Cardiology Flashcards
what is cardiomegaly?
Enlarged left heart or right heart
what if pulm circulation is overcirculated?
prominence of pulmonary vasculature
“wet appearing” lung ,
Egg on a String - shaped heart..
Transposition of the great arteries
Boot shaped heart
T of F
what does an echo show?
Structures
- Blood flow
- Estimates of pressure in chambers
Increased precordial activity –
cardiomegay lg right side of heart
Displaced PMI
enlarged
RV heave =
rv HTN
liver size enlargement
enlarged from congestion
extremities what do you look for?
perfusion, edema, clubbing
Wk LE pulse
CoA
bounding pulse
run-off lesions (L→R PDA shunt, AI )
Weak pulses
cardiogenic shock or CoA
what is Pulsus paradoxus and what does it indicate
exaggerated SBP drop with inspiration → tamponade or bad asthma
what is pulses alterans? indicates?
altering pulse strength → LV mechanical dysfunction
what is S1
closing of mitral and tricuspid valves, LLSB or apex
what is S2
closing of aortic (A2)and pulmonic (P2) valves
what is S3
– heard in diastole ,related to rapid ventricular filling , can be normal, or abnormal -accentuated with dilated ventricles
what is S4?
Always bad..late in diastole just before S1 – always bad.
Decreased vent compliance / heart failure
Ejection click
AS or PS
Mid-systolic click
MVP
Loud S2
Pulmonary HTN
Single S2
= one semilunar valve (truncus), anterior aorta (TGA), pulmonary HTN
Fixed, split S2
ASD, PS
Gallop (S3)
may be due to cardiac dysfunction/ volume overload
Muffled heart sounds and/or a rub
pericardial effusion ± tamponade
innocent heart murmurs?
Heart murmurs which occur in the absence of anatomic or physiologic abnormalities of the heart or circulation
heart murmur described based on
Location and radiation
Relationship to cardiac cycle and duration
Intensity
Quality
heard first days of life, LLSB , 1-2/6 , gone by 2-3 weeks of life
newborn
often in newborn period from branching PA. Heard in axillae and back short, high pitched 1-2/6
Peripheral pulmonary arterial stenosis (PPS
most common murmur of early childhood. Heard ages 2-7yrs. Musical, vibratory, mid to lower LSB, 1-3/6. loudest when patient supine.
Still murmur
most common innocent murmur in older children, ages 3 yrs and up. ULSB, soft ejection murmur , 1-2/6.
Pulmonary ejection Murmur –
heard after age 2, infraclavicular (where blood is coming together from jug and subclav) R>L, Continuous musical hum. Best heard sitting. Comes from turbulence at confluence of subclavian and jugular vein.
Venous Hum
older child and adolescent. Rt supraclavicular area, harsh, 2-3/6.
Innominate or carotid Bruit
LOC and muscle tone
Usually benign
syncope
in kids syncope is d/t
Vasovagal or neurocardiogenic
what Usually has prodrome of pallor, lightheadedness
Can be in response to pain, heat, blood, fright
syncope
if syncope is d/t cardiac disease…
BAD - arrhythmia or CHD
if syncope is d/t circuation what is it?
Hypovolemia, orthostatic hypotension
chest pain in child is…
rarely cardiac…;Usually musculoskeletal
Pulmonary origin
GERD
asthma
if CP is d/t cardiac?
ischemia, inflammation, arrhythmia
what is common. Some conducted, some non-conducted. Slight not-quite compensatory pause before next beat. Benign
PACs
what has wide QRS, no compensatory pause, typically benign unless they come several in a row
PVC’s
very uncommon in young children
Seen occasionally in older children and adolescents…
PVC
3 PVC’s in a row means
Vtach , uncommon, unstable, needs cardioverting
most common arrhythmia in kids
PAC
Supraventricular Tachycardia (SVT) is defined as
280-300 bpm Well tolerated unless underlying heart disease
what is Wolff-Parkinson-White Syndrome
Re-entrant tachycardia - Abrupt onset and termination
how do you stop SVT?
