Cardiology COPY Flashcards
Murmur ID:
- MLSB or between LLSB and apex
- grade 2-3/6
- “twanging string”, groaning, squeaking or musical
- ages 3-6yrs, occasionally in infancy
Classic vibratory/Still’s murmur
Murmur ID:
- ULSB
- Early to midsystolic ejection murmur
- 1-3/6
- “blowing”
- ages 8-14yrs
Pulmonary ejection murmur
Murmur ID:
- Premature and full-term newborns
- Usually disappears by 3-6mos
- ULSB
- transmits to axilla and back
- 1-2/6
Pulmonary flow murmur of newborn (PPS?)
Murmur ID:
- continuous, grade 1-2/6
- R or L supraclavicular and infraclavicular areas
- inaudible in supine position
- intensity changes with rotation of the head and compression of the jugular vein
- ages 3-6yrs
Venous hum
Murmur ID:
- R supra-clavicular area and over the carotids
- 2-3/6
- occasional thrill over carotid
- any age
Carotid brunt (systolic)
Time of functional closure of the ductus arteriosus?
12-24hrs of life
Time of anatomic closure of the ductus arteriosus?
2-3 weeks of age
Types of CHD that present with shock?
2/2 left heart obstruction:
- CoA
- HLHS
- interrupted Ao arch
- critical AS
- obstructive TAPVR
(systemic perfusion dependent on PDA, symptoms worsen after PDA closure)
Treatment of shock 2/2 CHD
- PGE1
- Avoid excess O2 –> pulm vasodilation (decr PVR) –> increased left to right shunting
- Gentle fluid resuscitation (10mL/kg boluses etc)
- Inotropic agents to improve CO (dobutamine, dopamine, epi)
Most common causes of central cyanosis?
CHD, pulmonary disease, and CNS depression
Amt of hgb that must be reduced to perceive cyanosis.
5g/dL
- In infants with nml hgb levels, apparent at 75-80%
- In polycythemic infants, cyanosis at higher O2 saturations
- In anemic infants, no cyanosis until more significant desaturation occurs
How do you interpret a hyperoxia test?
PO2>100mmHg or incr in PO2>30mmHg above on RA = pulmonary etiology likely
PO2L shunt (CHD or PPHN) or a mixing lesion
Preductal > postductal saturations
PPHN and cardiac conditions with decr systemic pressures (LV obstructive lesions = AS, interrupted arch, CoA)
Postductal>preductal saturations
TGA with obstruction (interrupted arch or CoA)
Acyanotic Congenital Heart Defects
- VSD
- PDA
- ASD
- AV canal (complete endocardial cushion defect)
Name the CHD:
- asymptomatic to CHF at 6-8wks of age
- loud, harsh, holosystolic murmur at LLSB +/- thrill (+/- in newborn period)
- CXR = cardiomegaly, incr PVM
- EKG = LVH +/- LAE
- Most common CHD requiring f/u and intervention
VSD
Name the CHD:
- Asymptomatic to hemodynamically unstable (preterm infants)
- Continuous machinery-like murmur at LUSB
- Bounding pulses with wide pulse pressure
- CXR = cardiomegaly, incr PVM
- EKG = LVH, BVH with large lesion
PDA
- normally closes by 72HOL
- treated with surgery, indomethicin or ibuprofen
Name the CHD:
- rarely symptomatic before 30-40’s
- may present with CHF and pulm HTN
- wide, fixed split S2 +/- SEM at the LUSB
- CXR = cardiomegaly +/- RA and RV enlargement
- EKG = RAD, RVH, RBBB (rsR’ in V1)
- Can lead to atrial arrhythmias in adults
ASD
Name that CHD:
- CHF at 4-6wks of age
- holosystolic murmur of VSD
- CXR = cardiomegaly with four-chamber enlargement, incr PVM
- EKG = superior QRS axis, RVH or RBBB
- common in pts with Down syndrome
Complete endocardial cushion defect (AV canal)
Name that CHD:
- critical lesions –> cyanosis, tachypnea, exertional dyspnea, fatigue, CHF
- loud SEM at ULSB radiating to back and lung fields
- CXR - prominent PA segment, normal to decreased PVM
- EKG - RAD, RVH
Pulmonary stenosis (PS)
- treated with PGE1 to incr pulmonary perfusion and ultimately balloon valvuloplasty for surgical correction
Name that CHD:
- Neonates: hypoperfusion, resp distress, cyanosis with R–>L ductal flow
- Children: chest pain, syncope, dyspnea
- Ejection click, harsh midsystoloic murmur, systolic thrill at suprasternal notch
- CXR = cardiomegaly, incr PVM
- EKG = LVH +/- strain
Aortic stenosis
- PGE1/balloon valvuloplasty or surgical correction
- supravalvular AS is common in Williams Syndrome
Name that CHD:
- Infants: CHF, respiratory distress, shock, diminished pulses and cyanosis of the lower extremities, BP differential (RA>leg)
- Children: HTN in right arm, decr femoral pulses
- no murmur in 50% VS ejection click, SEM
- CXR: cardiomegaly, incr PVM, E-shaped esophagus on barium esophagram, rib notching
- EKG: LAD, LVH
- 70% with associated aortic valve abnormality
Coarctation of the aorta (CoA)
- surgery, then balloon angioplasty for recoarctation
