Lecture 5: Cardiology

Question 1

chest pain

Answer 1

• frequent pediatric complaint
• most pediatric chest pain is musculoskeletal in origin
• older children are more likely to have psychogenic reasons
• younger children are more likely to have a cause related to respiratory disease

Question 2

chest pain etiologies

Answer 2

• etiologies
  
  • musculoskeletal (>20% prevalence)
  • idiopathic (>20% prevalence)
  • psychogenic/psychiatric (<30% prevalence)
  • respiratory disorders (<10% prevalence)
  • gastrointestinal (<8% prevalence)
  • cardiac (<6% prevalence)
  • breast (<5% prevalence)
  • pulmonary vascular disorders
  • toxic exposure

Question 3

approach to chest pain

Answer 3

• distinguish acute vs. chronic
• distinguish pleuritic from non-pleuritic
• identify co-morbid risk factors
• herald signs of serious causes (red flags)
  
  • chest pain with exertion
  • exertional syncope
  • acute pain that is acutely worsening
  • acute onset of fever with chest pain
  • findings on history or exam referable to cardiac or respiratory systems
• rule out severe distress
• chest tenderness is very reassuring against a cardiac source
• initial workup typically starts with EKG and chest plain film

Question 4

musculoskeletal source of chest pain

Answer 4

• chest tenderness with or without movement
• overuse injury or strain of chest wall muscle
• direct trauma
  
  • rib fracture
  • contusion of chest wall
• precordial catch (Texidor’s twinge)
  
  • sharp pain at the left sternal border, lasts less than 3 minutes, associated bubble or popping sensation
• costochondritis
  
  • pain at sites of costal cartilage reproduced by eliciting tenderness over the costochondral junctions or with AP compression of the chest

Question 5

respiratory source of chest pain

Answer 5

• illnesses with persistent or forceful cough
• pneumonia +/- pleural effusion
• asthma +/- pneumomediastinum
• spontaneous pneumothorax
  
  • asthma
  • cystic fibrosis
  • Marfan’s syndrome
• pleurisy

Question 6

pulmonary vascular disorder source of chest pain

Answer 6

• pulmonary embolism
  
  • rare in children but can occur in those with risk factors
    
    • oral contraceptives
    • termination of pregnancy
    • trauma, particularly of lower extremities
  • classic presentation
    
    • acute onset of pleuritic chest pain, dyspnea, hypoxia
    • presentation is not always classic
• pulmonary hypertension
  
  • pain typically related to underlying heart or lung disease
• acute chest syndrome
  
  • chest source crisis in patients with sickle cell disease

Question 7

psychogenic source of chest pain

Answer 7

• anxiety disorder or conversion disorder
  
  • relative or friend with cardiac disease
  • family history of depression, somatization
  • triggered by stress
• hyperventilation

Question 8

GI source chest pain

Answer 8

• reflux esophagitis
  
  • burning, substernal pain
    
    • worse with reclining or certain foods
  • may be associated with esophageal spasm (mimicks angina)
  • severe cases complicated by esophageal candidiasis
• intrathoracic foreign body

Question 9

mammary source chest pain

Answer 9

• females
  
  • mastitis
  • pregnancy
  • fibrocystic disease
• males
  
  • gynecomastia

Question 10

cardiac source chest pain

Answer 10

• Rare cause of chest pain in children
• Co-morbid risk factors raise likelihood of cardiac-source chest pain
  
  • diabetes mellitus
  • Kawasaki’s disease
  • stimulant use
    
    • cocaine
    • amphetamines
• cardiac ischemia
  
  • may result from
    
    • anomalous coronary arteries
    • left ventricular outflow tract obstruction (LVOTO)
    • cardiac infection - endocarditis
    • embolic phenomena
    • Vasculitis
    • pulmonary hypertension
    • valvular disease (congenital or acquired)
    • cardiomyopathy
    • subaortic stenosis
    • arrhythmia
• myocardial infarction
  
  • rare in children
  • herald sign – pain with exertion
• mitral valve prolapse
• pericarditis and myocarditis may cause chest pain without ischemia
• hypertrophic obstructive cardiomyopathy (HOCM)
  
  • autosomal dominant inheritance
  • systolic murmur worsening with change from lying to standing or with squat to standing or Valsalva
    
    • procedures that reduce blood return to ventricles (reduce preload).
  • pain with exertion

Question 11

cardiac infections: pericarditis

Answer 11

• inflammation of the pericardium
  
  • fever
  • respiratory distress
  • sharp, stabbing substernal chest pain
  • often unable to lie flat
  • pain improves with sitting up or leaning forward
  • friction rub, distant heart sounds
  • jugular venous distension
  • pulsus paradoxus
  • Abnormal EKG – Diffuse ST elevations

Question 12

cardiac infections: myocarditis

Answer 12

• inflammation of the heart muscle
  
  • pain develops over a few days
  • fever
  • systemic symptoms consistent with CHF
    
