Cardiology Flashcards
Differentiate peripheral from central cyanosis?
Peripheral cyanosis
- can occur with normal oxygen saturation
- due to reduced peripheral circulation, which allows the tissues to extract more oxygen, leaving the venous end of the capillaries with more reduced hemoglobin
- (extremities cold and blue, mucous membranes pink)
- exposure to cold, polycythemia, acrocyanosis
Central cyanosis
- result of arterial desaturation
- best seen in the tongue, oral mucous membranes, and trunk.
What is acrocyanosis?
Benign condition
Peripheral cyanosis of hands/feet at birth
What does significant delay or absence of the femoral pulse compared to the radial pulse indicate?
Coarctation of the Aorta
What does a rapid rising or bounding pulse indicate?
Large PDA
Aortic Valve insufficiency
In what conditions might one hear a systolic ejection click?
Heard when there is an enlarged great vessel at the base of the heart or when there is a thickened/abnormal semilunar valve
Eg:
- Thickened semilunar valves (e.g., aortic stenosis, bicuspid aortic valve, pulmonarystenosis)
- Enlarged aorta (e.g., tetralogy ofFallot [TOF])
- Truncus arteriosus (multivalved greatvessel)
In what conditions do you hear fixed splitting of the 2nd heart sound?
Fixed splitting S2 is due to delayed right ventricular emptying and can indicate:
- ASD
- Right bundle-branch block (RBBB)
- Severe pulmonary stenosis
Which is almost always abnormal in a child: a 3rd or 4th heart sound?
S3 = normal in children and pregnant women.
S4 = almost always abnormal in children
- Can be heard with aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, and hypertension with left ventricularhypertrophy.
What is the most common “innocent” murmur in an infant?
Physiologic peripheral pulmonary stenosis
What happens to an innocent systolic murmur when the child is placed in a supine position?
Get LOUDER when placed supine, because stroke volume increases with this maneuver.
What happens to an innocent systolic murmur with Valsalva maneuvers?
Get SOFTER or disappear with a Valsalva maneuver
If Valsalva increases the murmur, think hypertrophic cardiomyopathy or obstructive left heartlesions!
What distinguishes Still’s murmur from others?
Still’s murmur (a.k.a. vibratory murmur)
Common & Benign
Systolic ejection murmur with a musical quality or vibratory character eg. “kazoo”
LLSB, not in the back
Decreases in intensity with expiration, positional changes that decrease venous return (e.g., standing), and with faster heart rates.
*The musical quality is what makes this easily recognizable.
Where on the thorax do you usually hear peripheral pulmonary stenosis?
Turbulence causes a soft, Grade 1–2 midsystolic ejection murmur
Heard best at RUSB or with radiation to the back and axilla
What causes a venous hum murmur?
Caused by blood draining down collapsed jugular veins into dilated intrathoracic veins
Which illicit drug can cause acute MI in adolescents?
Cocaine
ie. Crack
An adolescent with Marfan syndrome presents with acute chest pain that is “tearing” and radiating to his back. What are you immediately concerned about?
Aortic Dissection
What type of chest pain occurs over the rib/cartilage junction and is often reproducible with palpation over the area?
Costochondritis
What is the most common cause of syncope in children?
Vasovagal syncope
a.k.a. vasodepressor, neurocardiogenic
What do you do if you suspect vasodepressor syncope?
Increasing fluid and salt intake! Others: - Discourage caffeine - Beta-blockers can be helpful - Fludrocortisone, a mineralocorticoid, and α-agonists, such as midodrine
If you suspect an arrhythmia as an etiology for syncope, what testing do you perform?
24-hour Holter and ECG
Note: An ECG is probably the best test to order in a patient with recurrent, unexplained syncope!
What is the most common cause of sudden death in the young U.S. athlete?
Hypertrophic cardiomyopathy
What is the screening recommendation before an athlete can participate in high school or college sports?
None
Targeted History + FHx and exam
Look for:
- Exertional syncope, near syncope, chest pain, excessive fatigue, or SOB
- FHx for premature death or disability from heart disease in young relatives (
With which family history risk factors is it recommended that a fasting lipid profile be obtained at an early age (2–8 years of age) in children?
Myocardialinfarction
Stroke
Peripheral vasculardisease
Sudden cardiac death in a parent or grandparent 240 mg/dL or a known history of familialhypercholesterolemia
or
If the family history is notknown
If there are other risk factors present, such as obesity orsmoking
By what age should lipid screening for all children occur? If the lipid profile is normal, how often should it be repeated?
At risk children = Before 8–10years of age
Normal = between 9 and 11 years of age and again between 17 and 21 years ofage
List the major and minor Jones criteria for RF?
