Cardiology Flashcards
low pitched systolic ejection murmur at base with fixed split S2 (1)
ASD •Fixed and wide splitting of the 2nd heart sound (volume load, delayed right bundle conduction). •diastolic rumble at the mid to lower right sternal border (increased flow across TV)
Systolic ejection murmur radiating to the neck (1)
aortic stenosis
systolic ejection murmur radiating to the back (3)
pulmonary stenosis
PDA
coarctation
high pitched short systolic regurgitation murmur at the apex or LLSB
small VSD
mitral regurgitation
what are some features of cardiac syncope
little or no prodrome
prolonged LOC >5min
exercise-induced
fright/startle induced
associated chest pain or palpitations
history of cardiac disease- AS, pulmonary hypertension
positive family hx (long QT, arrhythmia syndromes, devices, cardiomyopathy, sudden death)
long QT and deafness=
Jervell Lange- Nielson syndrome
autosomal recessive
palpitations while swimming
long QT syndrome
where should you measure QTc
lead II or V5
what is QTc
QT/√RR
what is a normal QTc Boys? girls?
Boys >10: <0.45
Girls >10: <0.47
younger kids <0.46
when can you not interpret QTc
cannot interpret in presence of abnormal depolarization
BBB
WPW
what electrolyte abnormalities can cause long QT interval? what class of drugs?
low Ca
low Mg
low K
drugs (tricyclic antidepressants)
what is the first line treatment for long QT syndrome
beta blockers
when do we see torsades de point?
form of polymorphic VT
long QT syndrome
or hypomagnesemia
tx: magnesium
what are the EKG findings associated with WPW (3)
delta wave
short PR
what are two complications of WPW
sudden death
SVT
what are the treatment options for WPW
no symptoms
SVT
fainting with palpitations
no symptoms- no treatment
SVT- beta blockers or ablation (no digoxin!)
fainting with palpitations- ablation
what is the most common congenital heart defect with trisomy 21
VSD
who should get palivizumab in children with CHD
children <1 with cyanotic CHD or hemodynamically significant cyanotic CHD (requiring meds)
what is the Norwood/Sano procedure
1st surgery for HLHS
used for patients with hypoplastic left heart syndrome
1. connect pulmonary artery to the aorta, close PDA
2. augment the aortic arch
3. create ASD (or make bigger to allow oxygenated blood to right ventricle)
4. place a shunt from right subclavian (aorta) to right pulmonary artery or Sano shunt from right ventricle to pulmonary artery
usual saturations 75-85% ** (too high is bad too, too much pulmonary blood flow
what is the surgical treatment for TGA
arterial switch procedure
usual saturations are 100%
what is the surgical treatment for too much pulmonary artery blood flow
pulmonary artery band
what are two complications of Fontan
plastic bronchitis
protein losing enteropathy **
what are the surgeries for a single functional ventricle
- Glenn- SVC to RPA
sats: 75%-85% - Fontan
IVC to RPA
expected sats >90% (usually)
who needs antibiotic prophylaxis for endocarditis before high risk procedures? (4)
1) a prothetic heart valve
2) a history of endocarditis
3) a heart transplant with abnormal heart valve function
4) certain congenital heart defects including:
- cyanotic congenital heart disease
- a congenital heart defect that has been completely repaired with prosthetic material for the first 6 months after repair
repaired congenital heart disease with residual defects such adjacent to the prosthetic device
what is considered a high risk procedure requiring endocarditis prophylaxis (2)
dental procedure where the gums or lining of the mouth are likely to be injured (Eg extraction or surgery)
usually not routine cleaning
gut or genitourinary surgery through an area that is infected
things that do NOT need antibiotic prophylaxis for endocarditis
injections of anaesthetic to mouth
loss of baby teeth
accidental injury to gums/mouth
nosebleeds
routine placement or adjustment of braces
deliveries and episiotomies
most surgeries and procedures, including non-infected gut and urinary tract procedures
Ddx of cyanosis in a newborn
heart
- cyanotic congenital heart disease
- severe congestive heart failure
lung
- parenchymal disease: RDS, pneumonia, pulmonary hemorrhage
- non parenchymal disease: CPAM, pleural effusion, CDH
neurological
Blood
- polycythemia
- methemoglobinemia
Types of cyanotic congenital heart disease (8)
T- Transposition of the great arteries T- Tetralogy of Fallot T- Tricuspid atresia T- Total anomalous pulmonary venous connections T- Truncus arteriosus T- 'Tingle' ventricle (single ventricle)
A- pulmonary atresia
A- Ebstein’s anomaly
what are the characteristics of pericarditis on history
sharp stabbing or squeezing chest pain
better with sitting up
worse with lying down
often pleuritic
no sensory innervation of the pericardium( pain referred from diaphragmatic and pleural irritation)
friction rub on exam
what are the EKG findings for pericarditis
4 stages on EKG: ST elevation/PR depression T wave flattening T wave inversion resolution
ECHO is diagnostic
what are some causes of pericarditis?
