Cardiology Flashcards
Causes of CHD
Genetic Susceptibility + Environmental Factors
Name some Environmental Factors of CHD
Drugs - Alcohol, Amphetamines, Cocaine, Ecstasy, Lithium
Infections - TORCHES
Teratogenic Insult - occurs most commonly 18-60 days post conception
Chromosomal Abnormalities -
Trisomy 21 (downs): AVSD
Trisomy 18: VSD and PDA
Trisomy 13 (pataus): AVD or VSD
Other Less Common Chromosomal defects
Turners - Coarctation (particularly Females)
Noonan - Pulmonary Stenosis
Williams - Supravalvular AS
22q11, De George syndrome : Interrupted Aortic Arch
Concepts to look at with Murmur chatacterisation
Timing within cycle - Diastolic Versus Systolic
Duration: Pan/Holo, Ejection, Early/mid/late
Pitch/Quality - Harsh or mixed frequency, Soft, Vibratory etc.
Common Features of Innocent Murmurs
Systolic soft Localised No other cardiac signs Vibratory/Melodic Varies with Position and Respiration
What are the Features of STILL’s murmur (Innocent)
2-7 years
Soft, ‘Twangy’ Systolic Murmur
Heard best a LLSE
increased when Supine
THINK STILL's S - Supine/systolic T - Twangy I - Infant LL - Lower Left
What are the Features of Pulmonary Outflow Murmur (innocent)
Age 8-10 'Vibratory' systolic ULSE with no radiation Increased when supine and with exercise Narrow Chest
What are the Features of Carotid/Brachiocephalic arterial Bruits (Innocent)
Age 2-10 years 1 or 2 out of 6 HARSH Supraclavicular and Neck increased with Exercise Decreased by turning head and extending neck
Characteristics of a Venous Hum (innocent)
Age 3-8 Soft and indistinct Continuous hum, Often with Diastolic accentuation Supraclavicular ONLY HEARD IN UPRIGHT POSITION
What are the 3 main Types of ventricular septal Defect
Perimembranous (most common) -
Muscular
Subaortic
Clinical Presentation of VSD
Pansystolic murmur - LLSE (sometimes with a Thrill)
If very small –> Early Systolic Murmur - Asymptomatic
When large –> mitral stenosis occurs –> diastolic murmur
Exercise intolerance, increased resp effort and tachypnoea, poor feeding, failure to thrive
poor weight gain is a good indication of HF in Paeds
Parasternal Heave (L) - Excessive pulmonary blood flow may lead to increased pulmonary vascular resistance and HTN. –> EISENMENGERS syndrome
Chest Px, Syncope, Dyspnoea and Cyanosis
Biventricular Hypertrophy and Pulmonary HTN
Loud Pansystolic murmur
Clubbing
Ix and treatment of VSD
CXR
ECHO
Patch closure
Amplatzer device Closure
NOTE: VSD may lead to congestive heart failure.
Clinical Signs in Atrial Septal Defects
Very Few in early childhood - may result in spontaneous closure
Detected in Adulthood as AF or pulmonary HTN
Palpatations, dyspnoea, cyanosis
Wide splitting of H2 and a pulmonary flow murmur - this is late stage
Left parasternal Heave due to RVH
Clinical Features of Pulmonary Stenosis
Mild = Asymptomatic
Moderate - Severe = SOB on exertion
Ejection systolic murmur - heard at ULSE
radiation to the Back
Treatment of Pulmonary Stenosis
Balloon Valvostomy
Clinical Features of Aortic Stenosis
mostly Asymptomatic in children
If severe - Reduced exercise tolerance. Chest pain and Syncope
Ejection ‘Click’ systolic murmur
URST radiating to carotids
Treatment of Aortic Stenosis
Balloon Valvostomy
What are the 5 changes of Fetal Circulation at Birht
Pulmonary vascular resistance decreases (and flow increased) systemic Vascular resistance increases DA closure Foramen Ovale Closure Ductous Venosus closure
Patent Ductus Arteriosus
Failure of DA to close after birth –> persistent communication between aorta and pulmonary artery
Allows blood to Shunt from Systemic Circulation into Pulmonary (L to R) –> Excessive pulmonary flow
Aortic Coarctation Treatment
Re-open DA with Prostiglandin E1 or E2
Resection and end to end anastomsis
Subclavian patch Repair
Balloon Aortoplasty
Tetralogy of Fallot
Overriding aorta
Pulmonary Stenosis
RV hypertrophy
VSD
All Leads to Cyanosis (especially when crying or upset) as the O2 poor Blood Mixes with O2 Rich blood and leaves via the aorta.