- present in 30% of pts with Turner’s syndrome
Name that cyanotic CHD:
- initially cyanosis/dyspnea on exertion, later hypoxic spells
- single S2; long, loud SEM at MULSB
- CXR: decr PVM, “BOOT-SHAPED” heart, R aortic arch in 25%
- EKG: RAD, RVH
- degree o cyanosis and symptoms is related to severity of PS
- MOST COMMON CYANOTIC CHD
Tetralogy of Fallot:
- large VSD
- RVOT obstruction (PS)
- RVH
- overriding aorta
- PGE1 if cyanotic, primary surgical repair, occasionally palliative Blalock-Taussig shunt (subclavian artery to ipsilateral PA)
Name that cyanotic CHD:
- severe cyanosis and tachypnea in pt with normally related great vessels
- murmur from associated lesions (VSD, PDA)
- CXR: decr PVM
- EKG: leftward or superior QRS axis, RAE, minimal positive forces in V1 and V2
- 30% with TGA
Tricuspid Atresia
- PGE1, rare balloon atrial septostomy, BT shunt 1st stage of repair, definitive repair is a single ventricle Fontan-type repair
- Associated mixing defects needed for survival
Name that cyanotic CHD:
- severe cyanosis and tachypnea n the neonatal period
- intra-atrial communication necessary for survival
- single S2, murmur absent +/- PDA murmur
- decr PVM, dark lung fields
- EKG = LVH, RAH
- commonly associated with coronary artery anomalies
Pulmonary atresia with intact ventricular septum
Name that cyanotic CHD:
- cyanosis, arrhythmias (SVT). ASD or PFO always present
- triple or quadruple rhythm (wide split S2 +/- split S1, S3 or S4)
- CXR: decr PVM, massive cardiomegaly with BALLOON-SHAPED HEART
- EKG: RBBB, RAH, 1st degree AV block, delta wave
- Frequently associated with WPW
Epstein’s anomaly = downward displacement of TV, resulting funcitonal RV hypoplasia
Name the cyanotic CHD:
- severe cyanosis, signs of CHF in the 1st week of life
- single S2, often no murmur
- CXR = incr PVM, EGG-SHAPED HEART, or EGG ON A STRING
- EKG = RAD, RVH
- VSD present in 30-40%
Transposition of the great arteries
Name that cyanotic CHD:
- mild cyanosis immediately after birth, CHF in days to weeks
- large VSD located beneath truncal valve
- single S2, systolic ejection click at the apex, murmur of VSD
- bounding pulses with wide pulse pressure
- CXR = incr PVM, cardiomegaly, R aortic arch in 30%
- EKG = BVH
- Coronary artery anomalies are common
Truncus arteriosus
- Digeorge syndrome in 1/3 of pts
Name that cyanotic CHD:
- resp distress, CHF
- types vary with vessel insertion:
Supracardiac - SVC = most common
Cardiac - RA or coronary sinus
Infracardiac - portal veins, IVC; commonly leads to obstruction of venous return
- quadruple rhythm (S1, widely splitS2, and S3 or S4, hepatomegaly)
- CXR = cardiomegaly, sign incr PVM, SNOWMAN SIGN or FIGURE 8 SIGN
- EKG = RVH, rsR’ in V1
Total anomalous pulmonary venous return (TAPVR)
- PGE1 may worsen condition in obstructed TAPVR
Name that cyanotic CHD:
- respiratory distress, shock and CHF within the 1st week of life
- loud single S2, commonly no murmur, hepatomegaly
- CXR = incr PVM, pulmonary venous congestion, edema +/- cardiomegaly
- EKG = RVH, RAE, minimal positive forces in V5 and V6
Hypoplastic left heart syndrome (HLHS)
Causes of CHF in 1st week of life?
Severe obstructive CHD = HLHS, critical AS or PS, obstructive TAPVR, interrupted aortic arch
TGA
Volume overload = severe tricuspid or pulmonary insufficiency, systemic arterio-venous fistula
Genetic or metabolic cardiomyopathy
Causes of CHF at 1-4 weeks of life
Less severe obstructive lesions = coarctation, AS or PS, TAPVR
Truncus arteriosus
Genetic or metabolic cardiomyopathy
Causes of CHF in infants >1 month of age:
Large L–>R shunts = ECD @ 4-6wks, large VSD or PDA at 6-8wks
Arrhythmias (SVT)
Myocarditis
Genetic or metabolic cardiomyopathy
Causes of CHF in older children
Inflammatory - Kawasaki, myocarditis, rheumatic fever
Acute HTN (HUS)
Genetic or metabolic cardiomyopathy
List the JONES criteria for rheumatic heart disease:
Laboratory evidence of prior streptococcal infection PLUS 2 major criteria or 1 major and 2 minor criteria
J = joints (migratory, polyarthritis of large joints) O = carditis (1 Endocarditis, 2 myocarditis, 3 pericarditis) N = nodules (SQ, on extensor surfaces of extremities, "Aschoff bodies" on histology) E = erythema marginatum S = sydenham chorea
MINOR CRITERIA: arthralgia, prolonged PR interval, fever, elevated ESR +/- CRP, elevated WBC, previous rheumatic fever
Characteristics of innocent murmurs:
Short duration
Low intensity (grade I/II)
Vibratory or musical in quality
