CVS Flashcards
Are heart murmurs common in pediatric populations?
Yes
-50-80% of children have audible heart murmurs at some point in childhood
T/ F most heart murmurs discovered in pediatric patients are due to a structural cause
False
Most are innocent/ functional (i.e., caused by turbulent blood flow) and are not associated with a structural abnormality.
Describe the following for an innocent heart murmur
-signs and symptoms
-grade
-sound
-relationship with position
-typical history
-Asymptomatic
-Grade is <3/6
-Soft, blowing, vibratory, musical
-No extra sounds or clicks
-Murmur varies with positional changes (lower intensity sitting)
-No family or personal history CHD, no phx genetic anomalies
Describe the following for a pathologic heart murmur
-signs and symptoms
-grade
-sound
-relationship with position
-typical history
S/S of cardiac disease (failure to thrive, exercise intolerance)
-Diastolic, pansystolic, or continuous
-Grade 3/6+
-Palpable thrill
-Harsh, hit pitch, better heard with diaphragm
-May have extra sounds/ clicks (abnormal S2, gallop, friction rubs)
-Unchanged by position
-Family or phx CHD, phx of genetic condition
You are taking the history of a child with a heart murmur. What are some associated signs/ symptoms you will ask about?
dyspnea, resp difficulties, cyanosis, poor growth, feeding intolerance/ poor feeding, diaphoresis, chest pain, syncopal episodes
What physical exam will you conduct for a child with a heart murmur?
-Gen appearance (congenital anomalies)
-VS (HR and rhythm, difference in SCP between R arm and leg)
-CVS- complete assessment including pulses (asymmetry, deficits?), inspection of chest, palpation for thrills and apical impulse, listening at each area of the heart with bell and diaphragm
-Hepatomegaly
-Resp
When would you refer a child with a murmur to cardiology?
Criteria as outlined by up to date:
Abnormal fetal echo, underlying genetic disorder associated with increased risk CHD, and symptoms suggestive of heart disease
Murmur is grade 3+ intensity, holosystolic timing, maximum intensity at left upper sternal border, harsh or blowing quality, increased in upright position, diastolic murmur
Other abnormal heart sounds (S2, gallop rhythm, systolic click, friction rub)
>10mmHg SBP gradient between R arm and leg
Abnormal pulses
Abnormal CXR (i.e., cardiomegaly, pulmonary edema) or ECG
What education will you provide the the patient/ family about a heart murmur?
- A murmur is a physical assessment finding, not necessary a specific diagnosis
- It is heart sound that comes from turbulent blood flow in the heart
- Heart murmurs are common in children. ~50% of healthy children have heart murmurs and the majority (~98%) of these are not pathological/ harmful
- Red flags/ signs to seek reassessment or urgent care (i.e., if develops signs/ symptoms of cardiac disease such as dyspnea, cyanosis, poor growth, diaphoresis, chest pain, syncope)
What is a systolic murmur??
Starts with or after S1, stops before or at S2
What is a diastolic murmur?
Starts with or after S2, ends at or before S1
What is a holosystolic murmur?
Starts with S1 and obscures S1 and S2
What is a continuous murmur?
Continuous murmurs begin in systole and continue without interruption through the second heart sound (S2) into all or part of diastole.
Describe each grade of heart murmur
1- faint
2- soft, readily detectable
3- loud, no thrill
4- louder, with palpable precordial thrill
5- very loud, audible with stethscope placed lightly on chest, with precordial thrill
6- loudest, audible with stethoscope off chest, with precordial thrill
What are some risk factors for congenital heart disease?
Genetic predisposition
Prenatal exposure to teratogens
Prenatal viral illness (coxsakie virus, cytomegalovirus, influenza B, mumps, rubella, parvovirus, varicella, etc)
Maternal factors (age>40, IDDM, lupus)
Congenital infection with GABHS
Prematurity
What are red flags in the general peds history that may lead to an urgent cardiac assessment?
Lethargy
Tiredness
Failure to thrive
Syncope – acute collapse (often with exertion), few warning symptoms preceding the event
What are red flags in the general inspection of peds patients that may lead to an urgent cardiac assessment?
Cyanosis, clubbing, abnormal breathing (tachypnea, intercostal indrawing)
What are red flags in the palpation section of the assessment of peds patients that may lead to an urgent cardiac assessment?
Parasternal or apical impulse, abnormal pulses – diminished, absent or delayed femoral pulses
What features of murmurs would lead to an urgent cardiac referral?
Systolic murmur which is pansystolic or grade 3 or higher
Purely diastolic murmur
Radiation of the murmur to the back
Any other findings that would warrant a cardiac referral?
Abnormal heart sounds
Presence of an early or mid-systolic click
Cardiac failure or arrhythmia
Common presenting symptoms of infants with heart disease
Lethargy, irritability, tachypnea, sweating, poor feeding, poor weight gain
Common presenting symptoms of older children with cardiac disease
Lethargy
Exercise intolerance
Respiratory distress
What are initial diagnostics recommended to determine need for referral if unsure
Chest x-ray
ECG
These are usually not diagnostic, but can be helpful in differentiating resp/cardiac disease and identifying children who need further assessment
T/F: Chest pain in children is often of a cardiac origin
FALSE – majority of chest pain in peds is not cardiac related.
What are common causes of pediatric chest pain?
MSK pain/strain
Inflammation (pericarditis/myocarditis)
Gastroesophageal irritation
Psychogenic
Pulmonary
T/F: Anxiety/emotional stress is the most common source of pediatric chest pain
FALSE – Costochondritis is the most common cause (20-75%)
Anxiety and emotional stress accounts for 9-20%
Cardiac chest pain is rare, but does need to be considered. When would you refer to a cardiologist?
Abnormal physical exam
Abnormal ECG
Personal history of CHD
Prior arrhythmia
Severe familial hypercholesterolemia
Kawasaki disease with coronary artery aneurysm
What is acute rheumatic fever and when does it occur?
Rheumatic fever is a nonsuppurative sequela of GAS pharyngitis, occurs 2-4 weeks after infection
What are the major manifestations of Acute Rheumatic Fever (ARF)?
History of GAS pharyngitis
THESE WOULD BE THE RED FLAG SYMPTOMS TO WATCH FOR *
Has to meet criteria for a minimum number of symptoms. Symptoms can include:
Migratory arthritis – usually large joints
Carditis – pancarditis affecting the pericardium, epicardium, myocardium and endocardium. Valvulitis is the most common.
Sydenham chorea – neurological disorder – abrupt, nonrhythmic movements, muscular weakness
Erythema marginatum – a rash
Subcutaneous nodules
Arthralgia, fever, prolonged PR interval
How is ARF treated?
Abx – Pen G
NSAIDs for arthritis
Supportive management of carditis
What is the serious sequelae of ARF? When does this occur?
Rheumatic heart disease. Usually 10-20 years after original illness.
T/F: Rheumatic heart disease is the most common cause of acquired valvular heart disease in the world
TRUE
How can we prevent acute rheumatic fever?
Prompt recognition and treatment of GAS pharyngitis
How can we prevent rheumatic heart disease in someone who has had acute rheumatic fever?
Subsequent exposures to GAS infections can trigger ARF and lead to development/progression of RHD. Chronic antimicrobial prophylaxis is recommended – typically long acting pen G q28days
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