Cardiology Flashcards
What are the 2 main (general) causes of congenital heart disease? (2)
Genetics (mono/poly)
External teratogens
How may congenital heart disease initially present? (5)
Antenatal Dx
Detection of heart murmur (NB innocents)
Heart failure
Shock
Cyanosis
What are the symptoms of a L-R shunt?
Give some egs (3)
Breathless
ASD
VSD
PDA
What are the symptoms of a R-L shunt
Give some egs (2)
Blue
ToF
TGA
What are some symptoms of common mixing
Give an eg
Breathless + blue
AVSD
Give egs (2) of heart conditions seen in well children with obstrn
Aortic stenosis
Pulm stenosis
In sick neonates with obstrn heart disease
How would they present?
Give some egs (2)
Collapsed with shock
Coarc of Ao
HLHS
List the causes of heart failure in:
Neonates (3)
Infants (3)
Older children / adolescents (3)
Neonates - obstruction / duct dependant lesions:
Hypoplastic LH
Critical Aortic Stenosis
Severe coarctation of Ao
Infants - high plum flow:
VSD
AVSD
Large PDA
Older - L/R heart failure:
Eisenmengers (R HF only)
Rheumatic heart disease
Cardiomyopathy
List some symptoms (4) of heart failure in children
List some signs (6)
SOB
Poor feeding
Sweating
Recurrent chest infections
Tachypnoea/tachycardia Poor wt gain Heart murmur / gallop Enlarged heart Hepatomegaly Cool peripheries
What types of drugs may be used in heart failure for infants (L-R shunt / high plum flow) (3)
Diuretics
ACEi (captopril)
+ poss B-blocker/digoxin
What are the features of an innoSent murmur (4S’s +3)
Soft
Systolic
aSymp
left Sternal edge
+ no parasternal thrill
+ no added sounds
+ no radiation
What ages are innocent murmurs often heard?
What other scenarios / conditions may one be heard in? (2)
30% of 3-4y/o
Febrile illness / Anaemia (due to increased CO)
When / where may a venous hum be heard
Common + harmless
May disappear on supine/ jugular occlusion/ head sideways
Heard over R clavicle
List the diff types of acyanotic heart disease (7)
ASD VSD AVSD PDA AS PS Coarc of Ao
List the diff types of cyanotic heart disease (5)
Hypoplastic LH ToF Transposition of Great Vessels Pulm atresia Tricuspid atresia
What are the 2 diff types of ASD
How do they present? (6)
Secundum (80%) - involves foramen ovale
or Partial AVSD (pAVSD)
→ Both sim presentation:
Usually asymp
Recurrent chest infections/wheeze
Ejection systolic (L sternal edge - pulm valve flow)
Split 2nd heart sound
pAVSD - apex pansystolic (AV valve regurg)
Arrhythmias when middle aged
What 3 Ix can be done into ASD?
+ what would be seen in each?
CXR: enlarged heart / enlarged pulm aa’s / increased pulm vasc markings
ECG:
Secundum; RBBB / R axis deviation
pAVSD; -ve deflection in aVF (displaced AV node)
ECHO - confirms anatomy (Dx)
How is a secundum ASD managed?
How is a pAVSD managed?
Secundum → catheter device closure/occlusion at 3-5yrs
pAVSD → surgical correction at 3yrs
What is the proportion of small VSDs to large?
How small is considered a small VSD?
VSDs are 30% all congenital heart disease
Small VSDs - 80-90% VSDs
Large VSDs - 10-20%
Small VSDs are <3mm (smaller than aortic valve)
What will be seen O/E + CXR/ECG/ECHO in a small VSD
O/E: loud pansystolic (L lower sternal edge)
CXR: normal
ECG: normal
ECHO: shows anatomy w. no pulm HT (+doppler echo assess haemodynamic effects)
How are small VSDs managed?
Will close spontaneously
Ensure good dental hygiene to prevent endocarditis
What are the features of a large VSD?
Heart failure symptoms: SOB Poor feeding / failure to thrive after 1wk old Tachypnoea/cardia Recurrent chest infections Hepatomegaly
Heave
Soft (large) pan systolic at LLSE
Apical pan-diastolic (mitral flow)
Loud pulm 2nd sound (pulm aa BP)
What will be seen on CXR/ECG/ECHO in large VSD?
CXR - Similar to ASD: Enlarged heart Enlarged pulm aa's Increased pulm vascular markings \+ Pulm oedema (not in ASD)
ECG: bilateral hypertrophy (upright T wave) (pulm HT)
ECHO: shows defect
What is the risk of not surgically treating large VSDs early enough?
Must be done by 3-6m otherwise → chronic pulm HT → Eisenmengers
What signs may be elicited O/E in pulmonary stenosis? (3)
What may be seen on CXR/ECG?
