Paediatric Cardiology Flashcards
What is ventricular septal defect?
VSD - MC congenital heart disease.
spontaneously happen in 50% pts.
Aetiology of Ventricular septal defect
congenital VSD association with chromosomal disorders:
- downs syndrome
- edwards syndrome
- patau syndrome
- cri-du chat syndrome
congenital infections
acquired causes:
- post-myocardial infarction
can VSD be detected in utero and how?
yes during 20week scan.
tell me some post natal presentations of ventricular septal defect
failure to thrive
features of HF: hepatomegaly, tachypnoea, tachycardia, pallor
classically - pan-systolic murmur - louder in smaller defects
how would you manage a ventricular septal defect?
if small VSD asymptomatic : they often close spontaneously and simple require monitoring
moderate to large VSD : result in degree of HF in 1st few months:
nutritional support
med for HF: diuretics
surgical closure of the defect
complications of ventricular septal defects
aortic regurgitation : due to poorly supported right coronary cusp results in cusp prolapse.
infective endocarditis
right HF
pulmonary HTN: pregnancy CI in women with pulmonary HTN - 30-50% mortality
eisenmenger’s complex - due to prolonged pulmonary htn from left to right shunt = RV hypertrophy = increase RV pressure. = exceeds LV pressure = reversal of blood flow. = clubbing and cyanosis.
what is the eisenmengers complex an indication for ?
heart-lung transplant
what is an atrial septal defect?
most likely congenital found in adulthood.
50% pts dead by 50.
2 types:
ostium secundum - MC
ostium primum
features of atrial septal defects
ejection systolic murmur, fixed splitting of s2
embolism might pass from venous system to left side of heart = stroke
tell me about ostium secundum - 70% of ASDs
ecg finding
associated with holt-oram syndrome - (tri-phalangeal thumbs)
ecg: RBBB with Right axis deviation
tell me about ostium primum
presents earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with left axis deviation , prolonged PR interval
what is tetralogy of fallot?
mc cyanotic congenital heart disease.
presents around 1-2 mths - could not be picked up by 6 mths.
why does TOF happen.
anterior malalignment of the aorticopulmonary septum
4 characteristic features of tetralogy of fallot
ventricular septal defect
RV hypertrophy
RV outflow tract obstruction, pulmonary stenosis
overriding aorta
in TOF what determines the degree of cyanosis and clinical severity?
the severity of the right ventricular outflow tract obstruction (pulmonary stenosis)
other general features of TOF
cyanosis : unrepaired TOF infants could get episodic hyper cyanotic “tet” spells due to near occlusion of RV outflow tract.
right to left shunt
ejection systolic murmur at left sternal edge - due to pulmonary stenosis (VSD doesnt usually cause murmur)
right sided aortic arch - 25% pts
cxr : “boot-shaped” heart,
ECG: RV hypertrophy
tell me a little bit about tet spell - TOF
in unrepaired TOF infants
hypercyanotic spell due to near occlusion of RV outflow tract.
features :
tachypnoea
severe cyanosis could result in loss of conciousness
typically when:
infant upset
in pain
fever
how would you manage TOF?
surgical repair in 2 parts
cyanotic episodes : beta blockers to reduce infundibular spasm
at birth what is the most common lesion in patients with TOF?
transposition of the great arteries.
what is heart failure?
cause?
heart unable to pump enough blood to meet met needs of body.
structural or functional heart disease.
classifying heart disease by ejection fraction
either normal LVEF or abnormal LVEF.
measure using echocardiography
reduced LVEF = <35%-40%. - HF-rEF - 50% of HF pts.
other 50% : HF-pEF - preserved LVEF.
systolic vs diastolic dysfunction - HF
HF-rEF : systolic dysfunction - impaired myocardial contraction during systole
HF-pEF: diastolic dysfunction : impaired ventricular filling during diastole.
can you give me some causes of systolic dysfunction?
ischaemic heart disease
dilated cardiomyopathy
myocarditis
arrhythmias
can you give me some causes of diastolic dysfunction?
hypertrophic obstructive cardiomyopathy
restrictive cardiomyopathy
cardiac tamponade
constrictive pericarditis
categorising HF by time
acute : acute exacerbation of chronic HF.
urgent sx due to LV failure = pulmonary oedema.
categorising HF by left/right
HF-rEF and HF-pEF most develop left HF.
due to :
increased ventricular afterload (arterial htn/aortic stenosis)
backflow to LV
right HF : caused by increased RV afterload (pulmonary htn) or increased RV preload (tricuspid regurgitation)
what signs does lv failure typically result in?
pulmonary oedema :
- dyspnoea
-orthopnoea
- paroxysmal noctural dyspnoea
- bibasal fine crackles
what signs does rv failure typically result in ?
peripheral oedema - ankle/sacral odema
raised jugular venous pressure
hepatomegaly
weight gain bc of fluid retention
anorexia (cardiac cachexia)
what does it mean by high-output HF?
where normal heart cant pump enough blood to meet the metabolic needs of body
causes of high output HF
anaemia
pagets disease
arteriovenous malformation
pregnancy
thyrotoxicosis
thiamine deficiency (wet beri-beri)
different between afterload and preload - hf?
preload - amount of blood in the ventricle at the end of diastole (before contraction)
afterload - resistance the ventricle must overcome to pump blood out during systole
features of chronic heart failure
dyspnoea
cough: possible worse at night : pink/frothy sputum
orthopnoea
paroxysmal noctural dyspnoea
wheeze : cardiac wheeze
bibasal crackles on auscultation
signs of right sided HF: raised JVP , ankle oedema and hepatomegaly
weight loss : cardiac cachexia : 15% pts - could be hidden by weight gained secondary to edema
diagnosing chronic heart failure?
1st line
what to do ?
1st line: N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test
if high : specialist assessment (transthoracic echocardiography too) within 2 weeks
if raised : within 6 weeks
what is bnp and what are high levels?
b-type natriuretic peptide - produced by LV myocardium responding to strain. - very high levels = poor prognosis
high levels are:
bnp : >400 pg/ml (116 pmol/l)
NTproBNP: >2000 pg/ml (236 pmmol/l)
raised levels are :
bnp : 100-400 pg/ml (29-116 pmol/l)
NTproBNP: 400- 2000 pg/mol (47-236 pmol/l)
normal levels:
bnp: <100 pg/ml (29 pmol/l)
NTproBNP: <400 pg/ml (47 pmol/l)
name some factors that can increase BNP
lv hypertrophy
sepsis
copd
diabetes
age over 70
liver cirrhosis
hypoxemia - includes pulmonary embolism
rv overload
tachycardia
ischaemia
factors decreasing bnp levels
obesity
diuretics
acei
beta-blockers
aldosterone antagonists
angiotensin 2 receptor blockers
what is the classification used to classify severity of chronic heart failure?
NYHA - new york heart association
class 1 -4
1: no sx. no limitation : ordinary physical exercise doesnt cause undue fatigue, dyspnoea or palpitations
2: mild sx. slight limitation of physical activity. comfortable at rest- ordinary activity = fatigue, palpitations/dyspnoea
- moderate sx. marked limitation of physical activity. comfortable at rest - less than ordinary activity = sx.
- severe sx. cant do physical activity without discomfort. hf sx present at rest - increased discomfort with any physical activity.
How to manage chronic heart failure?
1st line: ace-inhibitor and beta blocker.
start 1 drug at a time. clinical judgement on which one
2nd line:
3rd line:
