Cardiology Flashcards
Essential hypertension stages
- Normal: < 120/80 or < 0th percentile for age/height
- Elevated: 120/80 - 129/80 or between 90-95th percentiles
- Stage 1: 130/80 - 139/89 or > 95th percentile + 12 mm Hg
- Stage 2: > 140/90 or > 95th + 12 mm Hg
Essential hypertension workup/initial management
- Start with lifestyle modifications and recheck in 3 months.
- If still elevated, do ambulatory BP monitoring followed by investigation of cause and then treatment
- Initial workup is often UA, electrolytes, 4 extremity pulse/BP
Infective endocarditis organisms
Staph aureus for native valve, strep viridans for abnormal valves (CHD, rheumatic heart disease, etc).
Others: AACEK (Kingella)
Infective endocarditis symptoms
FROM JANE: Fever Roth spots (retinal hemorrhages) Osler's nodes (painful nodules on toes/fingers) Murmur Janeway lesions (painless hemorrhagic lesions on palms/soles) Anemia Nail hemorrhage Emboli
Duke criteria - need 2 major, 1 major and 3 minor, or 5 minor
Major:
- Positive blood culture with typical organism
- Echo consistent with endocarditis
Minor:
- Predisposing heart condition
- Fever
- Vascular phenomena
- Immunological phenomena
- microbiological evidence (positive culture but not consistent with IE organism)
Causes of hypertension
- Polycystic kidney disease
- 11 hydroxylase deficiency
- Urinary reflux nephropathy
- Renal artery stenosis
- Neurofibromatosis
- 17 hydroxylase deficiency
- Coarctation
- Pheochromocytoma
- Lupus/rheum disorders
- Cushings
- Hyperthyroidism
- Drugs: albuterol, OCPs, steroids, decongestants, illicit drugs
Family history of hypertension cause hint
- Renal or endocrine problems that run in the family
Prematurity cause hint of hypertension
Renal artery stenosis secondary to umbilical catheterization
Joint pain/swelling cause hint of hypertension
Lupus
Flushing, palpitations, fever, weight loss cause hint of hypertension
Pheochromocytoma
Muscle craps, weakness cause hint of hypertension
Hyperaldosternoism
Onset with sexual development cause hint of hypertension
Enzyme deficiencies
Pharmacological management of hypertension
- CCBs: nifedipine or amlodipine
- Vasodilators: hydralazine
- ACEIs: lisinopril or enalapril
- ARBs: losartan
- Beta blockers: propranolol or atenolol
- Alpha 2 agonists: clonidine
- Diuretics: thiazides, furosemide, spironolactone
Rheumatic fever diagnostic criteria
2 major OR 1 major plus 2 minor with evidence of GAS infection
Major: JONES
- Joints (polyarthritis)
- Heart (carditis)
- Nodules (subq)
- Erythema marginatum
- Sydenham chorea (emotional lability with rapid movements of extremities - this is enough to diagnose RF alone)
Minor
- Fever > 38.5
- Arthralgia
- Elevated ESR or CRP
- Prolonged PR interval
Percentage of kids that will have a murmur at some point
90% of kids will have a murmur at some point in their life and only 5% are pathologic
Normal variant of 3rd heart sound
If child is lying down it could be normal, it will go away when they sit up if it’s benign
Fixed split second heart sound, decreased exercise tolerance, murmur at left upper sternal border
ASD
- Murmur is from relative increase in flow through the pulmonary valve (relative pulmonic stenosis)
- If ASD is missed it could lead to Eisenmenger syndrome (right to left flow due to PH and blue kid)
Blowing/harsh holosystolic murmur at left lower sternal border
VSD
- Bigger the VSD = quieter murmur but more symptoms
Systolic (ejection) click that varies with respiration, normal splitting S2 with murmur at LUSB
Pulmonary stenosis
- Often have RVH
- Can also have a thrill and it can radiate to the back
Systolic (ejection) click heard at the apex that does NOT vary with respiration, murmur heard best at RUSB
Aortic stenosis
- Often have LVH
To and fro or continuous machine murmur
PDA
Stills murmur vs venous hum
- Venous hum is vibratory/musical and disappears with pressure on jugular vein
- Stills murmur will be louder supine and softer on standing
Association with right sided aortic arch
22q11 deletion
Left axis deviation without LVH
Tricuspid atresia and AV canal defects (due to effect on conduction system)
LVH without left axis deviation
Hypertrophic cardiomyopathy
CCHD screening guidelines
- Passing is 94-96%
- Repeat screening can limit false positives for PDA
- Most reliable after 24 hours of age
- Greater sensitivity is achieved with pulse ox on right hand (pre-ductal) compared to pulse ox on a foot (post-ductal)
Systolic murmur in left axilla with radiation to back, can have early diastolic component
Coarctation
- Have systolic hypertension and decreased pulses in lower extremities
- Coarc in a neonate presents with RVH because RV is pumping chamber in fetus
HLHS neonatal symptoms
- Trouble when PDA closes
