Cardiology Flashcards
Chest pain is a frequent pediatric complaint & is most often related to what?
musculoskeletal in origin
CP & older children are most likely to have what type of reason for it?
psychogenic
younger CH are more likely to have CP d/t what?
respiratory dz: cough, asthma, pneumonia
etiologies of CP
MS idiopathic psychogenic/psychiatric respiratory d/o's GI cardiac breast pulmonary vascular d/o's toxic exposure
approach to CP
acute vs. chronic pleuritic vs. non-pleuritic co-morbid risk factors herald signs of serious causes r/o severe distress
heral signs of serious causes
CP w/ exertion
acute pain that is acutely worsening
acute onset of fever w/ CP
findings on hx or exam referable to cardiac or respiratory systmes
chest tenderness is very reassuring against what?
cardiac source
initial workup for CP usually starts w/ what?
EKG
chest plain film
MS sources of CP
chest tenderness w/ or w/o mvnt overuse injury/strain of chest wall m. direct trauma slipping rib syndrome precordial catch (Texidor's twinge) costochondritis
direct trauma & CP
rib fracture
contusion of chest wall
slipping rib syndrome
involves 8th, 9th, 10th ribs slipping & impinging on intercostal n.
precordial catch (Texidor’s twinge)
sharp pain at the left sternal border, lasts < 3 mins
costochondritis
pain at sites of costal cartilage reproduced by eliciting tenderness over the costochondral junctions or with AP compression of the chest
pleurisy
involves pleuritic CP
infectious
respiratory source of CP
illnesses w/ persistent/forceful cough pneumonia +/- pleural effusion asthma +/- pneumomediastinum spontaneous pneumothorax pleurisy
some causes of spontaneous pneumothorax
asthma
cystic fibrosis
Marfan’s syndrome
pulmonary vascular d/o’s as sources of CP
pulmonary embolism
pulmonary HTN
acute chest syndrome
pulmonary embolism
rare in CH but can occur in those with risk factors
classic presentation= acute onset of pleuritic CP, dyspnea, hypoxia- presentation not always classic
risk factors for pulmonary embolism in CH
oral contraceptives
termination of pregnancy
trauma, particularly of lower extremities
pulmonary HTN
pain typically related to underlying heart or lung dz
acute chest syndrome
chest source crisis in pts w/ sickle cell dz
psychogenic source of CP
anxiety d/o or conversion d/o
hyperventilation
anxiety d/o or conversion d/o
relative or friend w/ cardiac dz
FH of depression, somatization
triggered by stress
GI source of CP
reflux esophagitis
intrathoracic FB
pill esophagitis
reflux esophagitis sx’s
burning, substernal pain- worse w/ reclining or certain pain
may be assoc. w/ esophageal spasm (mimicks angina)
severe cases complicated by esophageal candidiasis
mammary source of CP
females: mastitis, thelarche, pregnancy, fibrocystic dz
males: gynecomastia
cardiac source of CP
rare cause of CP in CH
co-morbid risk factors raise likelihood of cardiac-source CP
cardiac ischemia
myocardial infarction
mitral valve prolapse
pericarditis & myocarditis
hypertrophic obstructive cardiomyopathy (HOCM)
what are some co-morbid risk factors that raise the likelihood of cardiac-source CP
DM
Kawasaki’s dz
chronic anemia
stimulant use- cocaine, amphetamines
cardiac ischemia may result from
anomalous coronary arteries
left ventricular outflow tract obstruction (LVOTO)- coarctation of the aorta, aortic dissection
cardiac infxn
embolic phenomena- endocarditis, aneurysm d/t Kawasaki dz
medium vessel vasculitis
pulmonary HTN, valvular dz (congenita or acquired), cardiomyopathy, subaortic stenosis, arrhythmia
myocardial infarction
rare in CH
herald sign- pain w/ exertion
what is a herald sign
pain w/ exertion
hypertrophic obstructive cardiomyopathy (HOCM)
autosomal dominant inheritance
systolic murmur worsening w/ change from lying to standing or w/ squat/Valsalva (procedures that reduce blood return to ventricles-reduced preload)
pain w/ exertion
pericarditis
fever respiratory distress sharp, stabbing substernal CP often unable to lie flat (pain improves w/ sitting up or leaning forward) friction rub, distant heart sounds jugular venous distension pulsus paradoxus
what are you looking for in pre-sports physicals?
hypertrophic obstructive cardiomyopathy (HOCM)
if a murmur worsens with reduced preload, most likely d/t what?
hypertrophic obstructive cardiomyopathy (HOCM)
myocarditis
pain develops over a few days fever systemic symptoms (vomiting, lightheadedness, etc.) gallop rhythm (S3, S4 sounds) tachycardia orthostatic HoTN CXR- cardiomegaly abnormal EKG
what is the MC pediatric dysrhythmia?