Ejection systolic murmur (+click) at ULSE
Poss thrill
Poss heave (in severe)
CXR: Normal OR Pulm aa dilation
ECG: RV hypertrophy (upright T in V1)
How is pulmonary stenosis surgically managed?
Balloon valvotomy (trans-catheter balloon dilation)
What other cardiac structural defects can be assoc w. aortic stenosis in children?
AS can be individual
or assoc w. mitral stenosis + Ao Coarc
How does Aortic Stenosis present?
Most are asymp Severe: Reduced exercise tolerance Chest pain on exertion Syncope
What signs can be elicited O/E in Aortic Stenosis (5)
Carotid thrill (always) Slow-rising pulse Ejection-systolic at URSE 2nd Ao sound Apex ejection click
What may be seen on CXR / ECG in Aortic Stenosis
CXR:
Normal
OR Enlarged LV ± Dilated ascending aorta
ECG: LV hypertrophy (Deep S in V2 + Tall R in V6) LV strain (downwards T) (severe AS)
What % of Down’s syndrome kids have AVSD?
15-20%
What other cardiac structural defect is seen in AVSD?
Also obliteration of pulm/aortic valves
+ only AV valves left (but often v leaky)
What are some possible murmur characteristics that may be seen in AVSD? (3)
Systolic ejection (pulm valve flow + S2 splitting) Mid-diastolic (LLSE - mitral flow) Apical holosystolic (radiating to L axilla - mitral insuff)
What will be seen on CXR in AVSD? (2)
+ on ECG? (5)
Cardiomegaly + Increased pulm vasculature
L axis deviation RA enlarged Bi-ventricular hypertrophy Incomplete RBBB Prolonged PR interval (1st degree block - abnorm AVN)
How is AVSD managed?
Medically treat heart failure
Surgically repair defect at 3-6m
What lesions may cause outflow obstruction in a well child? (3)
Pulm stenosis
Aortic stenosis
Coarctation
What signs seen in Aortic Stenosis? (2)
+ in Pulm Stenosis? (1)
+ in Coarctation? (2)
Murmur URSE + carotid thrill
Murmur ULSE (+ no carotid thrill)
Systemic hypertension + Radio-femoral delay
How does Coarctation of Aorta occur (pathophysiology)?
What other conditions is is assoc w.? (3)
Arterial duct tissue encircling aorta at ductus arteriosus → aorta constriction when duct closes
→ severe LV outflow obstrn
Assoc w. VSD, Turners, Bicuspid aortic valve
How does coarctation of aorta present?
Normal Ex on 1st day 2nd day (duct closing) → acute circulatory collapse: Severe heart failure Absent femoral pulse Severe metab acidosis Poss ULSE murmur
What will be seen on CXR + ECG in Coarctation?
CXR - cardiomegaly from HF/shock
ECG - normal
How is Coarctation of Aorta managed?
Prostaglandins
HF drugs
Surgical repair: angioplasty ± stenting
What is tricuspid atresia?
Valve absent/abnormal → blood flow from RA-RV blocked
Must have ASD+VSD to survive (+ usually has PDA)
What is pulmonary atresia?
How will it present?
Valve absent/abnormal → blood flow heart-lungs blocked
No prob in utero but after birth quickly cyanosed (only thing providing O2 to lungs is PDA)
List some duct-dependant lesions (7)
Coarctation TGA HLHS PA TA AS PS
What is the immediate management for duct-dependant lesions? (2)
IV prostaglandins short term
Formaldehyde infiltration longer-term
What time frame is classed as persistent patent ductus arteriosus?
Why does it occur?
Persistent = not closed within 1m of EDD (common in pre terms)
Due to failed mechanism constricting duct
What are the features seen in PDA? (4)
Breathlessness (L-R shunt)
Continuous murmur behind L clavicle
Raised pulse pressure (collapsing/bounding pulse)
Pulm HT ± HF (if duct v large)
What is seen in PDA on CXR / ECG / ECHO?
CXR: normal
ECG: normal (if v big - sim features to large VSD)
ECHO: duct easily seen
What are the risks if PDA is not closed up? (2)
How is it closed?
Bacterial endocarditis
Pulmonary vascular disease
Closure done trans-catheter - coil/occlusion device at 1y/o
Occasionally surgical ligation req
List some causes for cyanosis in newborn/infants
Cyanotic congenital heart disease Resp: Surfactant defc Meconium asp Pulm hypoplasia
Persistent pulm HT of newborn (pulm resisx failed to fall)
Infection / septicaemia (GrpB Strep etc)
Metab acidosis + shock
What are the 4 features in Tetralogy of Fallot?
Large VSD
Overriding of Aorta (w. respect to vent septum)
Subpulmonary Stenosis (RV outflow obstrn)
RV hypertrophy (as result)
How may ToF present?
Antenatal Dx OR Dx after murmur in 1st 2m life OR Hypercyanotic spells in 1st few days (irritability/SOB/pallor)
What clinical signs may be seen in ToF?