5 major:
- Subcutaneousnodules
- Pancarditis
- Arthritis(migratory)
- Chorea
- Erythemamarginatum
- **SPACE!!
5 minor:
- Increased CRP
- Arthralgia
- Fever
- Increased ESR
- Prolonged PRinterval
- **CAFE PR
Describe the arthritis of RF?
Acute, migratory polyarthritis of the large joints, with fever
Which heart valves are most often affected in RF?
Mitral regurgitation (MR) = most common - Apical pansystolic murmur
Aortic regurgitation (AR) = 2nd most common - Early diastolic murmur
Which 2 murmurs occur most frequently in acute RF?
Mitral regurgitation (MR) = most common - Apical pansystolic murmur
Aortic regurgitation (AR) = 2nd most common - Early diastolic murmur
Describe chorea seen in RF?
Sudden, involuntary, irregular movements of the extremities associated with emotional lability and weakness
A child with RF presents and is found to be culture-negative for S. pyogenes. Do you give him penicillin therapy?
In acute RF, always give penicillin (PCN), even if cultures are negative for GAS
Which cardiac residual lesions are most likely to occur after RF in childhood?
Mitral insufficiency and
Aortic insufficiency
Which drugs are used for monthly prophylaxis after acute RF? What if the child is penicillin-allergic?
Abx given for a minimum of 5 years, or until 21yo - whichever is longer
1) IM Benzathine penicillin monthly
2) Oral Penicillin VK BD
Erythromycin 250mg BD for those who are penicillin or sulpha allergic
What are the only instances in which antibiotics are recommended to prevent endocarditis?
Dental procedures, respiratory procedures, or infected skin procedures only in the presenceof:
- Prosthetic cardiacvalve
- Previous history ofendocarditis
- Unrepaired cyanotic heartdisease
- Completely repaired congenital heart disease with prosthetic material or device, for 6 monthspostprocedure
- Repaired congenital heart disease with a residual lesion (i.e., VSD S/P repair with a VSD patchleak)
- Cardiac transplant recipients who develop cardiacvalvulopathy
Antibiotic options for endocarditis prophylaxis?
Standard general prophylaxis = PO amoxicillin 1hr before procedure
Unable to take oral = IV/IM Ampicillin 30mins before
Allergic to penicillin = PO Clindamycin, Cephalexin, or Azithro or Clarithromycin
Allergic to penicillin and can’t take oral = IV/IM Clindamycin or Cefazolin
**NO POSTPROCEDURE DOSES
What are the criteria to diagnose Kawasaki disease?
Diagnosis made clinically with fever for ≥ 5 days and 4 of:
- Conjunctival injection withoutdrainage
- Cervical lymphadenopathy (unilateral >1.5cm)
- Extremity changes with erythema and edema of the hands and feet and laterdesquamation
- Mucous membrane changes with erythema, cracked and peeling lips, and strawberrytongue
- Polymorphous exanthema—usually macular or maculopapular erythematous, but any rash except vesicles andbullae
Atypical Kawasaki’s =
What is the pathognomonic finding of Kawasaki disease?
Coronary artery aneurysms
Develop in 20–25% of inadequately treated cases
What is the most common cause of myocarditis in children?
INFECTION
- Enterovirus (coxsackie B) and Adenovirus
What are the 3 main types of cardiomyopathy?
Hypertrophic, Dilated and Restrictive
Which type of cardiomyopathy is most common in children?
Dilated
What are the presenting signs of dilated cardiomyopathy in both infants/toddlers and in older children?
Infants and toddlers = tachypnea, tachycardia, weak peripheral pulses, low BP, and hepatomegaly.
In extreme cases, presents in shock.
Older children = dependent edema, rales, and elevated jugular venous pulses
Cardiac exam = tachycardia, gallop rhythm, and murmurs from mitral and tricuspid regurgitation
How is dilated cardiomyopathy treated?
Diuretics
ACE (angiotensin-converting enzyme) inhibitors
Beta-blockers, and
Antiarrhythmic medications
Which systemic diseases can cause restrictive cardiomyopathy?
Most often idiopathic
Can be secondary to a systemic disease:
- Hemochromatosis
- Amyloidosis
- Connective tissue disease
What does a pericardial friction rub almost always indicate?
Acute Pericarditis
What are the classic ECG findings in acute pericarditis?
Widespread ST elevation
Muffled heart sounds can be indicative of which disorder?
Pericardial effusion
What is Kussmaul sign?
With tamponade, however, the increase in venous return cannot be accommodated. This causes the jugular venous pressure to rise with inspiration, known as Kussmaul sign. (More commonly, it is seen in constrictive pericarditis.)