adenosine
how do you manage SVT
B blocker
Prolonged QTc syndrome
can but someone in SVT also but not as common as reentrant
what is the most common SVT in kids
Re-entrant tachycard
what causes congenital heart block
Maternal Lupus
what is result of first degree heart block?
prolonged PR
what is 2nd degree heart block?
not all P waves are conducted
what is type 1 second degree HB?
progressively longer PR interval until a QRS is dropped
what is type 2 second degree HB?
same PR interval, occasional QRS droppedThird Degree – complete dissociation of SA with AV
what is 3rd degree HB
Av node does not transmit message from SA
from maternal lupus CHB –>moms lupus damages the AV node of baby
Children’s heart disease is particularly d/t
congenital heart disease is due to structural abnormalities
what is the number one cause of congenital heart disease?
multifactorial>genetic>Maternal infections and diseases and teratogens:
what are examples of maternal infections and diseases and teratogens that cause CHD
Examples: fetal alcohol syndrome, Down syndrome, Trisomy 13 and Trisomy 18, Turner syndrome, congenital rubella syndrome, Maternal Lupus
Coxsackie B in mom causes
Myocarditis
parvo in mom causes
Myocarditis
rubella in mom causes
PDA, PS, AS, TOF
Lithium in mom causes
ebsteins
ibuprofen antinatally
PHTN
ETOH antenatally
VSD, ASD, TOF, CoA
phenytoin
ASD, VSD, CoA, PDA, PS, TOF
Retinoic Acid
TGA, TOF, DORV, TA, AA probs, HLHS
Lupus in mom
Congenital Heart Block
diab in mom
TGA, VSD, ventricular hypertrophy
5%, most common CHD presenting in the first week of life
Transposition of Great Arteries
1%, second most common presenting in the first week of life
Hypoplastic Left Heart Syndrome
10%, most common CHD presenting beyond infancy
TOF
For the fetus the ____ is the oxygenator so the lungs do little work
placenta
in fetus _____ contribute equally to the systemic circulation and pump against similar resistance
RV and LV
what are the shunts in the fetus needed for survival? 3
ductus venosus (bypasses liver) foramen ovale (R→L atrial level shunt) ductus arteriosus (R→L arterial level shunt)
what is ductus venosus
by passes liver
what is foramen ovale
R–>L atria
ductus arteriosis
R–>L arteral shunt
what happens to the fetal heart at birth? 3 things.. what constricts ductus arteriosis, and closes foramen ovale?
- Mechanical expansion of lungs and increased arterial PO2 decreases pulmonary vascular restrictive
- Over several days the increased PaO2 constricts the ductus arteriosis
- The increased plmonary blood flow returning to left atrium increases pressure in LA leading to closure of PFO.
Cyanotic CHD?
= R –> L shunt ( blood bypasses lungs)
Acyanotic CHD
L –> R shunt
what are obstructions in CHD?
Coarctation, stenosis
what are mixing/ reversal of flow CHD?
Septal defects, patent fetal paths
what are parallel circuit of CHD?
Transposition of the Great Vessels
If acyanotic?
Left to Right shunt or
Obstruction to outflow
ex. of l–> shuntopening in the VSD –>blood will flow from l to r during systole
if cyanotic…
Right to Left shunt or
Parallel circuit
if increase pulmonary flow
Left to Right shunt – blood flows to chamber with lower
if decreased pulmonary flow
right to left shunt
ie pulm valve is stenotic
symptoms of decrease pulm flow in infant..
Cyanosis
Squatting
Loss of Consciousness
symptoms of decrease pulm flow in older child
Dizziness
syncope
symptoms of increased pulm flow in infant
Tachypnea with activity/feeds
Diaphoresis
Poor weight gain
symptoms of increased pulm flow in older child?
Exercise intolerance
Dyspnea on exertion/diaphoresis
acyanotc CHDs 6 types
Atrial septal defects (ASD)10% Ventricular septal defects (VSD) 25% Patent ductus arteriosus (PDA) 5-10% Obstruction to blood flow Pulmonic stenosis (PS)10% Aortic stenosis (AS) 5% Aortic coarctation 10%
how does ASD present
childhood w/ murmur or exercise intolerance
what is going on in ASD?