Clubbing (fingers + toes)
Loud harsh ejection systolic murmur (L sternal edge)
Cyanosis + shortening murmur (as RB outflow obstrn worsens)
What is seen on CXR in ToF? (5)
EGG ON SIDE
Relatively small heart
Uptilted apex (RB hypertrophy)
Pulmonary aa ‘bay’ - concavity on L heart border
R sided aortic arch (poss)
Reduced pulm vasc markings (reduced flow)
What is seen on ECG in ToF?
Normal at birth
RV hypertrophy when older (upright T wave in V1)
How is ToF managed initially/medically? (5)
Hypercyanotic spells usually self-limiting
Any hyper cyanotic spells >15mins req prompt Tx:
Sedation
IV propanolol
IV fluids
HCO3- (for acidosis)
Paralysis + ventilation
How may ToF be surgically managed?
VSD/Pulm valve repair (using patch)
V cyanosed infants → BT shunt (subclav aa → pulm aa)
What are the main features of TGA?
Cyanosis***: profound + presents 2nd day (ductal closure)
Less severe if more mixing/other abns
Usually no murmur (poss from LV/pulmonary high flow)
What would be seen on CXR in TGA? (3)
+ on ECG
Narrow upper mediastinum (pedicle)
Egg on side contour (RV hypertrophy)
Increased pulm vasc markings
ECG usually normal
How is TGA managed? (3)
IV prostaglandins
Balloon atrial septostomy (reverses foramen ovale valve)
Later arterial switch (+ coronary aa transfer)
What congenital heart lesion is commonly seen in Turners?
Coarctation of Ao
What congenital heart lesions may be seen in Noonan’s syndrome?
Pulmonary stenosis* (usually asymp)
Hypertrophic cardiomyopathy (infancy HF)
ASD/VSD
What are the 4 features of a hypoplastic L heart?
Mitral valve small/atretic
LV v small
Aortic atresia
Coarctation of Aorta
What would be the presentation of a neonate after birth, with hypoplastic L heart? (3)
V SICK
Ductal constriction → profound acidosis / rapid CV collapse
Weak/absence of all peripheral pulses
What are the cardiac effects in Marfans? (2)
Weakened walls of aorta (→ aneurysm/dissection)
Mitral/tricuspid prolapse → regurg
What are the ECG features of supra ventricular tachycardia (SVT)? (3)
Narrow complex tachycardia at 250-300bpm
T wave inversion (occurs w. HF)
Short PR if in sinus rhythm
What are the possible effects of SVT in utero?
How does SVT present in a neonate?
Can → hydrous fetalis / intrauterine death
Neonate: poor CO + pulm oedema → HF
How is immediate management of SVT managed? (4)
Circulatory (correct acidosis) + Resp support (vent if req)
Vagal stimulation manouvres (carotid sinus massage)
IV adenosine - 1st line (induces AV block)
Electrical cardioverion w. synchronised DC shock - if adenosine fails
How is SVT managed once sinus rhythm is restored?
+ how managed if WPW syndrome?
Maintenance therapy e.g. flecainide / sotalol
WPW - atrial pacing / ablation of accessory pathway
List some causes of myocarditis
Viruses: influenza / coxsackie / adenovirus
Rubella / polio / Lyme
Medication allergies
Exposure to certain chems/fungi/parasites/radiation/drugs
What is myocarditis?
Which age group is it more severe in?
Immune chemical + disease/infection damage → swollen/thick myocardium → HF
Affects infants more severe > children
List some symptoms of myocarditis in infants (7)
Failure to thrive
Feeding probs
HF
Fever
Low urine output
Pale peripheries
Anxiousness
List some symptoms of myocarditis in children > 2yrs (6)
Nausea Fatigue Cough Chest pain Belly ache Swelling (legs, feet, face)
What Ix can be done into myocarditis? (8 (5 bloods))
CXR (enlarged borders)
ECHO (Dx)
Blood cultures LFTs U&Es FBC Ab screen Heart biopsy
How is myocarditis managed (4)
NO CURE - treat symps/minimise damage until resolves Diuretics ACEis B-Blocker (carvedilol) Abx/Steroids/NSAIDs/IVIGs
What are the main cardiac-related RFs for subacute bacterial endocarditis (SBE)? (4)
Turbulent flow: VSD Coarctation PDA Prosthetics
What are the classical signs of SBE? (5)
+ any peripheral signs that may be present? (7)
Fever Malaise Raised ESR Anaemia Haematuria Always consider SBE with these features + excluded other DDx
Clubbing (late sign) Splinter haemorrhages Necrotic skin lesions Signs of neuro infarcts Retinal infarcts Arthritis/arthralgia Splenomegaly
What is the commonest cause of SBE?
Streptococcus viridians (a-haemolytic)
How is SBE managed?
High-dose IV penicillin/aminoglycoside (genta) 6wks