supraventricular tachycardia
pediatric arrhythmias
sinus arrhythmia can be very pronounced in CH- HR slows w/ expiration
mechanisms of pediatric arrhythmias include
intra-atrial reentry
AV nodal reentrant tachycardia
AV accessory conduction- Wolff-Parkinson-White syndrome, slurred upstroke of the QRS (delta wave)
murmur description
intensity (grade I-VI)
quality
timing- relationship to cardiac cycle, duration
location
variation w/ position- increase in intensity w/ lying to standing or Valsalva in generally concerning for HOCM
intensity
how loud it is I- can barely hear it w/ stethoscope II III IV V VI- can hear w/o stethoscope
quality
harsh & soft
timing
holosystolic- you don’t hear S2
midsystolic/earlysystolic- you hear the heart beat in between
location
will localize to specific valves
all murmurs that come from the heart that are normal are?
systolic murmurs
SEM
systolic ejection murmur
systolic murmurs
SEM
Pansystolic
SEM fall into 2 categories
normal & abnormal
normal SEM
Still’s
Pulm eject
carotid bruit
abnormal SEM
aortic stenosis pulmonic stenosis coarctaion ASD HOCM
pansystolic murmurs
VSD
MR
TR
diastolic murmurs are always
abnormal (except venous hum)
continuous murmurs
abnormal &
PDA, AP window, AVM
innocent is synonymous w/ what terms?
functional
benign
flow
innocent murmurs
newborn murmur peripheral pulmonic stenosis Still's (vibratory) murmur adolescent ejection murmur venous hum carotid bruit
all innocent murmurs are what?
systolic ejection murmurs
all vibratory murmurs are?
innocent
newborn murmur
heard during 1st few days of life (neonate)
grade I-II
soft, short, vibratory (newborn Still’s)
LLSB (lower/upper easy to distinguish in neonates)
w/o radiation
peripheral pulmonic stenosis (PPS)
caused by the change in direction of the branches of the pulmonary aretery grade I-II soft, short, high pitched loudest over LUSB radiates to back & axillae
murmur best heard in LLSB
newborn murmur
which murmur is loudest over LUSB?
peripheral pulmonic stenosis
Still’s (vibratory) murmur
heard from age 2+ grade I-III musical, vibratory, short LLSB to apex loudest when pt is in supine position; diminishes when pt sits or stands
adolescent ejection murmur
heard from age 8+ grade I-II in intensity soft well localized to the LUSB louder when pt is supine
venous hum
heard after age 2
continuous musical hum
located at the upper right & left sternal borders (usually louder on the right)
intensity changes w/ turning of the neck
carotid bruit
any age-more common in older child & adolescent grade II-III long, systolic ejection murmur heard in right supraclavicular area radiates to neck
systemic (left) & pulmonary (right) circuits generally operate in ?
series
a shunt implies…
a connection that allows communication bet. the 2 systems
shunting proceeds down__________in pressure
gradient
how long do newborns have high pulmonary pressure (high pulmonary resistance) for
until 2-8 wks of life
left-to-right shunts commonly become evident in this period
right to left shunts cause?
cyanosis
mixing lesions my have either (or both) directions of______present
shunt
acyanotic congenital heart dz
ASD, VSD (25% of all CHD), PDA
semilunar valvular defects
coarctation of the aorta
ASD or PFO (patent foramen ovale) places pts at risk for what?
systemic embolism & altitude sickness
aortic stenosis & pulmonic stenosis are
uncommon
AS 5% of all CHD, PS 10% of all CHD
AS & PS at risk for
endocarditis
small VSD
80-85% of VSDs
asymptomatic
generally close on own w/o surgery
moderate VSD
may shunt left-to-right
or pressures equal on right & left creates situation of no flow across VSD (no pulmonary HTN, no CHF)
serially monitored by cardiologist
large VSD w/ nml pulmonary vascular resistance
left-to-right shunting as pulmonary vascular resistance naturally decreases (2-8 wks of life)
infant develops CHF- FTT, difficulty feeding, labored breathing/pulmonary edema
Eisenmenger’s Syndrome
an untreated large VSD which causes pulmonary overcirculation–>pulmonary HTN
nml left2right shunt reverse to right2left shunt as pulmonary system pressures surpass systemic pressures
prolonged cyanosis
prolonged cyanosis can lead to
organ & vascular damage
platelet dysfunction
treatable only w/ heart transplant
coarctation of the aorta is d/t
main artery to body is stenotic or interrupted
coarctation of the aorta causes what
upper extremity HTN & reduced flow to abdominal organs & lower extremities
newborns screened for femoral pulses to check for
coarctation of the aorta
suspicion prompts 4 extremity BP & O2 saturation measurements
mild cases of coarctation of the aorta may have long term growth problems such as
aortic valve abnormalities audible on exam
may have chronic leg discomfort or lower extremity wasting
in non-mild cases_________needs to be kept open to ensure survival
PDA
if PDA closes, shock & acidosis ensue rapidly
cyanotic congenital heart dz
tetralogy of Fallot
not presented: tricuspid atresia, truncus arteriosus, TGA, TAPVR, hypoplastic left heart
cyanotic CHD is separated into
lesions w/ obstructive lesions leading to nml pulmonary blood flow
lesions w/ increased pulmonary blood flow
prolonged cyanosis leads to polycythemia assoc. w/ cyanotic CHD
enables easier visual recognition of cyanosis
five MC cyanotic CHD
tetralogy of Fallot tricuspid atresia transposition of the great arteries truncus arteriosus total anomalous pulmonary venous return
tetralogy of Fallot caused by what?