Assoc. W/ DiGeorge syndrome
Clinical Features of Aortic Coarctation
Weak/Absent Femoral Pulses
HTN in arms but not legs
Severe –> neonatal Shock when Ductus Closes
Less Severe –> HF, Murmur heard on back, HTN
X - Ray Rib Notching
SOB Tachypnoea FTT Poor Apettite Dizzy Chest Px Fatigue intermittent claudication
Treatment of Teralogy of Fallot
Acute Spells - O2, analgesia, Beta blocker.
Sx repair by 6 months
Classifications of ASD
Ostium Primum - AKA endocardial Cushion defect - Less common but most serious
lies adjacent to AV valves
A/W Down’s Syndrome
Ostium Secondum - More Common but less serious
Mid septum around foramen ovale - makes up
around 70% of cases
How Does splitting of Heart Sound 2 occur in ASD
Shunting of blood left to right –> more blood encouraged into right side of the heart –> RVH due to pressure –> pulmonary valve forced to close later that aortic valve –> 2 dubs.
Ix of ASD`
Auscultation
ECG
Ostium Primum - Left axis deviation
Osteum Secondum - Right axis deviation
Right Bundle Branch Block may indicate RV and RA
hypertrophy
CXR
Large Hilar Arteries, enlarged RA and RV, increased
pulmonary vasculature
Echo
Mx of ASD
Can Leave is small
Symptoms in Adults or Teens –> Sx closure
presentation of a PDA
Machinery murmur - May be asymptomatic if small
Murmur heard loudest below left clavicle - radiates to back
Bounding/Collapsing pulse - strong in radial (not normal for paeds)
Wide Pulse Pressure due to collapse
Ix and management of PDA
ECHO
CRX
ECG
Fluid restriction Prostoglandin Antagonist (indomethacin) SX - Ligation of Duct/ Trans catheter occlusion
Clinical Features of ToF
Symptoms Cyanosis SOB tachypnoea Loss of Conscousness Poor Feeding and WEight Gain Crying and irritable
Signs Clubbing Ejection systolic murmur at LLSE Single Heart SOund Child may SQUAT to increase venous pressure
Ix of Tof`
High risk Mothers Get foetal USS (if +ve for trisomy 21)
Normal aortic root makes ToF Dx unlikely
AP CXR will show heart shape - Boot shape due to RVH
EXG - Right axis deviation - RVH + dominant R wave in R precordial chest lead
Transthoracic Echo
Transpostion of the Great Arteries TPGA)
Aorta arises from Right Ventricle and Pulmonary artery arises from left ventricle–> creates 2 parallel circulations
Most common congenital heart lesion presenting in neonates.
Symptoms of TPGA
cyanosis with closed DA
As pulmonary flow increases, HF may occur at 3-6wks
May present similarly to ToF
Signs of TPGA
Tachycardia and Tachypnoea
Ejection systolic murmur if Left ventricular outflow obstruction
Otherwise HS normal - no audible murmus
Ix of TPGA
CXR - Egg on side appearance
Echo
Mx of TPGA`
Prostiglandin analogues to maintain ductus patency (E1 or E2)
Switch operation is definitive Sx.
Levine Scale of Heart Murmurs
- Murmur only audible on careful listening for some time
- Murmur is fain but immediately audible on placing stethoscope on chest
- Loud murmur readily audible WITH NO palpable thrill
- Loud murmur with palpable thrill
- Loud murmur with thrill - so loud it is audible with only the rim of the stethoscope
- A loud murmur with Thrill - So loud you do not require stethoscope to hear.
