Cardiology Flashcards
How can congenital heart defects be classified?
Acyanotic vs. cyanotic…
Acyanotic:
- Ventricular septal defect (VSD)
- Atrial septal defect (ASD)
- Persistent ductus arteriosus (PDA)
Cyanotic:
- Tetralogy of Fallot (ToF)
- Transposition of the great arteries (TGA)
Which congenital heart defects are associated with outflow obstruction in a well child?
- Pulmonary stenosis
- Aortic stenosis
Which congenital heart defect is associated with outflow obstruction in a sick neonate?
Coarctation of the aorta
Which chromosomal disorders are associated with which specific congenital heart defects?
- Down’s syndrome = AVSD
- Turner’s syndrome = bicuspid aortic valve, CoA
- William’s syndrome = supravalvular aortic stenosis
- Noonan syndrome = pulmonary stenosis
How are congenital heart defects picked up?
- Antenatal ultrasound diagnosis
- Asymptomatic murmur
- Symptoms of heart failure, cyanosis or shock
What are the features of an innocent murmur?
Hallmarks of an innocent murmur are (all have an S, innoSent):
- aSymptomatic
- Soft blowing murmur
- Systolic murmur only, not diastolic
- left Sternal edge
- poSture (varies with change in posture)
What is an ASD?
An ASD is a condition where there is a hole in the atrial septum
Which murmur is associated with ASD?
Ejection systolic murmur (plus fixed split S2)
Describe the management of ASD
- Small = close spontaneously
- Large = catheter device closure/surgery
Describe the epidemiology of VSDs
VSDs are the most common type of congenital heart defect - they account for around 30% of all congenital heart defects
Which murmur is associated with VSD?
Pansystolic murmur
Describe the management of VSDs
- Small = close spontaneously
- Large = catheter device closure/surgery
What is the ductus arteriosus?
Describe the pathophysiology of PDA
The ductus arteriosus connects the pulmonary artery to the descending aorta (it is an essential part of the foetal circulation)
In term infants, the DA normally closes shortly after birth; in PDA, it has failed to close by 1 month after expected date of delivery
Which murmur is associated with PDA?
Continuous “machinery” murmur
Describe the medical and interventional management of PDA
Medical:
- Indomethacin or ibuprofen
Interventional:
- Catheter device closure
What are the four cardinal features of Tetralogy of Fallot?
- Large VSD
- Overriding aorta
- Pulmonary stenosis (causing RV outflow obstruction)
- and RV hypertrophy as a result
What are the symptoms and signs of Tetralogy of Fallot?
Symptoms:
- Severe cyanosis/hypercyanotic spells
Signs:
- Ejection systolic murmur
- Clubbing in older children
Describe the immediate and definitive management of Tetralogy of Fallot
Immediate:
- In the sick, cyanosed neonate the key is to improve mixing of blood by maintaining patency of ductus arteriosus
- This is done using a prostaglandin infusion
Definitive:
- Surgery to correct VSD/pulmonary stenosis
Describe the pathophysiology of transposition of the great arteries (TGA)
In TGA, the aorta is connected to the right ventricle and the pulmonary artery is connected to the left ventricle
What are the symptoms and signs of TGA?
Symptoms:
- Cyanosis
Signs:
- Usually no murmur
Describe the immediate and definitive management of TGA
Immediate:
- In the sick, cyanosed neonate the key is to improve mixing by maintaining the patency of the ductus arteriosus
- This is done using a prostaglandin infusion
Definitive:
- Arterial switch procedure
Describe the pathophysiology of AVSD
Which group of patients is this defect most commonly seen in?
- A complete AVSD is a hole in the middle of the heart with a single five-leaflet valve between the atria and ventricles, which stretches across the entire atrioventricular junction
- This defect is most commonly seen in children with Down’s syndrome
How is AVSD usually detected?
Either:
- Detected on antenatal USS
- Detected on routine echocardiography screening in a newborn baby with Down’s syndrome
Describe the management of AVSD
Surgery to correct defect
Describe the pathophysiology of aortic stenosis
Narrowing of the left ventricular outflow tract due to partial fusion of the aortic valve leaflets
Which murmur is associated with aortic stenosis?