Idiopathic- most common viral bacterial- rare now secondary to H. Influenza vaccination neoplastic- leukemia, lymphoma inflammatory- lupus, JIA
- common with connective tissue diseases- RA, rheumatoid factor, SLE
what would you see on physical exam for pericarditis? (3)
narrow pulse pressure
pericardial friction rub
pulsus paradoxus >15mmHg
what is Pulsus paradoxus
Pulsus paradoxus refers to an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg.
what is the treatment of pericarditis
NSAIDs
steroids if persistent
pericardial tap if evidence of tamponade or persistent on meds
antibiotics if suppurative pericarditis is suspected (Rare in Canada and pt is very sick)
what are 3 cardinal signs of CHF in infants?
tachycardia
tachypnea
hepatomegaly
what are the causes of CHF by age:
first week of life
2-6 weeks
older children
first week of life: obstructions primarily - hypo plastic left heart syndrome (d3-5) - severe aortic stenosis - coarctation (d7-10) asphyxia severe mitral or tricuspid regurgitation uncontrolled tachycardias (SVT>24h)
2-6weeks: L to R shunts VSD AVSD PDA NOT ASD!!! (DO NOT CAUSE OBSTRUCTION- low pressure shunt)
older children: pump failure
dilated cardiomyopathy
myocarditis
tachycardia (sustained tachycardia) induced cardiomyopathy
what are some symptoms of congestive heart failure in infants
poor feeding poor weight gain sweating, especially with feeds shortness of breath with feeds, grunting frequent chest infections
what are some symptoms of congestive heart failure in older chidren
shortness of breath with activity decreased activity tolerance easily tired puffiness of eyelids swollen feet
what are some supportive treatment options for CHF
head of the bed up (decrease respiratory distress)
tube feeds (Decrease work for heart)
high calorie formula
salt restrictions (in older children- avoids excess preload)
fluid limitation (if severe)
immunize (RSV, flu)
Medication:
Improve contractility
• Dopamine, dobutamine, milrinone, epinephrine, norepinephrine
– Decrease preload or filling of the heart
• Diuretics
– Decrease afterload (pump related dysfunction)
• ACE inhibitors, angiotensin receptor blockers
– Minimize ongoing damage (pump related dysfunction)
• Beta blockers
AV re-entry tachyarhythmias R to P interval
R to P distance is shorter than the P to R distance
almost certainly had an AV re-entry mechanism
responds to adenosine
Ectopic- R to P interval
R to P distance is longer then the P to R interval
not an artioventricular re-entry mechanism
NOT likely to respond favourably to adenosine
what investigations can be done for palpiations
TSH
lytes, ca, Ng
EKG +/- holter (of having at least once per day)
if event only every 2 weeks then an event monitor would be better
not everyone would do lytes but most would do TSH
what are 4 physical exam findings of endocarditis?