Flow is from L > R
- RA and RV volume overload (enlargement)
- Increased pulmonary blood flow
ASD is not a problem when?
at birth –> problem shows up later
Clincal findings of SD - growth, symptoms, heart sounds, murmur?
-Most children are asymptomatic
-May be undergrown
-Easy fatigueability in older children /adults
-Acyanotic, RV lift, normal pulses
-Persistently split second heart sound (S2)
Pulmonary ejection murmur
Diastolic flow murmur over tricuspid valve
what finding is consistent with split S2?
ASD
how do you treat ASDs?
ASDs may be closed either by device placement during catheterization or surgically
ADSs after ___y/o will not close alone
2
what is VSD
opening in the ventrical
what happens in the VSD?
-L –>R shunt because of low pulmonary vascular resistance
-Increased pulmonary blood flow - Increased pressure
-Pulmonary venous congestion
Left sided overload (enlargement) and hypertrophy – back up of flow.
-Pulmonary hypertension
- Primarily right sided problem
What are VSD symotoms and at inc risk for what?
Congestive heart failure Poor growth Shortness of breath/Increased respiratory effort Easy fatigue Recurrent respiratory infections
what are clinical findings of VSD? growth, resp, precordial, murmors?
Growth and development may be delayed Respiratory effort and heart rate may be increased if heart failure Precordial activity may be “bounding” Holosystolic murmur –holosystolic, harsh LLSB, +/- thrill Systemic and pulmonary venous congestion
how do you treat VSD
30% will close spontaneously Observation Anti-congestive heart failure medications diuretics Fortified diet Surgery (open heart defect)
Endocardial cushion defect AV valve insufficiency Heart Failure over 6-8 weeks Poor growth Trisomy 21... what is this?
AVSD
what is the treatment of AVSD
surgery
what is a PDA treatment
indocin/ibuprofen….. surgery
what if a pt has symp of T21 what is the murmur d/t
AVSD
what do you give to keep PDA like in coarc?
PG
what does persistent PDA cause?
increase pulmonary flow; pulmonary overload
murmur of PDA
Soft murmur LLSB 1-3/6
pulmonic stenosis
cant get blood out into Pulm art very well so back up to r side of heart
aortic stenosis is primarily
bicuspid valve
what is: Obstruction of LV output
LV hypertrophy
Low cardiac output
LV failure
aortic stenosis
what is first sign of AS
Heart murmur is usually the first sign
Ejection click
Basilar ejection murmur
Precordial or suprasternal thrill
what may AS cause if severe
low cardiac output or congestive heart failure
Neonatal heart failure
older child with AS presents with…
chest pain, dizziness, syncope (especially with exertion)
how do you treat mild A stenosis?
may not req tx
how do you treat AS
All treatment is palliative
Balloon valve angioplasty
Surgery , valve replacement
Life style alterations
what is the physiology of CoA?
Narrowing near where the ductus enters the aorta
what other defect is CoA associated with
bicuspid aortic valve
Pt with CoA has what?
Poor perfusion, left ventricular failure
when does CoA present
mostly in infants
what is CoA thought to be from?
Not closing of PDA
neonates CoA present with
severe congestive cardiac failure and cardiovascular collapse
Older kids with CoA present with
hypertension, absent or weak femoral pulses, leg cramps, chronic pulmonary congestion, headaches, epistaxis
CoA murmur?
blowing systolic in left axilla
Lower body is cooler(less pulses) than upper body
CoA
what has a blowing systolic murmur in left axilla
CoA
treatment of CoA
surgery
Cyanotic CHD - 8
Tetralogy of Fallot (TOF) Tricuspid atresia (TA) Total anomalous pulmonary venous return (TAPVR) Truncus arteriosus Transposition of the great vessels 5 T’s Hypoplastic left heart syndrome (HLH) Pulmonary atresia (PA) / critical PS Double outlet right ventricle (DORV)
what is truncus arterioisis? shunt and PBF?
R–>L shunt increase PBF
how does truncus art present?