    • vomiting, lightheadedness, etc.
  • gallop rhythm (S3, S4 sounds)
  • Tachycardia, hepatomegaly
  • orthostatic hypotension
  • CXR - cardiomegaly
  • abnormal EKG, elevated CK and troponins

Question 13

pediatric arrhythmias

Answer 13

• sinus arrhythmia can be very pronounced in children
  
  • HR slows with expiration
• most common pediatric dysrhythmia is supraventricular tachycardia
• mechanisms include
  
  • intra-atrial reentry
  • AV nodal reentrant tachycardia
  • AV accessory conduction
    
    • Wolff-Parkinson-White syndrome
    • slurred upstroke of the QRS (delta wave) à
• Babies normal heartrates when they’re born are 130-160, a 2-3yo is around 100 etc. so tachycardia for younger ones is different than tachy in an adult

Question 14

approach to chest pain

Answer 14

• distinguish acute vs. chronic
• distinguish pleuritic from non-pleuritic
• identify co-morbid risk factors
• herald signs of serious causes (red flags)
  
  • chest pain with exertion
  • acute pain that is acutely worsening
  • acute onset of fever with chest pain
  • findings on history or exam referable to cardiac or respiratory systems
• rule out severe distress
• chest tenderness is very reassuring against a cardiac source
• initial workup typically starts with EKG and chest plain film

Question 15

describing a murmur

Answer 15

• intensity (grade I-VI)
• quality
• timing
  
  • relationship to cardiac cycle
  • Duration
  • “shape”
• location
• variation with position

Question 16

qualities of an innocent heart murmur

Answer 16

• Early Systolic Ejection
• Short Duration
• Soft - Low intensity (Grade 1 or 2)
• Vibrating or musical quality

Question 17

qualities of a pathologic murmur (one or more)

Answer 17

• Pansystolic
• Diastolic(except venous hum)
• Long loud systolic murmurs

Question 18

innocent murmurs

Answer 18

• roughly 80% of kids have a murmur at some time in their lives
  
  • “innocent” is synonymous with terms functional, benign, & flow
    
    • peripheral pulmonic stenosis
    • Still’s (vibratory) murmur
    • venous hum
    • carotid bruit

Question 19

innocent murmurs: peripheral pulmonic stenosis (PPS)

Answer 19

• peripheral pulmonic stenosis (PPS)
  
  • caused by turbulence in the branches of the pulmonary artery in neonates
  • grade I-II
  • soft, short, high-pitched
  • loudest over LUSB
  • radiates to back & axillae
  • Resolves by 3 to 6 months
• With a VSD, even the process of breast feeding is something that will make the baby SUPER tired

Question 20

innocent murmurs: still’s (vibratory) murmur

Answer 20

• heard from age 2 and up
• grade I-III
• musical, vibratory, short
• LLSB to apex
• loudest when patient is in the supine position; diminishes when the patient sits or stands

Question 21

innocent murmurs: venous hum

Answer 21

• heard after age 2
• continuous musical hum
• located at the upper right and left sternal borders
  
  • usually louder on the right
• intensity changes with turning of the neck
• Goes away when the patient lays down

Question 22

innocent murmurs: carotid bruit

Answer 22

• any age
  
  • more common in the older child and adolescent
• grade II-III
• long, systolic ejection murmur
• heard in right supraclavicular area
• radiates to neck

Question 23

congenital heart disease

Answer 23

• Shunts
  
  • systemic (left) and pulmonary (right) circuits generally operate in series
  • a shunt implies a connection that allows communication between the two systems
  • shunting proceeds down gradient in pressure
  • right-to-left shunts cause cyanosis

Question 24

acyanotic congenital heart disease

Answer 24

• ASD, VSD, PDA
• semilunar valvular defects
• coarctation of the aorta
• VSD accounts for about 25% of all CHD
• ASD or PFO places patients at risk for systemic embolism
• PDA covered in neonatal lecture
• aortic stenosis and pulmonic stenosis are uncommon
  
  • AS 5% of all CHD, PS 10% of all CHD
  • both at risk for endocarditis

Question 25

ventricular septal defect

Answer 25

• Small VSD
  
  • 80-85% of VSDs
  • asymptomatic
  • generally close on their own without surgery
• Moderate VSD
  
  • serially monitored by cardiologists
• Large VSD with normal pulmonary vascular resistance
• left-to-right shunting as pulmonary vascular resistance naturally decreases (2-8 weeks of life)
• infant develops congestive heart failure
  
  • failure to thrive
  • difficulty feeding
  • labored breathing/pulmonary edema

Question 26

Eisenmenger’s syndrome

Answer 26

• an untreated large VSD will cause pulmonary overcirculation
• overcirculation of pulmonary system causes pulmonary hypertension
• normal left-to-right shunt reverses to right-to-left shunt as pulmonary system pressures surpass systemic pressures
• prolonged cyanosis
  
  • causes organ and vascular damage
  • platelet dysfunction
  • treatable only with heart transplant