Janeway lesion- non tender
osler node- tender “OW”
splinter hemorrhage
embolus
what is seen pathologically with rheumatic fever
Aschoff bodies are characteristic lesions seen
what are the major criteria for rheumatic heart disease
carditis POLYarthrtiis subcutaneous nodules erythema marginatum syndenhams chorea
2 major or 1 major and 2 minor
RECURRENT: 2 major or 1 major and 2 minor or 3 MINOR
what are the minor criteria for rheumatic heart disease
Fever >38.5
Elevated CRP/ESR >60
Polyarthralgia (low risk)
prolonged PR interval on ECG (if carditis not major)
what is the definition of pulmonary hypertesion
pulmonary artery pressure >25mmHg
what is cor pulmonale
right heart dysfunction secondary to pulmonary disease
physical exam findings of cor pulmonale
precordial bulge RV heave single S2 TR, PR murmurs (Graham steele) pulsatile liver (tricuspid regurgitation) hepatomegaly oedema
what do you see on EKG for pulmonary hypertension?
RV strain
RVH
what would you see on CXR for hypoplastic left heart
wall to wall heart with increased pulmonary vasculature
Boot shaped heart on CXR
Tetralogy of Fallot
Egg on a string CXR
Transposition of the great arteries
snowman on CXR
TAPVR
Large LV on CXR (3)
cardiomyopathy
myocarditis
pericardial effusion
what is characteristic of still murmur
vibratory murmur
Still murmur: Grade 1 to 3, early systolic murmur;
Low to medium pitch with a vibratory or musical quality
Best heard at lower left sternal border
Loudest when patient is supine and decreases when patient stands
Infancy to adolescence, often 2 to 6 years old.
An infant is in shock with paroxysmal supraventricular tachycardia, what is the treatment?
synchronized cardioversion
Neonatal goiter. What anti-arrhythmic was mom on?
a. Digoxin
b. Procainimide
c. Amiodarone
d. Sotalol
Amiodarone contains iodine. The iodine load causes fetal/neonatal hypothyroidism and goiter, which is transient
What is the most common cardiac defect with Marfans?
Dilatation Ascending aorta
What is the most common cardiac lesion in a IDM?
HCM
what is the cardiac finding with neonatal lupus
complete heart block due to anti-rho/la
Baby 4 days old, now fussy, no work of breathing but sats 88% despite oxygen. Poor perfusion. You’re in a peripheral hospital. What’s the next step in management?
start prostaglandin
What’s the most common cyanotic congenital heart defect to present in the neonatal period?
TGA
what is the treatment for hypertrophic cardiomyopathy?
beta blockers
EKG findings ALCAPA
Signs anterolateral myocardial infarction
Q waves in leads I, aVL, V5 and V6
May progress to ischemic cardiomyopathy
Kid with occasional PVCs, what’s the sports recommendation?
No restrictions
WPW is strongly associated with which anomaly?
Ebsteins anomaly
what are the EKG findings for WPW
delat wave
short PR
wide QRS
List 4 Risk Factors for Artherosclerosis
Obesity Diabetes Hypertension Hyperlipidemia Smoking Metabolic syndrome (T2DM, abdominal obesity, hyperglycemia, dyslipidemia, and hypertension) Familial Hypercholestremia
what are 4 types of cardiomyopathy in children
dilated cardiomyopathy- most common
both ventricles dilated
hypertrophic cardiomyopathy with LV outflow obstruction
hypertrophic cardiomyopathy without LV outflow obstruction (storage diseases)
restrictive cardiomyopathy
Rib notching on CXR
Rib notching: Coarctation of the aorta (older children)
Describe the clinical manifestations of a large patent ductus arteriosus (PDA)
Tachypnea and tachycardia • Bounding pulses • Hyperdynamic precordium • Wide pulse pressure • Continuous murmur (older child) • Systolic murmur (premature infant) • Labile oxygenation (premature infant) • Apnea (premature infant)
what is a PDA
persistent patency of a normal fetal structure between the left PA and the descending aorta
shunts bloods from the aorta to the pulmonary artery and increases pulmonary blood flow
what type of murmur is associated with PDA
machinery continuous murmur best heard at the left infraclavicular area
on PE: bounding pulses, wide pulse pressure
AVSD is commonly associated with what?
Down syndrome
~70% have Down syndrome
Acyanotic congenital; heart lesions with increased pulmonary blood flow
ASD AV Septal Defect VSD PDA AV Malformation
Acyanotic congenital heart lesions with normal pulmonary blood flow
Pulmonic Stenosis
Mitral Stenosis/Regurgitation
Aortic Stenosis
Coarctation of the Aorta
what is the most common ASD
secundum (75%)
RAD on EKG
2nd most common CHD (6-10%)
Primum (15%) – associated with other endocardial cushion defects (cleft AV valves, inlet type VSD) Sinus Venosus (10%)
Treatment for ASD
Percutaneous Closure
– only for secundum ASD
– adequate superior/inferior rim around ASD
what is the most common congenital lesion?
