx: Echocardiogram, CXR, B-type natriuretic peptide serum level, EKG, occasionally cardiac catheterization.
Tx: Control symptoms of CHF prior to surgical correction, nutrition. Surgical correction is usually after the age of one.
Atrioventricular (AV) Canal
Results from the failure of the endocardial cushion to develop normally.
- 3 components: ASD, inlet VSD, abnormal formation of the AV valves.
- Left to right shunting.
S/S: Depend on type and configuration. Tachypnea, poor weight gain, other signs of CHF.
Dx: Echocardiogram, CXR.
Tx: Control CHF and encourage weight gain. Surgical management.
PDA
Vessel connects the left main pulmonary artery to the descending aorta, in utero is part of normal circulation, after birth, lesion closes, if remains open:
- Left to right shunting.
S/S: Depends on extent of shunting. Can result in CHF or pulmonary hypertension. Murmur, widened pulse pressure, low diastolic pressure and bounding pulses.
Tx: In preterm infants, medical management has been efficacious, but recent evidence suggests allowing spontaneous closure. Surgical closure can be accomplished.
Truncus Arteriosus
Rare lesion - failure of the primitive arterial trunk to septate and divide into aorta and pulmonary artery, causing mixture of systemic and pulmonary blood flow.
- Right to left shunting.
S/S: Usually diagnosed prenatally. Symptoms occur soon after birth with normal fall of PVR and include shock. Bounding peripheral pulses, cyanosis, harsh systolic murmur.
Dx: EKG - left atrial enlargement and biventricular hypertrophy.
Tx: Prostaglandin administration, managing shock and CHF. Surgery indicated once patient is stable.
Transposition of the Great Vessels
Aorta rises from the anatomic right ventricle and the pulmonary artery rises from the anatomic left ventricle.
- Right to left shunting.
S/S: Two separate and parallel circulations present.
Tx: Infants with intact ventricular and atrial septums will require immediate prostaglandin infusion, balloon septostomy ASAP.
Tetralogy of Fallot
4 findings: outlet type VSD, right ventricular outflow tract obstruction, overriding aorta, RVH.
- Right to left shunting.
S/S: Degree of cyanosis related to the degree of right ventricular outflow tract obstruction. Presentation varies.
Dx: Tet spells, EKG - persistence of RVH beyond 3 months of age. CXR - “boot shaped” heart.
Total Anomalous Pulmonary Venous Return (TAPVR)
Drainage from the pulmonary veins into a systemic venous structure or right atrium instead of the left atrium.
- Right to left shunting.
S/S: Clinical manifestations differ, depending on obstructed or unobstructed types. Pulmonary venous hypertension and pulmonary edema can develop. Presentation can be CHF, inadequate growth, frequent pulmonary infections, mild cyanosis.
Dx: “Snowman” sign on CXR. Echocardiogram indicated.
Tx: Treatment of symptoms. Surgical repair by age 2 or 3 years.
Obstructive: Coarctation of the Aorta
Variety of conditions occurring along the aortic arch - either discrete or generalized narrowing.
S/S: Can present either in neonate or older child. Pulmonary edema occurs in neonate with LV failure. Systemic hypertension occurs in older child. Can present in heart failure or cardiogenic shock in infant. Asymptomatic murmur and hypertension in older child.
Dx: CXR - not conclusive for diagnosis. Echocardiogram or doppler studies. MRI most definitive.
Tx: Surgical repair, stent placement.
Valvular Stenosis: Mitral and Aortic Stenosis
Typically congenital. Narrowing of the mitral or aortic valve. Mitral, aortic and tricuspid insufficiency can occur as a a result of chest trauma.
S/S: Cough, poor feeding, poor growth, SOB.
Tx: Valvular replacement.
Congestive Heart Failure
Progressive clinical and pathophysiological syndrome caused by cardiovascular and non cardiovascular abnormalities that result in edema, respiratory distress, growth failure, and exercise intolerance.
- Typically caused by congenital lesions, but can be caused by acquired lesions or cardiomyopathy.
S/S: Tachycardia, retractions, nasal flaring, grunting, crackles on auscultation, fatigue, pallor, diaphoresis, syncope, and cool, mottled, slow cap refill, weak pulses.
- Hypotension, thread pulse, decreased urine output and edema are later findings.
Dx: CXR, Echocardiogram, MRI, CT, Cardiac Catheterization, Endomyocardial biopsy, Exercise test, skeletal muscle biopsy, lab work.
Tx: (Based on etiology of symptoms) Digoxin, diuretics, ACE inhibitors, beta-blockers, anticoagulants.
Myocarditis
Serious, acute inflammation/infection of the myocardium. Often secondary to viral illness, such as coxsackie or adenovirus.
S/S: Sudden cardiac failure, murmur, gallop, tachypnea, life-threatening arrhythmia.
Dx: Biopsy (gold standard), elevated troponin, flat T-waves on ECG.
Tx: Support while critically ill. ACE inhibitors, digoxin, diuretics, IVIG.
Pericarditis
Sequelae to acute viral illness. Inflammation of the pericardium of the heart.
S/S: Fever, tachypnea, tachycardia, pericardial friction rub. May present with tamponade.
Dx: Echo may show fluid in pericardial sac. CXR - cardiomegaly.
Tx: If tamponade - emergent pericardiocentesis. Antibiotics 3-4 weeks for Staph and HFlu.
Endocarditis
Acute sepsis presentation.
S/S: Fever, murmur, embolic phenomena such as petechiae, vasculitis, osler nodes.
Dx: Echo - vegetation and small 2mm lesions.
Tx: (Strep) PCN, ceftriaxone or vancomycin. (Enterococci) Ampicillin. (Staph aureus) Nafcillin.
- Surgery for persistent positive BCx, abscess of valves and/or embolic events during antibiotic therapy.
Post-Pericardiotomy Syndrome
Rare syndrome that occurs after tissue injury to the myocardium - after cardiopulmonary bypass, trauma, myocardial infarction, pacemaker placement and repair of pectus excavatum. Occurs with the accumulation of pericardial fluid.
S/S: Fever, irritability, poor appetite, pleuritic chest pain, distant heart sounds and friction rub, pericardial tamponade.
Dx: CXR, EKG, Echocardiogram.
Tx: Empirical, symptom-based. NSAIDs for discomfort, systemic steroids, pericardial drainage.
Pulmonary Artery Hypertension
Mean pulmonary artery pressure greater than 25mmHG at rest. PAH is caused by vasoconstriction of endothelial and smooth muscle cells. Vasoconstriction reduces alveolar oxygen tension, resulting in alveolar hypoxia leading to reduced nitric oxide production and increased endothelin production.
S/S: Poor feeding, tachypnea, cyanotic spells, failure to thrive, syncope, irritability, loud second heart sound, murmurs, JVD, hepatosplenomegaly, peripheral edema.
Dx: Cardiac catheterization is the gold standard.
Tx: (Symptom Dependent) Oxygen, diuretics, calcium channel blockers, prostaglandins, anticoagulation, endothelin antagonists, phosphodiesterase type 5 inhibitors (sildenafil, tadalafil), inhaled nitric oxide.
Cardiac Tamponade
Accumulation of fluid within the pericardium resulting in depression of cardiac output.
S/S: Tachycardia, hypotension, and JVD.
Dysrhythmias/Arrhythmias
Most common arrhythmias in children are SVT and bradycardia.
Key Points
- Include cardiac lesions in the differentials for any infant who presents with lethargy, feeding issues, and respiratory distress.
- Include cardiac diagnoses in the differential for a child who has a seizure or altered neurologic event.