In which pericardial disease are you likely to see Kussmaul sign?
Constrictive Pericarditis
What is Beck triad?
Rising JVP
Dropping systolic BP
Quiet, Muffled HS
*Demonstrate Tamponade physiology
During cardiac tamponade, what do you expect the end-diastolic pressures to be in the 4 chambers of the heart?
Diastolic pressures will all be the same
What are the pathophysiologic categories of pediatric heart failure?
1) Ventricular dysfunction—this occurs when there is decreased ventricular contractility and can occur in structurally normal hearts as well as in those with complex congenital heart disease. Causes include cardiomyopathy, myocarditis, ischemia, arrhythmias, and drugs/toxins.
2) Volume overload—this occurs when there is a large left-to-right shunt from a congenital heart defect such as VSD, PDA, or AV septal defect (AVSD). Insufficient aortic, mitral, or pulmonary valves can also cause volume overload. Noncardiac causes, including renal failure with fluid overload and arteriovenous malformations, can also result in heartfailure.
3) Pressure overload—heart failure results from severe outflow obstruction with low cardiac output and increased filling pressures. These lesions include AS (aortic stenosis), PS (pulmonary stenosis), and CoA (coarctation of theaorta).
Does age at presentation of heart failure help in determining cause?
YES
1st week of life—left heart obstruction (e.g., critical coarctation, hypoplastic left heartsyndrome)
4–8 weeks of life—left-to-right shunt (e.g., VSD,AVSD)
6–8 years of life—acquired heart disease (e.g., rheumatic fever,myocarditis)
What are the symptoms of heart failure for infants? For young children? For older children?
Infant—poor growth, tachypnea, poor feeding, sweating with feeding, fatigue, andirritability
Young children—fatigue, abdominal pain due to ascites, nausea/vomiting, failure to thrive (FTT), and cough withwheezing
Older children—exercise intolerance, shortness of breath, decreased appetite, cough with wheezing, edema, palpitations, syncope, and chestpain
Which electrolytes can be depleted with loop diuretics?
Hypokalemia
Hyponatremia
Hypochloremia
Metabolic alkalosis
Which diuretic can actually increase serum potassium levels?
Spironolactone
Differentiate the effects of low-dose and high-dose dopamine. What does epinephrine do?
Dopamine = increased myocardial contractility
- Low dose = dilated peripheral vascular beds, improves renal and coronary perfusion
- High dose = α-adrenoceptor stimulation causes vasoconstriction, increased afterload, and a decrease in renal bloodflow.
Epinephrine = stimulates both α- and β-adrenoceptors
Dilates vasoconstricted beds and has potent, inotropic effects
At higher doses, it can cause systemicvasoconstriction.
How does acute digoxin toxicity present clinically?
Nausea, vomiting, and diarrhea
Also: Color-vision changes, confusion, or vertigo.
Palpitations and arrhythmias (AV block, SVT, or VT) are common also.
What is the most common congenital heart defect diagnosed in term newborns?
VSD
Lithium use during pregnancy is associated with which cardiac abnormality?
Ebstein anomaly of the tricuspid valve
Cardiac condition with Noonans syndrome?
Pulmonary Stenosis
Hypertrophic Cardiomyopathy
Cardiac condition with Apert syndrome?
VSD
CoA
Cardiac condition with Holt-Oram syndrome?
ASD
VSD
Cardiac condition with Alagille syndrome?
Pulmonary Stenosis
Branch pulmonary artery stenosis
Cardiac condition with Cru-du-chat syndrome?
VSD
Cardiac condition with Turners syndrome?
Bicuspid aortic valves
Dilated aortic root
CoA
Cardiac condition with DiGeorge (22q11)?
Interrupted aortic arch
Truncus arteriosus
TOF
Cardiac condition with Williams syndrome?
Supravalvular aortic stenosis
Cardiac condition with Downs syndrome (Trisomy 21)?
AVSD (endocardial cushion defect)
VSD
Cardiac condition with Trisomy 13?
VSD
Polyvalvular disease
Cardiac condition with Trisomy 18?
VSD
Are right heart saturations increased or decreased with a left-to-right shunt?
The left heart saturations are normal, and the right heart saturations are increased at the site of the shunt
What happens to left heart saturations with a right-to-left shunt?
Right heart saturations remain in the normal range, and the left heart saturations are decreased at the site of the shunt and beyond
In a 10-year-old, if the QRS is upright in lead I and down in aVF, what does this indicate about the axis?
LAD
What does LAD indicate?
Most often a result of:
- Tricuspid atresia
- AV septal defects (AV canal), and
- Left ventricular hypertrophy (LVH)
How do you determine heart rates on an ECG tracing?