VSD
when do VSDs typically become symptomatic
6-8 weeks •Large VSD’s may be silent and become symptomatic in first few weeks as pulmonary resistance decreases •SOB and diaphoresis with feeds •Poor weight gain •Systolic murmur •CXR demonstrates increased pulmonary vasculature, cardiomegaly
Treatment for AVSD
“All” require surgical intervention
• Repair at 4-6 months of age for complete
defects and about 3 years of age for primum
defects
Duke criteria for IE
2 major
1 major + 3 minor
or
0 major and 5 minor
BE JOAN OF ARC
Major criteria
B-blood culture positive
E- echo evidence of vegetation and valvular regurgitation
Minor criteria J- janeway lesion O- oslers node A- aneurysm(mycotic); abuse(idu) N- nephritis O- other predisposing heart condition F-fever A- arterial emboli R-roth's spot; rheumatoid factor C- culture positive not meeting major criteria
what is the classic cardiac finding with acute rheumatic fever?
mitral regurgitation most common
aortic regurgitation second most common
Jones major criteria
Major
–Carditis (40-50% in initial episode, up to 90% overall; new/ changing murmur, cardiomegaly, CHF)
–migratory polyarthritis (large joints)
–Chorea (F>M)
–erythema marginatum (erythema w serpiginous, advancing margins, central clearing, trunk, inner thighs)
–subcutaneous nodules (usually with carditis, extensor surfaces)
Jones minor criteria (5)
–fever –arthralgia –history of previous ARF –elevated ESR, CRP –prolonged PR on ECG
What is the antibiotic treatment for rheumatic fever?
10 days of penicillin or amoxicillin
erythromycin if pen allergic
RF secondary prevention (3)
Without carditis: up to 5 years after last acute episode or until age 21 years, whichever longest
•Carditis without sequelae: 10 years from last acute episode or age 25 years
•Carditis with residual valvar lesions: at least age 40 years or life-long
what cardiac findings are associated with Pompe disease
Pompe disease: Cardiomegaly, increased wall thickness, supraventricular tachycardia, short PR interval, extremely tall high QRS voltages.
most common cause of sudden death in children and young adults < 35 years
hypertrophic cardiomyopathy
what is one syndrome associated with HCM (5)
Syndromic HCM •Noonan’s syndrome*** •LEOPARD syndrome •Friedreich’s ataxia •Beckwith-Wiedemann syndrome •Swyer’s syndrome
Pharmacologic agents that prolong QT Interval
Antiarrhhythmic Agents
•Procainamide, Flecainide, Amiodarone, Sotalol
- Antihistamines
- Diphenhydramine
- Antibiotics and Antifungals
- Erythromicin, Azithromycin, Clarithromycin, Trimethoprim, Sulfamethoxazole, Clindamycin, Ketoconazole, Fluconazole
Psychotropic Drugs •Tricyclic antidepressants (Amitriptyline, imipramine) •Phenothiazines (Chlorpromaxine, Thioridazine) •Haloperidol •Risperidone •Carbamazepine •Other •Cisapride •Epinephrine •Caffeine
EKG findings associated with Brugada syndrome
coved-ST elevation in right precordial leads (V1-3) and RBBB
leading cause of acquired heart disease in children in the U.S.