Presents more often with heart failure (except TGA)
Pulmonary congestion worsens as neonatal PVR lowers
what is the shunt of TOF? PBF?
R–> L decreased
how does TOF present? xray?
Presents more often with cyanosis
See oligemic lung fields (black –> more blood)
what makes TOF worse?
PDA closure
what are the 4 things of TOF
Ventricular septal defect
Pulmonic valve stenosis
Right ventricular hypertrophy
Overriding aortic valve
what are the typical features of TOF?
Cyanosis after the neonatal period
Hypoxemic spells during infancy
Right-sided aortic arch in 25% of all patients
Systlic ejection murmur at the upper LSB
what is the murmor of TOF
Systlic ejection murmur at the upper LSB
what is a hallmark of TOF
tet spells
what is a tet spell? 4 things
Sudden onset or deepening of cyanosis
Sudden onset of dyspnea
Alterations of consciousness
Decrease in intensity of systolic murmur
what happens to blood in TOF?
Limitation of pulmonary blood flow.. Right to left shunting
how does a child present with TOF? color, murmur, symptoms, other
Cyanosis Loud murmur (LUSB) Irritability, poor feeding, poor growth Hypercyanotic ‘spells’ Squatting
how do you treat TOF?
Treatment is dependent upon age, anatomy and degree of cyanosis:
PGE1 (prostaglandin )
(Emergency) systemic to pulmonary shunt
Complete repair
what is Transposition of the Great Arteries
2 trunks but they are on the wrong sides…
how does TGA present? color, murmur, labs?
Varying degrees of cyanosis
Typically no murmur
Tachypnea
Normal ECG for age
how do you treat TGA?
Balloon septostomy Create ASD Prostaglandin infusion Ductal dependent Surgical Correction
Infants WITH TGA whose ____ has closed and who have a small ___ will be intensely cyanotic
PDA, ASD
what causes obstruction to blood flowing out to lungs?
pulmonary stenosis
what causes obstruction to blood flowing out to body?
Aortic stenosis
what is a ductal dependent obstructive lesion?
requires open PDA to get blood beyond the obstruction
what are 3 ductal dependent obstructive lesions?
Critical PS/AS
Critical CoA/IAA
HLHS
how do you ductal dependent obstructive lesions present? and what is the treatment? at what age?
in CV shock at 2-3 days of age when PDA closes
+/- cyanosis
Needs PGE1
what are 3 non-ductal dependent obstructive lesions?
Mild-moderate AS
Mild-moderate CoA
Mild-moderate PS
how does non-ductal dependent obstructive lesions present? in what age?
Presents in older child w/ murmur, exercise intolerance, or HTN (in CoA)
Not cyanotic
what is hypoplastic left heart? what if you dont treat? how do you treat?
mitral atresia Aortic atresia Both. Death at 5-7 days untreated PGE
how does hypoplastic l heart present?
Shock and acidosis
hw does nonductal dependent present?
Presents in older child w/ murmur, exercise intolerance, or HTN (in CoA)
Not cyanotic
in infants with HF how do they present?
dyspnea, fatigue, poor feeding, FTT, tachycardia, gallop rhythm, hepatomegaly
heart sound associated with HF is
S4
in older children with HF how do you present?
exercise intolerance, somnolence, anorexia, (cough, wheeze, crackles in late failure)
what is cough wheeze and rales?
long standing HF with fluid in lungs
what is the best study for HF?
ECHO
ECHO measures?
heart size, function, structure
an infant with hepatomegaly and murmur what do you think?
long standing HF
what is the most common cardiomyopathy in kids?
dilated
what is dilated cardimyopathy?
Increased ventricle size with decreased contractility
(no evidence of coronary,valvular or pericardial disease
what other heart things are associated with dilated cardiomyopathy
Mitral insufficiency, ventricular ectopy, tachyarrhythmias
how do ppl present with dilated cardiomyopathy?
SOB, exercise intolerance, Fatigue
how do we treat dilated cardiomyopathy?
ACEI, B-blockers, Digoxin
dilated cardiomyopathy s/s?
inadequate CO and HF
Tachycard and pnea
Narrow pulse pressure
Rales may be audible
what is dilated cardiomyopathy caused by?