Question 27

coarctation of the aorta

Answer 27

• main artery to body stenotic or interrupted
• causes upper extremity hypertension and reduced flow to abdominal organs and lower extremities (SBP different by 20 should raise concern)
• all newborns screened for femoral pulses and saturations
• mild cases may have long-term growth problems,
  
  • often have aortic valve abnormalities audible on exam
  • may have chronic leg discomfort or lower extremity wasting
• in severe cases with pre ductal coarctation the PDA needs to be kept open to ensure survival
  
  • if PDA closes, shock and acidosis ensue rapidly

Question 28

cyanotic CHD

Answer 28

• five most common cyanotic CHD
  
  • truncus arteriosus
  • transposition of the great arteries
  • tricuspid atresia
  • tetralogy of Fallot
  • total anomalous pulmonary venous return

Question 29

tetralogy of fallot

Answer 29

• ~10% of all congenital heart disease
• four components to defect
  
  • ventricular septal defect
  • pulmonary stenosis
  • right ventricular hypertrophy
  • overriding aorta
• The patient may be ‘pink’ (not cyanotic) if pulmonic stenosis mild and VSD shunts left to right
• “Tet spells” where patient grows cyanotic, progressively worse with age
  
  • infants become agitated, tachypneic and have difficulty feeding
  • toddlers may squat to resolve Tet spell
• long systolic ejection murmur (from PS)
• classic CXR appearance - boot-shaped heart
• surgically repaired in infancy
• Tet spells are medical emergencies: SOB, cyanosis, loss of consciousness
  
  • Squatting helps to fix these

Question 30

rheumatic fever

Answer 30

• follows a previous infection with Strep pyogenes (GAβHS) – rate in untreated is approx. 3%
• typically between ages 5 and 15 years
• mortality of 2-5%
• pathophysiology
  
  • sensitization of B lymphocytes
  • formation of anti-streptococcal antibodies
  • formation of Immune complexes
  • myocardial & valvular inflammatory response
• major criteria JONES criteria (mnemonic J<3NES) –
• 2 major criteria make the diagnosis
  
  • joints – migratory polyarthritis
  • carditis
    
    • as myocarditis, pericarditis or valvular disease
  • nodules (subcutaneous)
    
    • extensor surfaces of extremities
  • erythema marginatum
    
    • pink-red macules grow, then coalesce into serpiginious long patches
  • Sydenham’s chorea – uncontrolled movements
    
    • with or without psychiatric disease
    • may define disease as a single criterion
• 1 major + 2 minor can also signify disease
• Minor criteria
  
  • polyarthralgia
  • fever
  • elevated ESR, CRP
  • prolonged PR interval
  • Previous rheumatic fever
• Supportive serology of previous infection
  
  • anti-streptolysin O is the best test
  • anti-DNAse B & streptozyme also used

Question 31

rheumatic fever treatment

Answer 31

• antibiotics
  
  • short-term to treat indolent infection
  • long-term to prevent recurrence
    
    • often every 3-4 weeks for life
• aspirin for anti-inflammatory effects
  
  • sometimes requires corticosteroids
• supportive
  
  • cardiac meds (digoxin, diuretics)
  • endocarditis prophylaxis for procedures

Question 32

infective endocarditis

Answer 32

• greatest risk is to those with preexisting heart disease or cardiac foreign material
• may be acute or subacute
• viridans streptococci
• S. aureus
• less common
  
  • enterococci
  • HACEK organisms (fastidious Gram-negative rods)
• fever
• chest pain
• symptoms of heart failure
  
  • fatigue, tachypnea, dyspnea on exertion
• changing murmur
• petechiae & embolic phenomena
• splenomegaly +/- hepatomegaly
• arthritis
• weight loss (subacute or chronic illness)
• Bacteremia with positive blood cultures
• hematuria
• markedly elevated inflammatory markers

Question 33

treatment of infective endocarditis

Answer 33

• treatment
  
  • long-term antibiotics
    
    • directed therapy (based on cultures)
  • surgical excision or valve repair sometimes warranted
  • supportive care for sequelae
    
    • congestive heart failure
• use transthoracic echos first and blood cultures, etc.
• Has to be treated for a very long time

Question 34

endocarditis prevention

Answer 34

• cardiac risk factors that are often indications for prophylaxis
  
  • prior history of infective endocarditis
  • any valvulopathy
  • prosthetic heart valves
  • unrepaired cyanotic CHD
  • repaired CHD with prosthetic material, device or venous pacer wires
• risk of procedure also important to determine need
  
  • dental/oral or upper respiratory tract
    
    • amoxicillin
  • GU/GI procedures
    
    • amoxicillin for enterococcal coverage
    • aminoglycoside - for gram-negative coverage
  • procedures that involved infected tissues
    
    • clindamycin or vancomycin to cover MRSA

Question 35

chest pain history

Answer 35

• Pain is in the center of the chest over the past 3 days.
• No history of chest pain
• Pain is worse with deep breathing
• No fever
• He has been coughing
• No history of pain with activity, some increase in symptoms while active
• No history of fainting
• No family history of cardiac disease