Ejection systolic murmur
Describe the management of aortic stenosis
Balloon dilatation
Describe the pathophysiology of pulmonary stenosis
Narrowing of the right ventricular outflow tract due to partial fusion of the pulmonary valve leaflets
Which murmur is associated with pulmonary stenosis?
Ejection systolic murmur
Describe the management of pulmonary stenosis
Balloon dilatation
Describe the pathophysiology of coarctation of the aorta
- Coarctation of the aorta is due to arterial duct tissue encircling the aorta just at the point of insertion of the ductus arteriosus
- When the duct closes, the aorta constricts, causing severe left ventricular outflow obstruction
What are the symptoms and signs of coarctation of the aorta?
Symptoms:
- Acute circulatory collapse, heart failure and shock in the first few days of life
Signs:
- Absent femoral pulses
Describe the management of coarctation of the aorta
- Maintain ABC
- Maintain patency of ductus arteriosus with prostaglandin infusion
- Surgical repair in neonatal period
What causes rheumatic fever?
- Rheumatic fever can develop following infection with group A beta haemolytic streptococcus, e.g. streptococcus pyogenes
- The most common manifestation of this infection is streptococcal pharyngitis (strep throat)
Describe the pathophysiology of rheumatic fever
Type II hypersensitivity reaction: antibodies produced against streptococcus also attack host cells (skin, joints, heart, brain)
Which criteria can be used to describe the symptoms/signs of rheumatic fever
Jones criteria…
Major criteria:
- Carditis
- Migratory arthritis
- Sydenham chorea
- Erythema marginatum
- Subcutaneous nodules
Minor criteria:
- Fever
- Polyarthralgia
- Raised CRP/ESR
- Prolonged P-R interval on ECG
What are the potential complications of recurrent rheumatic fever?
- Rheumatic HD, leading to fibrosis of the mitral valve
- This can lead to mitral stenosis/regurgitation and increased risk of infective endocarditis
Describe the prophylactic treatment of rheumatic fever
- Recurrence should be prevented once the acute episode of rheumatic fever is resolved, in order to prevent chronic rheumatic heart disease
- Prophylactic treatment is with monthly injections of benzathine penicillin (continued for 10 years)
Which group of patients is most at risk of infective endocarditis?
All patients with congenital heart disease
What are the signs of infective endocarditis?
FROM JANE
- Fever
- Roth spots (retinal haemorrhages)
- Osler’s nodes (nodules on finger and toe tips)
- Murmur
- Janeway lesions (macules on palms and soles)
- Anaemia
- Nail haemorrhage (splinter haemorrhage), necrotic skin lesions
- Emboli
What is the most common causative organism of infective endocarditis?
Alpha haemolytic streptococcus (streptococcus viridans)
Describe the investigation of infective endocarditis
- Blood cultures
- Echocardiography (characteristic vegetations)
Describe the management of infective endocarditis
- High dose penicillin + gentamicin (6 weeks of IV therapy)
- If prosthetic material, e.g. valves, are present these may require surgical removal in order to fully eradicate the infection
What advice is given to help prevent infective endocarditis?
- Practise good dental hygiene
- Avoid piercings/tattoos
What is Kawasaki disease?
Kawasaki disease is a systemic vasculitis
Describe the aetiology of Kawasaki disease
Unknown
Describe the clinical presentation of Kawasaki disease
Diagnosis of Kawasaki disease is based on the clinical features present. These clinical features include a high-grade fever persisting for at least 5 days, PLUS 4 of the following:
- Conjunctivitis
- Cervical lymphadenopathy (usually unilateral)
- Polymorphous rash affecting trunk and limbs
- Painful, red, oedematous, peeling palms and soles
- Strawberry tongue (+/- cracked lips)
Describe the management of Kawasaki disease
- Aspirin
- IVIG
What investigations must be undertaken in a case of suspected Kawasaki disease?
- Echocardiography at baseline and repeat echo at 6 weeks
- This is important to check for coronary artery aneurysm, which is a complication of Kawasaki disease