Often idiopathic
infection - echovirus and coxsackie B
Familial or 2ndary to systemic disease (lupus) or drugs
Cardiomyopathy on xrays show…
cardiomegaly
EKG of cardiomyopathies show
always abn but nonspecific:
Abd St-T wave seg, LV hypertrophy
Treatment for cardiomyopathies
diuretics, inotropic meds, afterload meds
what are 4 acquired heart diseases?
Myocarditis – Viral
Endocarditis , Pericarditis
Rheumatic Heart Disease
Kawasaki Disease
what is pericarditis caused by?
Most often viral
If bacterial: Staph A, Strep Pneumo
what are symptoms of pericarditis?
related to pericardial effusion
what is the best test for pericarditis?
ECHO best test
what does pericarditis show on CXR
cardiomegaly
how do you treat pericarditis
anti-inflammatories
how is at high risk for infective endocarditis?
with CHD not with simple ASD
what is infective endocarditis?
Vegetations on valves
Create clots
how does endocarditis present?
Fever , Anemia, Pallor, Splinter hemorrhages in nailbeds, clubbing, retinal infarcts
what is the number one cause of infective endocarditis? 2nd?
Strep Viridans (30-40%), Staph Aureus (25-30%) Need GOOD dental hygiene for prevention
how do you treat infective endocard?
high dose PCN and aminoglyc
what are tests for infective endocarditis?
: blood cluture ESR and CRP
CBC – leukocytosis, anemia
what are complications of infective endocarditis?
heart damage and clots
what is the most common cause of acquired HD?
kawasaki
what organs does RF affect?
heart, jts, brain, skin, subq nodules
how does RF affect heart?
Heart muscle & valves – myocarditis & endocarditis (pericarditis rare w/o the others)
how does RF affect joints
polyarth
how does RF affect brain?
Sydenham’s Chorea (“milkmaid’s grip” or better yet, “motor impersistance”)
how does RF affect skin?
erythema marginatum (serpiginous border) due to vasculitis
how does RF affect nodules?
non-tender, mobile and on extensor surfaces
what are pk ages of RF?
5-15
what is onset of RF
1 – 3 weeks following group A beta-hemolytic strep throat / pharynx infection
what is the patho of RF?
Abnormal immune response of B lymphocytes leading to antibodies/ complexes that cross-react with antigens on cardiac muscle -> inflammation of myocardium and valves, and other tissue
Also affects connective tissue and perivascular tissue
Arthritis , skin (subcutaneous nodules or erythema marginatum), CNS (chorea)
what question should you ask for RF
recent strep infection?
what are PE findings with RF?
Symptoms such as rashes, arthritis,
Heart rhythms or murmurs (pericardial rub)
what are labs to run for RF?
ESR and CRP (non specific) often elevated
Antistreptococcal antibody titer –difficult to obtain and interpret
Throat culture
ECG if signs of heart failure (call cardiology)
kid has gangrene on 3rd toe… what might it be?
Lesions from emboli
From endocarditis.. RF
what are 5 major jones criteria?
Migratory polyarthrits and carditis
chorea, erythma marginatum and subq nodules
what is the most common finding of RF?
migratory polyarthritis
what is Pink, slightly raised, non-pruritic rings on trunk and inner surfaces of extremities
erythema marginatum
what are minor findings for RF 4
Arthralgia (Cannot consider if patient also has arthritis)
Fever
Elevated acute phase reactants (ESR, CRP)
Prolonged P-R interval
how do you treat RF - 6
Benzathine penicillin G 0.6-1.2 million units IM x 1
Continuous antistreptococcal prophylaxis
Bacterial endocarditis prophylaxis
Aspirin for symptoms of pain and fever (2-4wks)
Corticosteroids for severe carditis and cardiac Rx for congestive heart failure
Prophylaxis- Pen V BID PO or Pen G IM q 4weeks until low risk.
what is a systemic vasculitis?
kawasaki disease
how do you tx kawasaki disease?
CBC, CMP, CRP, ESR, EKG, ECHO
how do you treat kawasaki disease?
