Cardiovascular Presentations Flashcards
Congenital Heart Disease and Congestive Heart Failure
Define HEART FAILURE.
Heart failure in children, as with in adults, is defined as insufficient cardiac output to meet physiological metabolic demands.
It is not uncommon for heart failure in children to be biventricular, due to high level of interdependence between the ventricles as well as child-specific pathologies.
Outline some common causes of HEART FAILURE in children.
CONGENITAL HEART DISEASE ✔️ VSD (presents within 4 to 6 weeks) ✔️ PDA (presents within 2 to 3 weeks) ✔️ large ASD ✔️ coarctation of aorta
MYOCARDITIS
✔️ viral-induced (e.g. Coxsackie Virus)
✔️ Kawasaki Disease
✔️ ARF
CARDIOMYOPATHIES
✔️ dilated cardiomyopathy
PRESSURE OVERLOAD
✔️ severe aortic stenosis
✔️ pulmonary stenosis
✔️ pulmonary hypertension
VOLUME OVERLOAD
✔️ left to right shunt
✔️ valve pathology
HIGH PRESSURE OUTPUT ✔️ thyrotoxicosis ✔️ severe anaemia ✔️ sepsis ✔️ acidosis
Describe how children present in heart failure.
INFANTS ✔️ reduced feeding ✔️ increased irritability ✔️ signs of increased work of breathing (e.g. tachypona, nasal flaring, subcostal or intercostal recessions, grunting, head bobbing) ✔️ cyanosis ✔️ reduced interaction / increased lethargy ✔️ weak cry ✔️ failure to thrive
CHILDREN ✔️ fatiguability ✔️ reduced exercise tolerance ✔️ reduced appetite; poor weight gain ✔️ failure to thrive ✔️ chronic cough ✔️ "asthma" episodes
Identify four key clinical signs suggesting heart failure on clinical examination.
- tachycardia
- tachyponea
- cardiomegaly
- hepatomegaly
Outline management principles of CHF in children.
- Identify and treat the underlying cause.
- Reduce fluid overload with frusemide (Lasix).
- ACE-I or ARB
- Beta-blocker (e.g. atenolol) to reduce risk of arrhythmia
- Oxygen (if required)
Describe the features of an INNOCENT HEART MURMUR.
Innocent heart murmurs include systolic ejection murmurs, pulmonary flow murmur and venous hum.
Features include: ✔️ present throughout systole only ✔️ localised ✔️ nil radiation ✔️ quiet (< 3 out of 6) ✔️ short in duration; cyclical ✔️ varies with position ✔️ varies with respiration ✔️ normal cardiovascular and respiratory findings ✔️ child is asymptomatic
Describe the features of an INDOLENT HEART MURMUR.
Indolent heart murmurs include VSD, PDA, aortic or pulmonary stenosis, coarctation of the aorta.
Features include: ✔️ present through diastole ✔️ pansystolic ✔️ radiation ✔️ loud (> 3 out of 6) ✔️ associated with thrills and heaves ✔️ associated with cardiovascular and respiratory symptoms
Define ACYANOTIC HEART DISEASE. Which conditions fit into this category?
Acyanotic congenital heart disease includes any form of congenital heart disease in which cyanosis is NOT a key feature.
Typically, these conditions are characterised by a left-to-right shunt which enables oxygenated blood to move into pulmonary circulation.
Right ventricular hypertrophy (due to pressure overload) may lead to reversal of this shunt and subsequent cyanosis (this is known as Eisenmenger Complex).
Diseases include: ✔️ ASD ✔️ VSD ✔️ PDA ✔️ coarctation of the aorta
Define CYANOTIC HEART DISEASE. Which conditions fit into this category?
Cyanotic heart disease is characterised by cyanosis (bluish tinge of mucus membranes and skin).
Typically, these conditions are characterised by a right-to-left shunt which enables deoxygenated blood to enter peripheral circulation without first passing through pulmonary circulation.
Diseases include: ✔️tetralogy of fallot ✔️transposition of the great arteries ✔️ tricuspid atresia ✔️ truncus arteriosis ✔️ total anomalous pulmonary venous return ✔️ pulmonary atresia ✔️ Ebstein's anomaly ✔️ hypo plastic left heart syndrome
ATRIAL SEPTAL DEFECT (ASD)
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Acyanotic.
Soft systolic flow murmur heard best over the pulmonary region.
Fixed-splitting S2 heart sound.
Typically asymptomatic.
VENTRICULAR SEPTAL DEFECT (VSD)
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Acyanotic. Can become cyanotic if there is reversal of the shunt.
Rasping, loud pan systolic murmur with radiation throughout the entire precordium.
Associated with a wide-splitting S2 heart sound.
Asymptomatic. May present as congestive heart failure around 4 to 6 weeks of age.
PATENT DUCTUS ARTERIOSUS (PDA)
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Acyanotic. Can become cyanotic if there is reversal of the shunt.
Loud, machinery-like murmur with palpable thrills and parasternal heaves heard best at ULSB with radiation to the left clavicle.
Asymptomatic. May present with congestive heart failure around 2 to 3 weeks of life.
Use NSAIDs to facilitate physiological closure (through reduced prostaglandin synthesis).
COARCTATION OF THE AORTA
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Acyanotic.
Ejection systolic murmur with early peak on ECG.
Pre-ductal coarctation can present as shock within the first few days of life.
Post-ductal coarctation can present with:
✔️ post-ductal saturation >3% different to pre-ductal
✔️ post-ductal saturation < 95%
✔️ hypertension of the upper limbs
✔️ hypotension of the lower limbs
TRANSPOSITION OF THE GREAT ARTERIES.
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Cyanotic immediately after birth. Relies on a PDA / VSD / ASD to facilitate perfusion.
Nil murmur.
Prostaglandins should be given to keep the duct open until septostomy can be performed (enables mixing of the oxygenated and deoxygenated blood).
TETRALOGY OF FALLOT
✔️ cyanotic versus acyanotic
✔️ murmur
✔️ key features
Cyanotic spells within the first to 3 months of life.
Ejection systolic murmur at LSB with single loud S2. Occasional thrills.
Key features:
- large VSD
- overriding aorta
- pulmonary stenosis
- right ventricular hypertrophy