1500/RR in mm
Divide 300 by Number of big square between RR
What is the most common cause of prolonged QT interval in a pediatric patient not on medications?
Genetic or congenital prolonged QT
What prescribed drug can cause prolonged QT interval in a depressed adolescent?
Tricyclic overdose (especially think about in theadolescent)
Hypocalcemia
Hypomagnesemia
Hypokalemia
Class Ia and III antiarrhythmics (Ia =quinidine, procainamide; III =amiodarone,sotalol)
Starvation with electrolyteabnormalities
CNSinsult
Nonsedating antihistamines
Azithromycin
Liquid proteindiet
Which P wave changes indicate RA enlargement?
Peaked P waves in II and V1
Which P wave changes indicate LA enlargement?
Broad negative P wave in V1 = sensitive
Notched M shaped P wave = specific
When do you find peaked T waves?
Hyperkalaemia
Intracerebral haemorrhage
What is the most common cause of cardiac chest pain in pediatrics?
Pericarditis
What effect does hypokalemia have on the ST segment?
ST depression
How does LVH present on ECG?
LAD
S wave in V1
R wave in V6
How does RVH present on ECG?
RAD R wave in V1 S wave in V6 rSR in V1 and V2 ST depression and flipped T wave in V1
True or false? In a normal term infant, what is considered RVH in an older child or adult is a common finding and considered “normal” on a standard ECG.
True
In a term infant, what does a positive T wave in V1 indicate after 1 week of age? What does a qR pattern in V1 indicate?
Pathological RVH
What is the leading mechanism of SVT in neonates and young infants?
AV reentry d/t accessory pathway
What is the leading mechanism of SVT in older children and adolescents?
AV node reentry
A stable infant presents with SVT. What are the possible treatments?
1) Vagal maneuvers
(diving reflex in infants—place ice bag to face for 10–20seconds)
2) IV adenosine or verapamil
- Avoid verapamil in infants (
Unstable SVT. What treatment?
DC Cardioversion
What is the drug of choice for a patient with WPW who develops atrial flutter?
NEVER treat with Digoxin. Verapamil needs careful monitoring.
- increase refractory period in AV node, but decrease it in accessory pathway -> VF -> Death
Better to treat acute A-fib or A-flutter in WPW with IV procainamide
What is the treatment for atrial flutter?
INITIAL
- Most effective = Synchronized electrical cardioversion
- If unstable, always shock
- Antiarrhythmic drugs = IV diltiazem, digoxin or beta blocker
LONG TERM
- Flecainide, sotalol, amiodarone and dofetilide
- Radiofrequency catheter ablation and cryoablation
What is the treatment for simple PVCs?
Reassurance
Which treatments can you use, and which can you not use, for ventricular tachycardia?
UNSTABLE
- Electrocardioversion
STABLE
- Lidocaine, procainamide, or amiodarone
- DO NOT USE VERAPAMIL
- If induced by exercise - beta blockers work best
For which patients do you not use verapamil to slow the heart rate?
Avoid verapamilwith:
- Infants (
When is it okay to use verapamil to slow the AV nodal conduction?
Okay to use verapamil (but never ininfants!):
- To control the ventricular response to A-fib in an otherwise healthyheart
- For SVT (2nd choice afteradenosine)
What is the definition of a prolonged QTc interval?
Normal QTc
- <0.46 in children and adolescents <15yrs
- Women <0.46
- Men <0.45
What is the pharmacologic treatment of long QT syndrome?
Beta-blocking agents (e.g., propranolol, nadolol)
- To decrease HR and reduce the chance of a dangerous rhythm
Which children require a pacemaker for sick sinus syndrome?
1) Symptomatic (eg. Syncope)
2) Tachyarrhythmias requiring therapy, which might precipitate signif bradycardia
True or false? Serum digoxin concentration is usually helpful in determining toxicity.
False
Changes in ECG = best way
Differentiate Mobitz 1 from Mobitz 2?
SECOND DEGREE HB
- Mobitz type 1 (Wenkebach)
- The PR interval gradually increases/prolongs until it does not conduct to the ventricles and misses a QRS
- Benign - Mobitz type 2
- The P waves that do not conduct to the ventricles are NOT proceeded by a gradual prolongation, and instead you just have a missed QRS beat
- Implies disease of Purkinje conduction system
- ABNROMAL
Tx = Pacemaker
With 3° AV block, what does a narrow (normal width) QRS complex indicate?
Junctional ectopic pacemaker
With 3° AV block, what does a wide QRS complex reflect?
Ventricular escape rate
Which children require a pacemaker for heart block?
Symptomatic 2° (Mobitz 2) and most 3° heart blocks