IVIG - decreases coronary art dilation
what is mucocutaneous lymphnode syndrome?
kawasaki disease
what are the 3 phases of kawasaki disease? symptoms of all
Acute – Fever, mucocutaneous symptoms (up to 2 wks)
Subacute – Thrombocytosis, coronary artery changes (wk 2-4)
Chronic – Slow resolution (2 months)
how do you treat kawasaki?
IVIG and high dose aspirin
what is the criteria of dx KD?
Must have fever PLUS 4 of the 5 other symptoms OR coronary aneurysms
what are the 6 symptoms of KD? describe them..
Fever – minimum 5 days
Conjunctivitis – injection without exudate, painless
Rash – polymorphous, usually urticarial, may be scarlatiniform
Changes in hands and feet – erythema and swelling, followed by desquamation
Mucous membrane involvement – swollen lips, pharyngitis, “strawberry tongue”
Cervical adenopathy – Often unilateral
what heart defect is associated with down syndrome
AVSD
what heart defect is associated with Turner syndrome?
CoA, bicuspid aortic valve
what heart defect is associated with Marfan syndrome
MVP, dilated aortic root, MR
what heart defect is associated with FAS?
VSD, PPS
what heart defect is associated with maternal rubella?
PDA, PPS
what heart defect is associated with T18?
VSD, AVSD, AS
what heart defect is associated with T13?
TOF ASD VSD
what heart defect is associated with VACTERL
VSD, TOF
what cyanotic HD have increased PBF? 4
Truncus arteriosus
Total anomalous pulm. venous return (TAPVR)
Transposition of the great arteries (TGA)
Tricuspid Atresia with large VSD
what cyanotic HD have decreased PBF? 4
Pulmonary Stenosis / Atresia
Tetralogy of Fallot
Tricuspid atresia
HLHS
what is heard in first days of life at the LLSB 1-2/6 and gone by the first 2-3 wks of life?
newborn murmur - common functional murmur
what is often in newborn period from a branching pulmonary artery. Heard in the axillae and back, short high pitched 1-2/6
peripheral pulmonary artery stenosis
what is the most common murmur of early childhood?
still murmur
what is heard in ages 2-7, described as musical vibratory mid-lower LSB 1-3/6 and loudest when the pt is supine?
still murmur
what are 4 signs of concerning murmurs as far as hx?
easy fatiguability, claudication, worse on exertion, FTT
what are the 6 most common fxnl murmurs
newborn murmur, peripheral pulmonary artery stenosis, still murmur, pulmonary ejection murmur, venous hum, innominate or carotid bruit.
what is most common innocent murmur in older children ages 3 and up?
pulmonary ejection murmur
what is heard at the ULSB soft ejection murumr 1-2/6?
pulm ejection murmur
what is heard after age 2, infraclavicular R>L, Continuous musical hum. Best heard sitting. Comes from turbulence at confluence of subclavian and jugular vein.
venous hum
what is heard in older child and adolescent. Rt supraclavicular area, harsh, 2-3/6.
innomate or carotid bruit
what are signs of concerning murmur on PE?
-Unequal pulses/pressures
-Hyperactive precordium, displaced Point of Maximum Impulse (PMI)
-Murmur itself
Holosystolic or continuous
Grade IV or higher
Other
what has s&s of inadequate output and HF, tachycardia and tachypnea, a narrow pulse pressure, and may have audible rales?
dilated cardiomyopathy
what are causes of dilated cardiomyopathy?
idiopathic or infection (echovirus or coxackie B) or could be familial or secondary to systemic disease (lupus) or meds
what is the most common cardiomyopathy?
dilated
what has increase in ventricle size with decreased contractility?
dilated cardiomyopathy
what cardiomyopathy has an assoc prolonged QT interval
hypertrophic
what does the xray show on cardiomyopathies
cardiomegaly
what may be the initial presentation of cardiomyopathy in older children
sudden death
what cardiomyopathy has LV hypertrophy?
hypertrophic
what is the treatmenf of all cardiomyopathies?
Diuretics, inotropic medications, afterload reducers