Kawasaki disease
Diagnostic criteria for Kawasaki disease
Diagnostic criteria:
–fever > 5 days and at least 4 of the following features:
–(1) bilateral, painless, nonexudative conjunctivitis
–(2) lip or oral cavity changes (eg, lip cracking and fissuring, strawberry tongue, and inflammation of the oral mucosa)
–(3) cervical lymphadenopathy (≥ 1.5 cm in diameter and usually unilateral)
–(4) polymorphous exanthem
–(5) extremity changes (redness and swelling of the hands and feet with subsequent desquamation)
what are the most common organisms for infective endocarditis
–Alpha-hemolytic streptococcus –Staphylococcus aureus- worst!! causes most damage to the heart –Coagulase neg staphylococcus –Beta-hemolytic streptococcus –Candida- hardest to treat!!
predisposing factors for SVT (4)
•Infection, fever, drug exposure (20-24%)
•WPW (10-22%)
•Congenital heart disease (20-23%)
–Ebstein, CC-TGA, cardiomyopathy, or postoperative TGA, ASD, or AVSD
•Idiopathic (40-50%)
Causes of left axis deviation on EKG (3)
AVSD
small RV (tricuspid atresia)
Noonan syndrome
RV hypertrophy
Tall R waves for age V1
Deep S waves for age V6
Q waves in V1
Upright T waves in V1 after day 5 and before “latency age”
LV hypertrophy
Tall R waves for age V6
Deep S waves for age V1
Flat T waves in contiguous leads, what does that mean? (2)
• Myocardial disease
myocarditis
cardiomyopathy
inferior leads
II, III and aVF
lateral leads
I, aVL, V5 and V6
what is the recurrence risk for congenital heart disease
~4%
post pericardiotomy syndrome
early pericardial effusion after surgery
when is the highest risk of onset of aneurysms with kawasaki? What are 3 risk factors for coronary artery involvement?
4-6 weeks after onset of fever
risk factors:
younger age (<6 months)- consider steroid tx
abnormal echo at presentation
severe disease (MAS, shock)
why do you need to monitor a baby on prostaglandin
need to monitor continuously for apnea
A 3 year old child is referred to your office after a murmur is picked up by the family doctor on routine physical examination. You hear a harsh continuous murmur in the right infraclavicular area that is loudest when sitting and disappears on lying flat. The remainder of her cardiac exam is within normal limits. What is this most consistent with:
PDA
Venous hum
Still’s murmur
venous hum
** disappears with lying down
A 2-day-old infant presents in congestive heart failure. He has hydrocephalus.
He has a seizure 1 hour after admission. Most likely cause:
a) vein of Galen aneurysm
b) intraventricular hemorrhage
c) hypoxic ischemic encephalopathy
d) cerebral abscess
e) meningitis
vein of Galen aneurysm
Locations of AVMs include the vein of Galen (the most common), cerebral hemispheres, thalamus and third ventricle, and choroid plexus. Most infants with vein of Galen malformations present with heart failure
You are seeing a teenager with a history of recurrent syncopal episodes. What is the best screening test for prolonged QT syndrome.
EKG
36) Infant with large VSD. The murmur cannot be heard. What is the cause?
VSD has closed
There is increased pulmonary outflow obstruction
Pulmonary arterial pressures have increased
Pulmonary arterial pressures have increased
what is seen on EKG with hyperkalemia following transfusion?
peaked t waves
- A baby has been diagnosed with truncus arteriosus. What is the most likely complication in the first week?
a) pulmonary edema
b) severe cyanosis
c) heart failure
d) ?
pulmonary edema
Both ventricles are at systemic pressure and both eject blood into the truncus
When pulmonary vascular resistance is relatively high immediately after birth, pulmonary blood flow may be normal; as pulmonary resistance drops in first month of life, blood flow to lungs is increased and heart failure ensues
what are 4 complications from prostaglandin
- apnea
- hypotension
- bradycardia
- fever/flushing
Neonate with PDA treated with indocid. List four side effects of indocid
NEC and spontaneous intestinal perforation
transient renal insufficiency
increased bleeding risk
kernicterus (theoretical risk - interfere with binding of albumin to bilirubin
List four clinical signs of endocarditis in a patient with fever and a new murmur
- Janeway lesions
- Osler nodes
- splinter hemorrhages
- Roth spots (white centered retinal hemorrhage)
Neonate with complete heart block. ECHO normal. List 2 causes
- neonatal lupus
- idiopathic
- congenital heart disease (AVSD, TGA)
- familial congenital heart block
what are 3 EKG findings that are consistent with SVT
absent p waves HR not variable HR >180 in children HR>220 in infants narrow QRS
4 week in obvious CHF. Huge voltages on EKG, short PR interval. Hypotonic and progressive weakness. Hepatosplenomegaly and large tongue. What does this child have?