- No murmur because even though there is flow across the ductus the pressures in the aorta and pulmonary arteries are equal
- Can have precordial hyperactivitiy and a loud single S2
Cyanotic heart disease with no murmur
- Transposition
- Tricuspid atresia
- Pulmonary atresia
- TAPVR
3 causes of severe cyanosis in the immediate newborn period (first few hours)
- TGA
- Pulmonary atresia
- Ebstein malformation
–> central cyanosis with no respiratory distress and no significant murmur (will not improve with 100% oxygen)
Associations with Ebstein’s anomaly
- Lithium or benzo use in pregnancy
- Abnormality of the tricuspid valve leaflets
Full term infant with increased RV activity, cyanosis, hypoxia, hypercarbia, and pulmonary edema
TAPVR
- CXR will have pulmonary congestion but normal/small heart
Most common cyanotic heart defect overall
Tetralogy of Fallot (but doesn’t present in the newborn period)
PROV: Pulmonary stenosis, RVH, Overriding aorta, VSD
Most common cyanotic lesion seen in newborn period
TGA
Palpable right ventricular impulse and a single 2nd heart sound
TOF
- EKG will show RVH
- CXR will show boot shaped heart with decreased pulmonary vasculature
- Typically present at 3-5 months of age
Factors that worsen cognitive prognosis with cyanotic heart disease
- Decreased neurological baseline before surgery
- Seizures after surgery
- Coexisting problems (genetic issues)
- Duration or intraoperative circulatory arrest greater than 75 minutes
Infant suddenly turns blue with deep rapid respiratory pattern
Tet spell
- Hypercyanotic hypoxic episodes due to increased R to L shunting during an acute episodes
- Tx: squatting or knee to chest (increase peripheral vascular resistance), morphine, propranolol, and volume expansion
Murmur from ToF
- Systolic murmur from flow across the pulmonary valve (not the VSD)
- The murmur disappears during a tet spell because of decreased flow to the lungs
Exam and CXR findings with TGA
- Single 2nd heart sound
- Egg shaped heart on CXR with increased pulmonary vascularity
Reason for differential O2 sat in TGA
- Arms are low because upper extremities are dependent on RV
- Legs are high because lower extremities are dependent on LV via duct
22q11 heart defect
Conotrunctal defects and VSD
Down syndrome heart defect
AV canal defect
Marfan syndrome heart defect
Aortic root dissection, mitral valve prolapse
William syndrome heart defect
Supravalvular aortic stenosis
Noonan syndrome heart defect
Supravalvular pulmonic stenosis
Turner syndrome heart defect
Coarctation of the aorta
Percentage of heart beats per day that can be PACs and PVCs
4%
EKG finding for atrial flutter/fib
Saw tooth waves
EKG findings for WPW
- Shortened PR interval (delta wave)
- Risk of SVT
Most common symptomatic arrhythmia in children
SVT (narrow complex tachycardia over 200-220)
Treatment of SVT
- Stable child: get an EKG, vasovagal maneuvers, adenosine (long term use amiodarone or procainamide)
- Unstable: adenosine then cardioversion
- Adenosine effects are diminished by methylxanthines (caffeine)
- Digoxin is sometimes used as long term med for SVT but CAN NOT be used in WPW
Prolonged QT Syndrome presentation
- While swimming
- FH sudden death, one car accidents, near drowning
- Can be followed by a seizure but the syncope happens first then the seizure
Definition of VT and treatment
- 3 or more PVCs in a row, rate will be 120-250
- Tx with synchronized cardioversion for sustained VT longer than 30 seconds
Cardiac causes of syncope
- Long QT syndrome
- Cardiomyopathy
- WPW syndrome
- Coronary anomalies
- Arrhythmias
- Valvar aortic stenosis
Most common murmur in rheumatic heart disease
Mitral regurg
Rheumatic heart fever treatment
- Penicillin to get rid of the strep and use for prophylaxis
- Aspirin for arthritis
- Steroids for carditis
- Haloperidol for chorea
- Digoxin if heart failure
Infective endocarditis prophylaxis
- If there is residual shunt or if had surgery in the last 6 months
- Amoxicillin (clinda if allergic)
New murmur in the setting of a recent viral illness
Myocarditis
- EKG can show diffuse low voltages, diagnosis is by MRI
- Often from coxsackie group B virus
- Treatment is supportive
Most common causes of pericarditis
Viral (URI), collagen vascular disease (JIA), bacteria (staph aureus)
Symptoms of pericarditis
- Leaning forward, pericardial friction rub, nonspecific chest/epigastric pain
- Diffuse ST segment elevation on EKG
- Muffled heart sounds
Alagille syndrome heart defect
Branch pulmonary artery stnosis
Digeorge syndrome heart defect
Truncus arteriosus
Holt-Oram syndrome heart defect
ASD
School aged child with early systolic vibratory murmur at LLSB
Still’s murmur
- Cause is ventricular false tendons
Most common congenital heart disease
- Bicuspid aortic valve (followed by VSD)
Snowman heart on xray
TAPVR
