Cardiology Flashcards
Congenital vs acquired heart disease
Congenital-cardiac abnormalities due to abnormal fetal heart development
Acquired-cardiac abnormalities due to disease processes
How do you diagnose all cardiac diseases?
Echocardiography
Causes of acquired heart disease
Sequelae from infection (rheumatic disease or kawasaki)
Genetic predisposition (hypertrophic cardiomyopathy)
Idiopathic
Like in adults
Signs/sxs of heart disease in infants vs older children
Infants: poor weight gain/FTT, tachypnea with feeding/activity
Older children: palpitations/chest pain, dizziness/syncope, exercise intolerance/dyspnea on exertion, unexplained HTN
What can cause a wide vs narrow split of S2?
Can be a normal split
Wide: atrial septal defect, pulmonary stenosis
Narrow: pulmonary HTN
When is a murmur usually innocent?
Short systolic Soft, grade <2/6 and softer upright Musical or vibratory quality Remainder of PE normal No family hx or syndromic hx
When is a murmur pathologic?
Holosystolic or diastolic Loud, grade >3/60 which means a thrill Harsh or blowing quality Abnormal pulses/vitals, hepatomegaly, MSK abnormalities Possible family hx or syndromic hx Increased intensity upright
What do you think of with bounding pulses?
Patent ductus arteriosus
What do you think of with delayed/weak/absent femoral pulses?
Coarctation of aorta (COA)
What is a cardinal sign of right heart failure?
Hepatomegaly
What do you see in chronic right heart failure?
Ascites
What is clubbing of the fingers/toes associated with?
Cyanotic congenital heart disease (after age 1)
Most common Echo
Transthoracic
What does an echo evaluate?
Cardiac anatomy, direction of BF, intracardiac pressures, ventricular function
Examples of innocent murmurs
Stills murmur, pulmonary flow murmur, venous hum
What is the most common innocent murmur of early childhood?
Still’s murmur (2-7)
Characteristics of Still’s murmur
Musical or vibratory quality, short, high-pitched grades I-III
Heard loudest supine and at LLSB!
Louder when pt is under stress (fever, anemia etc)
What is the most common innocent murmur in older children and adults?
Pulmonary flow murmur (3 and up)
Characteristics of pulmonary flow murmur
Soft and usually grade 2
Louder supine at ULSB
Characteristics of venous hum
2 and up
Continuous musical hum, grades 1-3
R/LUSB
Louder in diastole and in sitting position with head extended
How do you differentiate venous hum from PDA?
Alterations of intensity with position changes
What are the acyanotic congenital heart diseases?
VSD, ASD, patent ductus arteriosus and COA
What are the cyanotic congenital heart diseases?
5 Ts: Tetralogy of Fallot Transposition of great arteries Tricuspid atresia Truncus arteriosus Total anomolous pulmonary venous return (TAPVR) and Hypoplastic left heart syndrome
5 adaptations in fetal circulation
Umbilical vein Ductus venosus Foramen ovale Ductus arteriosus Umbilical arteries
When does the ductus arteriosus close?
7-14 days
What is the most common of all congenital heart defects?
Ventricular septal defect
What is VSD associated with?
Trisomy 21 and Tetralogy of Fallot
Presentation of VSD
If small, may be asymptomatic
Large: FTT, poor growth, dyspnea, frequent respiratory infections
Tachycardia, tachypnea, hepatomegaly
Blowing harsh holosystolic murmur at LLSB
What innocent murmur can VSD sound like?
Stills
Management of VSD
If asymptomatic it might just close on own
Treat CHF (diuretics, ACE inhibitor)
If failing med management then septal occlusion wtih cardiac catheterization or surgical closure via median sternotomy (preferred)
How do you classify atrial septal defects?
By anatomic location:
Ostium secundum (most common)
Ostium primum (associated with other anomalies)
Sinus venosus
Presentation of ASD
If large, CHF, recurrent respiratory infections, FTT (worse with age if don’t correct)
Tachypnea, hepatomegaly, rales, respiratory retractions
Midsystolic pulmonary flow/ejection murmur at ULSB
What can you see on a CXR for ASD?
Enlarged heart due to right side dilation, increased pulmonary vascularity
Management of ASD
None because spontaneous closure in kids when less than 6 mm
Can do surgery (percutaneous transcatheter closure, surgical patch closure)
When is patent ductus arterious more common?
Premature, in females and in maternal rubella
What happens when the L to R shunt is reversed in PDA?
Due to high pulmonary pressures so causes cyanosis (Eisenmenger syndrome)- medical emergency
What kind of murmur is seen in PDA?
Continuous machinery murmur
Also see wide pulse pressure and bounding pulses
Management for PDA
Keep it open with IV prostaglandin E1
Close it with IV indomethacin (prostaglandin inhibitor)
What is coarctation of the aorta?
Narrowing in the aortic arch, usually in the proximal descending aorta near the takeoff of the left subclavian artery and ductus arteriosus
What can increase the incidence of COA?