misplaced migration of neural crest to form the supracristal septum
rheumatic fever follows a previous infection w/
S. pyogenes (GAbetaHS)
rate in untreated is approx. 3%
rheumatic fever typically occurs between ages?
5-15yo
pathophys of rheumatic fever
sensitization of B lymphocytes
formation of anti-streptococcal Ab’s
formation of immune complexes
myocardial & valvular inflammatory response
four components to defect of tetralogy of Fallot
ventricular septal defect
pulmonary stenosis
right ventricular hypertrophy
overriding aorta- sometimes w/ dextroposition of aorta
child may be pink with tetralogy of Fallot if?
pulmonic stenoisis mild & VSD shunts left to right
what is a “tet spell”
pt grows cyanotic, progressively worse w/ age- infants become agitated, tachypneic & have difficulty feeding, toddlers may squat to resolve Tet spell
what type of murmur will you hear in tetralogy of Fallot
long systolic ejection murmur (from PS)
classic CXR appearance of tetralogy of Fallot
boot shaped heart
when is tetralogy of Fallot repaired?
surgically repaired in infancy- often allowed to grow for a few months before repair
major criteria for rheumatic fever
JCNES criteria
2 signify dz
JOINTS- CARDITIS NODULES ERYTHEMA marginatum SYDENHAM'S chorea
Joints
migratory polyarthritis
typically large joints
carditis
myocarditis
pericarditis
valvular dz
indolent carditis can be a single criterion defining dz
nodules
subcutaneous
extensor surfaces of extremities
erythema marginatum
can be locally exacerbated by heat
pink-red macules grow, then coalesce into serpiginious long patches
Sydenham’s chorea
w/ or w/o psychiatric dz
may define dz as a single criterion
minor criteria for rheumatic fever
1 major + 2 minor---> signifies dz polyarthralgia fever previous rheumatic fever elevated ESR, CRP, WBC prolonged PR interval supportive serology of previous infxn
what is the best test for looking for previous rheumatic fever infxn
anti-streptolysin O is the best test
anti-DNAase B & streptozyme also used
rheumatic fever tx
Abx- short term to tx indolent infxn, long term to prevent recurrence (often every 3-4 wks for life)
aspirin for anti-inflammatory effects (sometimes corticosteroids necessary)
supportive (cardiac meds- digoxin, diuretics; endocarditis prophylaxis for procedures
infective endocarditis
greatest risk is to those w/ preexisting heart dz or cardiac foreign material
may be acute/subacute
causes of infective endocarditis
viridans streptococci
S. aureus
less common- enterococci, HACEK organisms (fastidious gram negative rods)
S&S of infective endocarditis
fever CP heart failure sx's- fatigue, tachypnea, DOE changing murmur petechiae & embolic phenomena splenomegaly +/- hepatomegaly arthritis wt loss ( subacute/ chronic) bacteremia hematuria markedly elevated inflammatory markers
tx for infective endocarditis
long term Abx- directed therapy based on cultures
surgical excision or valve repair sometimes warranted
supportive care for sequelae- CHF
preventing endocarditis
cardiac risk factors that are often indications for prophylaxis- prior hx of infective endocarditis, any valvulopathy, prosthetic heart valves, unrepaired cyanotic CHD, repaired CHD w/ prosthetic material, device or venous pacer wires
endocarditis prevention dependent on type of procedure
dental/oral or upper respiratory tract- amoxicillin
GU/GI procedures- amoxicillin for enterococcal coverage, aminoglycoside for gram neg. coverage
procedures that involved infected tissues- clindamycin or vancomycin to cover MRSA