Pompe disease
Name 3 EKG finding of Hyperkalemia
- peaked T waves
- prominent u waves
- wide PR, wide QRS
what are 2 steps in management for long qt syndrome
- exercise restriction
- consult cardiology to start beta blocker or defibrillator
- check family members for long qt
what are 3 heart conditions that would have a single S2
- Tetralogy of Fallot
- Hypotrophic left heart syndrome
- Truncus arteriosus
- pulmonary stenosis
- Transposition of the great arteries
You are seeing a 7 year old with severe hypertension. List 4 investigations you would use to identify end organ damage.
ECG
Echocardiogram
Retinal examination
Albumin to creatinine ratio
A child has been confirmed to have hypertension. His urinalysis, lytes, BUN, and creatinine are normal. Name 4 investigations you need to do.
Blood chemistry (sodium, potassium, chloride, total CO2, and creatinine)
Urinalysis
Renal ultrasonography
Routine laboratory tests that should be performed for the assessment of cardiovascular risk in all children with hypertension include the following:
Fasting blood glucose
total cholesterol
HDL, LDL, TG
Name 3 types of benign heart murmurs in children.
Still’s murmur
Venous hum
flow murmur
What 4 features on a physical exam are most reassuring that a murmur is benign?
systolic
musical/vibratory
grade 1-2, no radiation
changes with position/respiration
BP for ≥ 13yo Normal BP Elevated BP Stage I HTN Stage II HTN
Normal BP<120/80
Elevated BP: 120/80- 129/80
Stage I HTN: 130/80- 139/89
Stage II HTN: ≥140/90
BP for 1-13 yo Normal BP Elevated BP Stage I HTN Stage II HTN
Normal BP <90th %ile
Elevated BP: >90th to <95%ile
Stage I HTN: >95 to <95 + 12
Stage II HTN: ≥95%ile +12mmHg
When should you consider a statin?
in a child >8 yo with
LDL-C > 4.9 mmol/L
LDL-C > 4.1 mmol/L + family history of early heart disease or > 2 risk factors present
LDL-C > 3.4 mmol/L + Diabetes Mellitus
what is POTS
HR increase of >40 beats/min during the 1st 10 min of upright tilt test without associated hypotension,
how do you diagnose POTS
head-up tilt test for at least 10 min
What are two management recommendations for POTS
- aerobic exercise program
2. salt supplementation
what is BT shunt
shunt from subclavian to pulmonary artery (done with Norwood for HLHS)
what is Sano shunt
shunt from right ventricle to pulmonary artery (done with Norwood for HLHS)
what are the 3 surgeries required for HLHS
- Norwood (1- weeks)
- Glenn (4-6 months)
- Fontan (18 months- 3 years)
what is the Glenn procedure
Glenn procedure is 2nd surgery for HLHS
occurs at 4-6 months because they have outgrown the shunt placed during the Norwood
goal is to take away some of the extra work from the RV (currently pumping to the lungs and the body)
- connect subclavian artery directly to the pulmonary artery
- remove shunt placed during Norwood
- Right ventricle now only pumps to the body and not to the lungs
Expected sats 75-85%
what is the Fontan procedure
Fontan is the 3rd surgery for HLHS
occurs at 18 months to 3 years
goal is to connect the inferior vena cava to the pulmonary artery via a conduit
there is a small fenestration between conduit and right atrium to act as a pop off valve
blood flow: IVC and SVC to the pulmonary artery- to the left atrium- to the right atrium- to the right ventricle- to the body
Expected sats > 90% (usually)**
Problems in Follow-up of “Repaired” CHD patients (10)
ongoing disease
arrhythmia
recurrence risk
social issues- employment, pregnancy
growth
development- increased risk of specific learning difficulties and ADHD
dental hygiene- few need SBE prophylaxis but all need good hygiene
scoliosis- children with thoracotomies
post pericardiotomy syndrome (early post operative pericardial effusion)
Fontan- protein losing enteropathy and plastic bronchitis
EKG axis deviation
lead I and II
both up- Normal axis
thumbs away from each other= left axis deviation
thumbs together= right axis deviation