Males over females
Seen with Turner syndrome (45 X-female)
Seen in kids with unexplained UE HTN
What is seen on the PE in COA?
Absent or decreased femoral pulses
UE SBP >20 mmh higher than LE
Blowing systolic murmur in back or left axilla
What do you see on a CXR for COA?
Figure 3 sign or rib notching
Tx of COA
Surgical repair or balloon angioplasty
What makes up tetralogy of fallot?
Right ventricular hypertrophy
VSD
Overriding aortia
RV outflow obstruction (pulm stenosis)
What is the most common cyanotic cardiac lesion?
Tetralogy of fallot
What are Tet spells?
Hypercyanotic episodes with sudden onset or worsening of cyanosis, dyspnea, alterations in consciousness and decrease/disappearance of systolic murmur (as RV becomes totally obstructed)
Start at 4-6 mos
What do kids do to relieve dyspnea?
Squat
What kind of murmur is associated with TOF?
Harsh systolic ejection crescendo-decrescendo at ULSB
What do you see on CXR for TOF?
Boot-shaped heart with upturned apex (might be pathognomic)
Tx of TOF
Need endocarditis abx prophylaxis until after repair
Meds: acutely for a spell need o2, fetal position, morphine and IVF bolus etc
Surgery: intracardiac repair usually by 1 YO
What is transposition of the great arteries?
Malformation where aorta comes off RV and pulmonary artery off LV
Presentation of TGA
Profoundly cyanotic neonate without respiratory distress or significiant murmur (blue baby)
What is pathognomonic on a CXR for TGA?
Egg on a string: globular heart and narrow superior mediastinum due to degradation and dysplasia of the thymus
Tx for TGA
Cardiac cath
Prostaglandin E1 to keep ductus arteriosus open
Surgery usually donea t 4-7 days (arterial switch operation)
What is tricuspid atresia?
Congenital absence of a tricuspid valve so no communication between RA and RV
Usually associated with other things (like ASD or VSD)
Presentation of tricuspid atresia
Central cyanosis at birth and 1 heart sound (s2)
Holosystolic murmur at LLSB (if have VSD too)
Tx for tricuspid atresia
Initial prostaglandin E1 to maintain PDA
Definitive: surgery (need 3 from birth to age 3)
What is truncus arteriosus?
Aorta and PA fail to separate so only 1 artery and VSD is always present
Presentation of truncus arteriosus
Cyanosis, CHF, pulmonary congestion
Loud single S2, prominent ejection click, systolic ejection murmur at LLSB
Narrow split
What might you see on an xray in truncus arteriosus?
Boot shaped heart (absence of PA and large aorta)
What is total anomalous pulmonary venous return (TAPVR)?
Rare
Abnormal pulmonary venous configuration leading to cyanosis (PVs drain into venous system like SVC)
Right to left shunt must occur
Tx of TAPVR
Surgery
What is hypoplastic left heart syndrome?
Hypoplasic (underdevelopment) of LV and stenosis or atresia of mitral and aortic valves
PDA dependent because sxs develop when it closes
Presentation of HLHS
Stable at birth when ductus is still open and rapid deterioration (shock, acidosis) when ductus closes
Tx of HLHS
Prostaglandin E1 is essential and life saving
Staged surgeries but even so 1 yr survival as low as 70%
What are some acquired heart diseases?
Acute rheumatic fever, kawasaki disease and hypertrophic cardiomyopathy
When does acute rheumatic fever occur?
2-4 wks after group A strep pharyngitis
What are the major jones criteria for rheumatic fever?
Pancarditis (pericarditis, endocarditis, myocarditis)
2 major or 1 major and 2 minor to diagnose
What happens when acute rheumatic fever involves the endocardium?
Presents as valvulitis especially of mitral (more common) and aortic valves
Presentation of Kawasaki Disease
Fever over 5 days and CRASH (conjunctivits, rash, adenopathy cervical, strawberry tongue, hands swollen)
Tx of Kawasaki
High dose aspirin or IVIG
What is the major cardiac complication of kawasaki disease?
Coronary artery aneurysms
What is the leading cause of cardiac death in young persons?
Hypertrophic cardiomyopathy
What is the most common cause of hypertrophic cardiomyopathy?
Familial hypertrophic cardiomyopathy
What may be noted on the PE for hypertrophic cardiomyopathy?
S4 gallop
Tx of hypertrophic cardiomyopathy
Sports restriction, meds (BB or verapamil), reduce septal size, consider defibrillator
When do you refer to cardio?
Weak femoral pulse or 10mmhg change in SBP between UE and LE
Generalized decreased pulses
Pathologic murmur
Abnormal ecg and pulse ox
Abnormal fetal echo
Anything associated with increased likelihood of CHD
What is associated with trisomy 21?
AVSD, TOF, PDA
What is associated with fetal alcohol syndrome?
ASD or VSD
